hospital_name,last_updated_on,version,hospital_location,hospital_address,license_number|WV,"To the best of its knowledge and belief, the hospital has included all applicable standard charge information in accordance with the requirements of 45 CFR 180.50, and the information encoded is true, accurate, and complete as of the date indicated.",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Mon Health Marion Neighborhood Hospital,2024-09-11,2.0.0,Mon Health Marion Neighborhood Hospital,"1200 J D Anderson Dr Morgantown, WV 26505",174,TRUE,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
description,code|1,code|1|type,code|2,code|2|type,code|3,code|3|type,setting,drug_unit_of_measurement,drug_type_of_measurement,standard_charge|gross,standard_charge|discounted_cash,modifiers,standard_charge|AETNA|COMMERCIAL|negotiated_dollar,standard_charge|AETNA|COMMERCIAL|negotiated_percentage,standard_charge|AETNA|COMMERCIAL|negotiated_algorithm,estimated_amount|AETNA|COMMERCIAL,standard_charge|AETNA|COMMERCIAL|methodology,additional_payer_notes|AETNA|COMMERCIAL,standard_charge|AETNA_MEDICAL_RENTAL|COMMERCIAL|negotiated_dollar,standard_charge|AETNA_MEDICAL_RENTAL|COMMERCIAL|negotiated_percentage,standard_charge|AETNA_MEDICAL_RENTAL|COMMERCIAL|negotiated_algorithm,estimated_amount|AETNA_MEDICAL_RENTAL|COMMERCIAL,standard_charge|AETNA_MEDICAL_RENTAL|COMMERCIAL|methodology,additional_payer_notes|AETNA_MEDICAL_RENTAL|COMMERCIAL,standard_charge|AETNA_MEDICARE|MEDICARE|negotiated_dollar,standard_charge|AETNA_MEDICARE|MEDICARE|negotiated_percentage,standard_charge|AETNA_MEDICARE|MEDICARE|negotiated_algorithm,estimated_amount|AETNA_MEDICARE|MEDICARE,standard_charge|AETNA_MEDICARE|MEDICARE|methodology,additional_payer_notes|AETNA_MEDICARE|MEDICARE,standard_charge|CARESOURCE_MEDICAID|MEDICAID|negotiated_dollar,standard_charge|CARESOURCE_MEDICAID|MEDICAID|negotiated_percentage,standard_charge|CARESOURCE_MEDICAID|MEDICAID|negotiated_algorithm,estimated_amount|CARESOURCE_MEDICAID|MEDICAID,standard_charge|CARESOURCE_MEDICAID|MEDICAID|methodology,additional_payer_notes|CARESOURCE_MEDICAID|MEDICAID,standard_charge|CARESOURCE_WV_MARKETPLACE|MEDICARE|negotiated_dollar,standard_charge|CARESOURCE_WV_MARKETPLACE|MEDICARE|negotiated_percentage,standard_charge|CARESOURCE_WV_MARKETPLACE|MEDICARE|negotiated_algorithm,estimated_amount|CARESOURCE_WV_MARKETPLACE|MEDICARE,standard_charge|CARESOURCE_WV_MARKETPLACE|MEDICARE|methodology,additional_payer_notes|CARESOURCE_WV_MARKETPLACE|MEDICARE,standard_charge|CHIP|COMMERCIAL|negotiated_dollar,standard_charge|CHIP|COMMERCIAL|negotiated_percentage,standard_charge|CHIP|COMMERCIAL|negotiated_algorithm,estimated_amount|CHIP|COMMERCIAL,standard_charge|CHIP|COMMERCIAL|methodology,additional_payer_notes|CHIP|COMMERCIAL,standard_charge|HIGHMARK_ACA|MEDICARE|negotiated_dollar,standard_charge|HIGHMARK_ACA|MEDICARE|negotiated_percentage,standard_charge|HIGHMARK_ACA|MEDICARE|negotiated_algorithm,estimated_amount|HIGHMARK_ACA|MEDICARE,standard_charge|HIGHMARK_ACA|MEDICARE|methodology,additional_payer_notes|HIGHMARK_ACA|MEDICARE,standard_charge|HIGHMARK_PPO_POS_FEP|MEDICARE|negotiated_dollar,standard_charge|HIGHMARK_PPO_POS_FEP|MEDICARE|negotiated_percentage,standard_charge|HIGHMARK_PPO_POS_FEP|MEDICARE|negotiated_algorithm,estimated_amount|HIGHMARK_PPO_POS_FEP|MEDICARE,standard_charge|HIGHMARK_PPO_POS_FEP|MEDICARE|methodology,additional_payer_notes|HIGHMARK_PPO_POS_FEP|MEDICARE,standard_charge|HIGHMARK_TRADITIONAL|MEDICARE|negotiated_dollar,standard_charge|HIGHMARK_TRADITIONAL|MEDICARE|negotiated_percentage,standard_charge|HIGHMARK_TRADITIONAL|MEDICARE|negotiated_algorithm,estimated_amount|HIGHMARK_TRADITIONAL|MEDICARE,standard_charge|HIGHMARK_TRADITIONAL|MEDICARE|methodology,additional_payer_notes|HIGHMARK_TRADITIONAL|MEDICARE,standard_charge|MEDICAID|MEDICAID|negotiated_dollar,standard_charge|MEDICAID|MEDICAID|negotiated_percentage,standard_charge|MEDICAID|MEDICAID|negotiated_algorithm,estimated_amount|MEDICAID|MEDICAID,standard_charge|MEDICAID|MEDICAID|methodology,additional_payer_notes|MEDICAID|MEDICAID,standard_charge|MEDICARE|MEDICARE|negotiated_dollar,standard_charge|MEDICARE|MEDICARE|negotiated_percentage,standard_charge|MEDICARE|MEDICARE|negotiated_algorithm,estimated_amount|MEDICARE|MEDICARE,standard_charge|MEDICARE|MEDICARE|methodology,additional_payer_notes|MEDICARE|MEDICARE,standard_charge|PEIA|COMMERCIAL|negotiated_dollar,standard_charge|PEIA|COMMERCIAL|negotiated_percentage,standard_charge|PEIA|COMMERCIAL|negotiated_algorithm,estimated_amount|PEIA|COMMERCIAL,standard_charge|PEIA|COMMERCIAL|methodology,additional_payer_notes|PEIA|COMMERCIAL,standard_charge|THE_HEALTH_PLAN_COMMERCIAL|COMMERCIAL|negotiated_dollar,standard_charge|THE_HEALTH_PLAN_COMMERCIAL|COMMERCIAL|negotiated_percentage,standard_charge|THE_HEALTH_PLAN_COMMERCIAL|COMMERCIAL|negotiated_algorithm,estimated_amount|THE_HEALTH_PLAN_COMMERCIAL|COMMERCIAL,standard_charge|THE_HEALTH_PLAN_COMMERCIAL|COMMERCIAL|methodology,additional_payer_notes|THE_HEALTH_PLAN_COMMERCIAL|COMMERCIAL,standard_charge|min,standard_charge|max,additional_generic_notes
10004 - PF Fine Needle Aspiration Bx w/o Imaging Guidance Each Additional Lesion,4315547,CDM,960,RC,10004,HCPCS,Outpatient,,,89.1,44.55,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
"10005 - Fine needle aspiration biopsy, including ultrasound",3572795,CDM,510,RC,10005,HCPCS,Outpatient,,,348.93,174.47,,261.7,75,,,percent of total billed charges,75% of total billed charges,261.7,75,,,percent of total billed charges,75% of total billed charges,610.13,100,,,Fee Schedule,100% of CMS OPPS Rate,254,102,,,Fee Schedule,102% of WV Medicaid Rate,1006.72,165,,,Fee Schedule,165% of CMS OPPS Rate,632.35,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1752.53,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2403.46,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,3010.58,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,249.02,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,610.13,100,,,Fee Schedule,100% of CMS OPPS Rate,632.35,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,48.85,14,,,percent of total billed charges,14% of total billed charges,48.85,3010.58,
10005-PF FINE NEEDLE ASPIRATION BX W/US GDN 1ST LESION,4321298,CDM,981,RC,10005,HCPCS,Outpatient,,,145.6,72.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
US add Needle Aspiration non breast,645160,CDM,320,RC,10005,HCPCS,Outpatient,,,338.88,169.44,,254.16,75,,,percent of total billed charges,75% of total billed charges,254.16,75,,,percent of total billed charges,75% of total billed charges,610.13,100,,,Fee Schedule,100% of CMS OPPS Rate,254,102,,,Fee Schedule,102% of WV Medicaid Rate,1006.72,165,,,Fee Schedule,165% of CMS OPPS Rate,632.35,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1752.53,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2403.46,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,3010.58,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,249.02,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,610.13,100,,,Fee Schedule,100% of CMS OPPS Rate,632.35,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,47.44,14,,,percent of total billed charges,14% of total billed charges,47.44,3010.58,
10006-MSA FNA BIOPSY W/ ULTSND GD ADD LES,3428647,CDM,361,RC,10006,HCPCS,Outpatient,,,156.74,78.37,,117.56,75,,,percent of total billed charges,75% of total billed charges,117.56,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.94,14,,,percent of total billed charges,14% of total billed charges,21.94,117.56,
US add Needle Asp non breast each add,3348377,CDM,320,RC,10006,HCPCS,Outpatient,,,154.47,77.24,,115.85,75,,,percent of total billed charges,75% of total billed charges,115.85,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.63,14,,,percent of total billed charges,14% of total billed charges,21.63,115.85,
10007- PF FNA Bx w/ Fluoro Gdn 1st Lsn,4347140,CDM,960,RC,10007,HCPCS,Outpatient,,,183.1,91.55,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
10007-MSA FNA BIOPSY W/ FLUORO GD 1ST LES,3428648,CDM,361,RC,10007,HCPCS,Outpatient,,,183.1,91.55,,137.33,75,,,percent of total billed charges,75% of total billed charges,137.33,75,,,percent of total billed charges,75% of total billed charges,610.13,100,,,Fee Schedule,100% of CMS OPPS Rate,191.36,102,,,Fee Schedule,102% of WV Medicaid Rate,1006.72,165,,,Fee Schedule,165% of CMS OPPS Rate,632.35,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1752.53,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2403.46,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,3010.58,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,187.61,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,610.13,100,,,Fee Schedule,100% of CMS OPPS Rate,632.35,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,25.63,14,,,percent of total billed charges,14% of total billed charges,25.63,3010.58,
DR Fluoro Fine Needle Aspiration/Bx,3348363,CDM,361,RC,10007,HCPCS,Outpatient,,,183.1,91.55,,137.33,75,,,percent of total billed charges,75% of total billed charges,137.33,75,,,percent of total billed charges,75% of total billed charges,610.13,100,,,Fee Schedule,100% of CMS OPPS Rate,191.36,102,,,Fee Schedule,102% of WV Medicaid Rate,1006.72,165,,,Fee Schedule,165% of CMS OPPS Rate,632.35,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1752.53,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2403.46,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,3010.58,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,187.61,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,610.13,100,,,Fee Schedule,100% of CMS OPPS Rate,632.35,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,25.63,14,,,percent of total billed charges,14% of total billed charges,25.63,3010.58,
10008- PF FNA Bx w/ Fluoro Gdn Ea Addl,4347141,CDM,960,RC,10008,HCPCS,Outpatient,,,107.17,53.59,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
10008-MSA FNA BIOPSY W/ FLUORO GD ADD LES,3428649,CDM,361,RC,10008,HCPCS,Outpatient,,,107.17,53.59,,80.38,75,,,percent of total billed charges,75% of total billed charges,80.38,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15,14,,,percent of total billed charges,14% of total billed charges,15,80.38,
10009-MSA FNA BIOPSY W/ CT GD 1ST LESION,3428650,CDM,361,RC,10009,HCPCS,Outpatient,,,1045.83,522.92,,784.37,75,,,percent of total billed charges,75% of total billed charges,784.37,75,,,percent of total billed charges,75% of total billed charges,610.13,100,,,Fee Schedule,100% of CMS OPPS Rate,254,102,,,Fee Schedule,102% of WV Medicaid Rate,1006.72,165,,,Fee Schedule,165% of CMS OPPS Rate,632.35,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1752.53,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2403.46,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,3010.58,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,249.02,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,610.13,100,,,Fee Schedule,100% of CMS OPPS Rate,632.35,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,146.42,14,,,percent of total billed charges,14% of total billed charges,146.42,3010.58,
10010-MSA FNA BIOPSY W/ CT GD ADD LESION,3428651,CDM,361,RC,10010,HCPCS,Outpatient,,,580.65,290.33,,435.49,75,,,percent of total billed charges,75% of total billed charges,435.49,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.29,14,,,percent of total billed charges,14% of total billed charges,81.29,435.49,
10021- Fine needle asp w/o image guide,3431472,CDM,761,RC,10021,HCPCS,Outpatient,,,111.98,55.99,,83.99,75,,,percent of total billed charges,75% of total billed charges,83.99,75,,,percent of total billed charges,75% of total billed charges,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,51.05,102,,,Fee Schedule,102% of WV Medicaid Rate,578.72,165,,,Fee Schedule,165% of CMS OPPS Rate,363.51,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1007.47,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1381.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1730.67,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,50.05,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,363.51,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,15.68,14,,,percent of total billed charges,14% of total billed charges,15.68,1730.67,
10021-PF FINE NEEDLE ASPIRATION BX W/O IMG GDN 1ST LESION,4321299,CDM,981,RC,10021,HCPCS,Outpatient,,,111.98,55.99,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
Read,3370903,CDM,972,RC,10021,HCPCS,Outpatient,,,111.98,55.99,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
Read,3370905,CDM,972,RC,10021,HCPCS,Outpatient,,,111.98,55.99,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
10030 I&D Abscess,3428313,CDM,983,RC,10030,HCPCS,Outpatient,,,274.03,137.02,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
CT Drainage Soft Tissue,3319651,CDM,350,RC,10030,HCPCS,Outpatient,,,274.03,137.02,,205.52,75,,,percent of total billed charges,75% of total billed charges,205.52,75,,,percent of total billed charges,75% of total billed charges,610.13,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1006.72,165,,,Fee Schedule,165% of CMS OPPS Rate,632.35,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1752.53,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2403.46,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,3010.58,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,610.13,100,,,Fee Schedule,100% of CMS OPPS Rate,632.35,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,38.36,14,,,percent of total billed charges,14% of total billed charges,38.36,3010.58,
Read,4181182,CDM,972,RC,10030,HCPCS,Outpatient,,,274.03,137.02,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
"10035 Placement of soft tissue localization device(s) (eg, clip, metallic pellet, wire/needle, radio",3621199,CDM,510,RC,10035,HCPCS,Outpatient,,,926.11,463.06,,694.58,75,,,percent of total billed charges,75% of total billed charges,694.58,75,,,percent of total billed charges,75% of total billed charges,610.13,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1006.72,165,,,Fee Schedule,165% of CMS OPPS Rate,632.35,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1752.53,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2403.46,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,3010.58,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,610.13,100,,,Fee Schedule,100% of CMS OPPS Rate,632.35,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,129.66,14,,,percent of total billed charges,14% of total billed charges,129.66,3010.58,
10040- Acne surgery,3431474,CDM,761,RC,10040,HCPCS,Outpatient,,,287.12,143.56,,215.34,75,,,percent of total billed charges,75% of total billed charges,215.34,75,,,percent of total billed charges,75% of total billed charges,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,280.12,165,,,Fee Schedule,165% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,487.65,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,668.78,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,837.71,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,40.2,14,,,percent of total billed charges,14% of total billed charges,40.2,837.71,
10060- Abscess/simple/single/I  & D,3431475,CDM,761,RC,10060,HCPCS,Outpatient,,,208.61,104.31,,156.46,75,,,percent of total billed charges,75% of total billed charges,156.46,75,,,percent of total billed charges,75% of total billed charges,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,64.15,102,,,Fee Schedule,102% of WV Medicaid Rate,280.12,165,,,Fee Schedule,165% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,487.65,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,668.77,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,837.71,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,62.89,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,29.21,14,,,percent of total billed charges,14% of total billed charges,29.21,837.71,
"10060- Incision and Drainage, Simple",3428468,CDM,761,RC,10060,HCPCS,Outpatient,,,1010.98,505.49,,758.24,75,,,percent of total billed charges,75% of total billed charges,758.24,75,,,percent of total billed charges,75% of total billed charges,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,64.15,102,,,Fee Schedule,102% of WV Medicaid Rate,280.12,165,,,Fee Schedule,165% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,487.65,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,668.77,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,837.71,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,62.89,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,141.54,14,,,percent of total billed charges,14% of total billed charges,62.89,837.71,
"10060- PF Incision and Drainage, Simple",4311917,CDM,960,RC,10060,HCPCS,Outpatient,,,208.61,104.31,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
10060-PF INCISION & DRAINAGE ABSCESS SIMPLE/SINGLE,4321292,CDM,981,RC,10060,HCPCS,Outpatient,,,208.61,104.31,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
"10061- I&D ,Abscess, Complex or S",3428656,CDM,761,RC,10061,HCPCS,Outpatient,,,366.63,183.32,,274.97,75,,,percent of total billed charges,75% of total billed charges,274.97,75,,,percent of total billed charges,75% of total billed charges,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,96.91,102,,,Fee Schedule,102% of WV Medicaid Rate,578.72,165,,,Fee Schedule,165% of CMS OPPS Rate,363.51,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1007.47,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1381.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1730.67,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,95.01,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,363.51,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,51.33,14,,,percent of total billed charges,14% of total billed charges,51.33,1730.67,
"10061- PF Incision and Drainage, Complex",4311918,CDM,960,RC,10061,HCPCS,Outpatient,,,366.63,183.32,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
10061-PF INCISION & DRAINAGE ABSCESS COMPLICATED/MULTIPLE,4321293,CDM,981,RC,10061,HCPCS,Outpatient,,,366.63,183.32,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
"10080- Incision and Drainage( IND) Pilonidal Cyst, Simple",3428657,CDM,510,RC,10080,HCPCS,Outpatient,,,208.5,104.25,,156.38,75,,,percent of total billed charges,75% of total billed charges,156.38,75,,,percent of total billed charges,75% of total billed charges,610.13,100,,,Fee Schedule,100% of CMS OPPS Rate,171.71,102,,,Fee Schedule,102% of WV Medicaid Rate,1006.72,165,,,Fee Schedule,165% of CMS OPPS Rate,632.35,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1752.53,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2403.46,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,3010.58,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,168.34,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,610.13,100,,,Fee Schedule,100% of CMS OPPS Rate,632.35,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,29.19,14,,,percent of total billed charges,14% of total billed charges,29.19,3010.58,
10080-PF INCISION & DRAINAGE PILONIDAL CYST SIMPLE,4321294,CDM,981,RC,10080,HCPCS,Outpatient,,,208.5,104.25,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
10081- I & D/pilonidal cyst/complicated,3431476,CDM,761,RC,10081,HCPCS,Outpatient,,,347.49,173.75,,260.62,75,,,percent of total billed charges,75% of total billed charges,260.62,75,,,percent of total billed charges,75% of total billed charges,610.13,100,,,Fee Schedule,100% of CMS OPPS Rate,206.38,102,,,Fee Schedule,102% of WV Medicaid Rate,1006.72,165,,,Fee Schedule,165% of CMS OPPS Rate,632.35,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1752.53,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2403.46,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,3010.58,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,202.33,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,610.13,100,,,Fee Schedule,100% of CMS OPPS Rate,632.35,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,48.65,14,,,percent of total billed charges,14% of total billed charges,48.65,3010.58,
10081-PF INCISION & DRAINAGE PILONIDAL CYST COMPLICATED,4321295,CDM,981,RC,10081,HCPCS,Outpatient,,,347.49,173.75,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
10120 - PF I&D Foreighn Body Subq Tiss Simple,4311464,CDM,960,RC,10120,HCPCS,Outpatient,,,207.48,103.74,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
10120- Incision/rmv FB/SQ tis/simple,3431477,CDM,761,RC,10120,HCPCS,Outpatient,,,207.48,103.74,,155.61,75,,,percent of total billed charges,75% of total billed charges,155.61,75,,,percent of total billed charges,75% of total billed charges,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,85.17,102,,,Fee Schedule,102% of WV Medicaid Rate,578.72,165,,,Fee Schedule,165% of CMS OPPS Rate,363.51,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1007.47,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1381.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1730.67,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,83.5,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,363.51,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,29.05,14,,,percent of total billed charges,14% of total billed charges,29.05,1730.67,
10120-PF INCISION & REMOVAL FOREIGN BODY SUBQ TISS SIMPLE,4321296,CDM,981,RC,10120,HCPCS,Outpatient,,,207.48,103.74,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
10121- Incision/rmv FB/SQ tis/complicat,3431478,CDM,761,RC,10121,HCPCS,Outpatient,,,369.64,184.82,,277.23,75,,,percent of total billed charges,75% of total billed charges,277.23,75,,,percent of total billed charges,75% of total billed charges,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,479.67,102,,,Fee Schedule,102% of WV Medicaid Rate,2326.19,165,,,Fee Schedule,165% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4049.52,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5553.61,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6956.46,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,470.26,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,51.75,14,,,percent of total billed charges,14% of total billed charges,51.75,6956.46,
10121-PF INCISION & REMOVAL FOREIGN BODY SUBQ TISS COMPL,4321297,CDM,981,RC,10121,HCPCS,Outpatient,,,369.64,184.82,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
10140 - PF Incision and Drainage Hematoma Seroma/Fluid Collection,4333236,CDM,960,RC,10140,HCPCS,Outpatient,,,235.62,117.81,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
"10140- Incision and Drainage of hematoma, seroma or fluid collection",4346598,CDM,510,RC,10140,HCPCS,Outpatient,,,235.62,117.81,,176.72,75,,,percent of total billed charges,75% of total billed charges,176.72,75,,,percent of total billed charges,75% of total billed charges,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,89.55,102,,,Fee Schedule,102% of WV Medicaid Rate,2326.19,165,,,Fee Schedule,165% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4049.52,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5553.61,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6956.46,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,87.79,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,32.99,14,,,percent of total billed charges,14% of total billed charges,32.99,6956.46,
10140-Defibrillation Hematoma Evacuation,3431745,CDM,360,RC,10140,HCPCS,Outpatient,,,235.62,117.81,,176.72,75,,,percent of total billed charges,75% of total billed charges,176.72,75,,,percent of total billed charges,75% of total billed charges,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,89.55,102,,,Fee Schedule,102% of WV Medicaid Rate,2326.19,165,,,Fee Schedule,165% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4049.52,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5553.61,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6956.46,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,87.79,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,32.99,14,,,percent of total billed charges,14% of total billed charges,32.99,6956.46,
10140-Pacemaker Hematoma Evacuation,3431746,CDM,481,RC,10140,HCPCS,Outpatient,,,235.62,117.81,,176.72,75,,,percent of total billed charges,75% of total billed charges,176.72,75,,,percent of total billed charges,75% of total billed charges,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,89.55,102,,,Fee Schedule,102% of WV Medicaid Rate,2326.19,165,,,Fee Schedule,165% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4049.52,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5553.61,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6956.46,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,87.79,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,32.99,14,,,percent of total billed charges,14% of total billed charges,32.99,6956.46,
10140-PF I&D HEMATOMA SEROMA/FLUID COLLECTION,4321301,CDM,981,RC,10140,HCPCS,Outpatient,,,235.62,117.81,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
Defibrillation Hematoma Evacuation,3427152,CDM,960,RC,10140,HCPCS,Outpatient,,,235.62,117.81,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
Nail Bed Hematoma Evacuation,3428487,CDM,761,RC,10140,HCPCS,Outpatient,,,235.62,117.81,,176.72,75,,,percent of total billed charges,75% of total billed charges,176.72,75,,,percent of total billed charges,75% of total billed charges,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,89.55,102,,,Fee Schedule,102% of WV Medicaid Rate,2326.19,165,,,Fee Schedule,165% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4049.52,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5553.61,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6956.46,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,87.79,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,32.99,14,,,percent of total billed charges,14% of total billed charges,32.99,6956.46,
Pacemaker Hematoma Evacuation,,,761,RC,10140,HCPCS,Outpatient,,,235.62,117.81,,176.72,75,,,percent of total billed charges,75% of total billed charges,176.72,75,,,percent of total billed charges,75% of total billed charges,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,89.55,102,,,Fee Schedule,102% of WV Medicaid Rate,2326.19,165,,,Fee Schedule,165% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4049.52,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5553.61,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6956.46,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,87.79,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,32.99,14,,,percent of total billed charges,14% of total billed charges,32.99,6956.46,
10160- Punc asp/abscess/hema/bulla/cyst,3428658,CDM,761,RC,10160,HCPCS,Outpatient,,,191.33,95.67,,143.5,75,,,percent of total billed charges,75% of total billed charges,143.5,75,,,percent of total billed charges,75% of total billed charges,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,66.88,102,,,Fee Schedule,102% of WV Medicaid Rate,578.72,165,,,Fee Schedule,165% of CMS OPPS Rate,363.51,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1007.47,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1381.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1730.67,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,65.57,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,363.51,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,26.79,14,,,percent of total billed charges,14% of total billed charges,26.79,1730.67,
10160-PF PUNCTURE ASPIRATION ABSCESS HEMATOMA BULLA/CYST,4321303,CDM,981,RC,10160,HCPCS,Outpatient,,,191.33,95.67,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
CT add Perc Aspiration or abscess,645108,CDM,360,RC,10160,HCPCS,Outpatient,,,323.12,161.56,,242.34,75,,,percent of total billed charges,75% of total billed charges,242.34,75,,,percent of total billed charges,75% of total billed charges,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,66.88,102,,,Fee Schedule,102% of WV Medicaid Rate,578.72,165,,,Fee Schedule,165% of CMS OPPS Rate,363.51,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1007.47,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1381.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1730.67,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,65.57,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,363.51,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,45.24,14,,,percent of total billed charges,14% of total billed charges,45.24,1730.67,
Read,4181226,CDM,972,RC,10160,HCPCS,Outpatient,,,191.33,95.67,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
10180 - PF I&D Comple PO Wound Infection,4311465,CDM,960,RC,10180,HCPCS,Outpatient,,,361.23,180.62,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
"10180- Incision and Drainage, Compex post-op wound infection",4346593,CDM,510,RC,10180,HCPCS,Outpatient,,,361.23,180.62,,270.92,75,,,percent of total billed charges,75% of total billed charges,270.92,75,,,percent of total billed charges,75% of total billed charges,2428.67,100,,,Fee Schedule,100% of CMS OPPS Rate,803.83,102,,,Fee Schedule,102% of WV Medicaid Rate,4007.32,165,,,Fee Schedule,165% of CMS OPPS Rate,2517.11,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,6976.06,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,9567.11,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,11983.78,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,788.07,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2428.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2517.11,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,50.57,14,,,percent of total billed charges,14% of total billed charges,50.57,11983.78,
10180- Postop wound infection/complex/I&D,3431479,CDM,761,RC,10180,HCPCS,Outpatient,,,361.23,180.62,,270.92,75,,,percent of total billed charges,75% of total billed charges,270.92,75,,,percent of total billed charges,75% of total billed charges,2428.67,100,,,Fee Schedule,100% of CMS OPPS Rate,803.83,102,,,Fee Schedule,102% of WV Medicaid Rate,4007.32,165,,,Fee Schedule,165% of CMS OPPS Rate,2517.11,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,6976.06,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,9567.11,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,11983.78,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,788.07,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2428.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2517.11,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,50.57,14,,,percent of total billed charges,14% of total billed charges,50.57,11983.78,
10180-PF 10140-PF INCISION & DRAINAGE COMPLEX PO WOUND INFECTION,4321305,CDM,981,RC,10180,HCPCS,Outpatient,,,361.23,180.62,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
11000- Debrid ecz/inf skin up tp 10% body,3428659,CDM,510,RC,11000,HCPCS,Outpatient,,,56.46,28.23,,42.35,75,,,percent of total billed charges,75% of total billed charges,42.35,75,,,percent of total billed charges,75% of total billed charges,546.17,100,,,Fee Schedule,100% of CMS OPPS Rate,29.48,102,,,Fee Schedule,102% of WV Medicaid Rate,901.2,165,,,Fee Schedule,165% of CMS OPPS Rate,566.07,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1568.84,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2151.55,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,2695.04,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,28.9,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,546.17,100,,,Fee Schedule,100% of CMS OPPS Rate,566.07,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,7.9,14,,,percent of total billed charges,14% of total billed charges,7.9,2695.04,
11000-PF DBRDMT EXTENSV ECZEMA/INFECT SKN UP 10% BDY SURF,4321307,CDM,981,RC,11000,HCPCS,Outpatient,,,56.46,28.23,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
11001 - DBRDMT EXTNSVE ECZEMA/INFECT SKN EA 10% BDY SURF,4037472,CDM,510,RC,11001,HCPCS,Outpatient,,,30.19,15.1,,22.64,75,,,percent of total billed charges,75% of total billed charges,22.64,75,,,percent of total billed charges,75% of total billed charges,9.66,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.23,14,,,percent of total billed charges,14% of total billed charges,4.23,22.64,
11001-PF DBRDMT EXTNSVE ECZEMA/INFECT SKN EA 10% BDY SURF,4321308,CDM,981,RC,11001,HCPCS,Outpatient,,,30.19,15.1,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
11004- Debride skn/sq/musc/ext genit/peri,3431480,CDM,510,RC,11004,HCPCS,Outpatient,,,1530.74,765.37,,1148.06,75,,,percent of total billed charges,75% of total billed charges,1148.06,75,,,percent of total billed charges,75% of total billed charges,1530.74,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,1530.74,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1530.74,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1530.74,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1530.74,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1530.74,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,1530.74,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1530.74,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,214.3,14,,,percent of total billed charges,14% of total billed charges,214.3,1530.74,
11004-PF DBRDMT SKN SUBQ T/M/F NECRO INFCTJ GENT&PR,4321300,CDM,981,RC,11004,HCPCS,Outpatient,,,1179.14,589.57,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
11005- Debride skn/sq/musc/abd wall,3431481,CDM,510,RC,11005,HCPCS,Outpatient,,,2101.66,1050.83,,1576.25,75,,,percent of total billed charges,75% of total billed charges,1576.25,75,,,percent of total billed charges,75% of total billed charges,2101.66,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,2101.66,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2101.66,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2101.66,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2101.66,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2101.66,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,2101.66,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2101.66,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,294.23,14,,,percent of total billed charges,14% of total billed charges,294.23,2101.66,
11006 - Dbrdmnt skn subq T/M/F necro infct gent/abdl,4241823,CDM,983,RC,11006,HCPCS,Outpatient,,,1491.21,745.61,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
11008 - PF Remove Prosth Matrl Abdl Wall for Infection,4311466,CDM,960,RC,11008,HCPCS,Outpatient,,,654.65,327.33,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
11008- Rmv prosth mat/mesh/abd wall/infec,3431482,CDM,510,RC,11008,HCPCS,Outpatient,,,741.69,370.85,,556.27,75,,,percent of total billed charges,75% of total billed charges,556.27,75,,,percent of total billed charges,75% of total billed charges,741.69,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,741.69,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,741.69,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,741.69,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,741.69,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,741.69,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,741.69,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,741.69,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,103.84,14,,,percent of total billed charges,14% of total billed charges,103.84,741.69,
11010-PFDBRDMT W/RMVL FM FX&/DISLC SKIN&SUBQ TISSUS,4321309,CDM,981,RC,11010,HCPCS,Outpatient,,,539.82,269.91,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
Debridement with Fracture or Dislocation,3428413,CDM,981,RC,11010,HCPCS,Outpatient,,,1150.82,575.41,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
11011- Debride/rmv FB/open fx/skin/sq/mus,3431484,CDM,510,RC,11011,HCPCS,Outpatient,,,610.39,305.2,,457.79,75,,,percent of total billed charges,75% of total billed charges,457.79,75,,,percent of total billed charges,75% of total billed charges,610.13,100,,,Fee Schedule,100% of CMS OPPS Rate,254,102,,,Fee Schedule,102% of WV Medicaid Rate,1006.72,165,,,Fee Schedule,165% of CMS OPPS Rate,632.35,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1752.53,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2403.46,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,3010.58,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,249.02,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,610.13,100,,,Fee Schedule,100% of CMS OPPS Rate,632.35,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,85.45,14,,,percent of total billed charges,14% of total billed charges,85.45,3010.58,
11011-PF DBRDMT W/RMVL FM FX&/DISLC SKN SUBQ T/M/F MUSC,4321311,CDM,981,RC,11011,HCPCS,Outpatient,,,610.39,305.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
"11012- Debride Skin/Muscle/Bone, FX",3428666,CDM,510,RC,11012,HCPCS,Outpatient,,,1661.66,830.83,,1246.25,75,,,percent of total billed charges,75% of total billed charges,1246.25,75,,,percent of total billed charges,75% of total billed charges,2428.67,100,,,Fee Schedule,100% of CMS OPPS Rate,803.83,102,,,Fee Schedule,102% of WV Medicaid Rate,4007.32,165,,,Fee Schedule,165% of CMS OPPS Rate,2517.11,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,6976.06,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,9567.11,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,11983.78,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,788.07,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2428.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2517.11,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,232.63,14,,,percent of total billed charges,14% of total billed charges,232.63,11983.78,
11012-PF DBRDMT FX&/DISLC SUBQ T/M/F BONE,4321313,CDM,981,RC,11012,HCPCS,Outpatient,,,821.06,410.53,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
11042 - PF Deb Subq Tiss 20 sq cm/ <,4311467,CDM,960,RC,11042,HCPCS,Outpatient,,,122.24,61.12,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
11042-DEB SUBQ Tissue 20 SQ CM/<,3574980,CDM,510,RC,11042,HCPCS,Outpatient,,,122.24,61.12,,91.68,75,,,percent of total billed charges,75% of total billed charges,91.68,75,,,percent of total billed charges,75% of total billed charges,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,141.09,102,,,Fee Schedule,102% of WV Medicaid Rate,578.72,165,,,Fee Schedule,165% of CMS OPPS Rate,363.51,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1007.47,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1381.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1730.67,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,138.32,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,363.51,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,17.11,14,,,percent of total billed charges,14% of total billed charges,17.11,1730.67,
11042-PF DEBRIDEMENT SUBCUTANEOUS TISSUE 20 SQ CM/<,4321315,CDM,981,RC,11042,HCPCS,Outpatient,,,122.24,61.12,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
11043 Deb Musc Fascia 20 Sq Cm less than,3572727,CDM,510,RC,11043,HCPCS,Outpatient,,,313,156.5,,234.75,75,,,percent of total billed charges,75% of total billed charges,234.75,75,,,percent of total billed charges,75% of total billed charges,546.17,100,,,Fee Schedule,100% of CMS OPPS Rate,213.77,102,,,Fee Schedule,102% of WV Medicaid Rate,901.2,165,,,Fee Schedule,165% of CMS OPPS Rate,566.07,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1568.84,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2151.55,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,2695.04,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,209.58,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,546.17,100,,,Fee Schedule,100% of CMS OPPS Rate,566.07,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,43.82,14,,,percent of total billed charges,14% of total billed charges,43.82,2695.04,
11043-PF DEBRIDEMENT MUSCLE & FASCIA 20 SQ CM/,4321317,CDM,981,RC,11043,HCPCS,Outpatient,,,313,156.5,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
"11044 Debridement, bone (includes epidermis, dermis, subcutaneous tissue, muscle and/or fascia, if p",3621458,CDM,510,RC,11044,HCPCS,Outpatient,,,462.97,231.49,,347.23,75,,,percent of total billed charges,75% of total billed charges,347.23,75,,,percent of total billed charges,75% of total billed charges,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,479.67,102,,,Fee Schedule,102% of WV Medicaid Rate,2326.19,165,,,Fee Schedule,165% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4049.52,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5553.61,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6956.46,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,470.26,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,64.82,14,,,percent of total billed charges,14% of total billed charges,64.82,6956.46,
11044-PF DEBRIDEMENT BONE MUSCLE &/FASCIA 20 SQ CM/<,4321319,CDM,981,RC,11044,HCPCS,Outpatient,,,462.97,231.49,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
11045 Debride subq tiss ea add 20sq cm,3570187,CDM,510,RC,11045,HCPCS,Outpatient,,,52.28,26.14,,39.21,75,,,percent of total billed charges,75% of total billed charges,39.21,75,,,percent of total billed charges,75% of total billed charges,16.73,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.32,14,,,percent of total billed charges,14% of total billed charges,7.32,39.21,
11045-PF DBRDMT SUBCUTANEOUS TISSUE EA ADDL 20 SQ CM,4321302,CDM,981,RC,11045,HCPCS,Outpatient,,,52.28,26.14,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
11046 Deb Mus Fasica Add On,3550404,CDM,510,RC,11046,HCPCS,Outpatient,,,113.61,56.81,,85.21,75,,,percent of total billed charges,75% of total billed charges,85.21,75,,,percent of total billed charges,75% of total billed charges,36.36,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.91,14,,,percent of total billed charges,14% of total billed charges,15.91,85.21,
11047- Debridement/bone/ea add 20 sq cm,3431488,CDM,761,RC,11047,HCPCS,Outpatient,,,201.02,100.51,,150.77,75,,,percent of total billed charges,75% of total billed charges,150.77,75,,,percent of total billed charges,75% of total billed charges,64.33,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.14,14,,,percent of total billed charges,14% of total billed charges,28.14,150.77,
11055- Trim hyperkeratotic lesion/sng,3431489,CDM,761,RC,11055,HCPCS,Outpatient,,,31.86,15.93,,23.9,75,,,percent of total billed charges,75% of total billed charges,23.9,75,,,percent of total billed charges,75% of total billed charges,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,280.12,165,,,Fee Schedule,165% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,487.65,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,668.78,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,837.71,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4.46,14,,,percent of total billed charges,14% of total billed charges,4.46,837.71,
11056- Trim hyperkeratotic lesion/2-4,3431490,CDM,761,RC,11056,HCPCS,Outpatient,,,44.99,22.5,,33.74,75,,,percent of total billed charges,75% of total billed charges,33.74,75,,,percent of total billed charges,75% of total billed charges,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,280.12,165,,,Fee Schedule,165% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,487.65,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,668.78,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,837.71,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,6.3,14,,,percent of total billed charges,14% of total billed charges,6.3,837.71,
11057- Trim hyperkeratotic lesion/>4,3431491,CDM,761,RC,11057,HCPCS,Outpatient,,,58.72,29.36,,44.04,75,,,percent of total billed charges,75% of total billed charges,44.04,75,,,percent of total billed charges,75% of total billed charges,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,54.87,102,,,Fee Schedule,102% of WV Medicaid Rate,280.12,165,,,Fee Schedule,165% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,487.65,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,668.77,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,837.71,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,53.79,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8.22,14,,,percent of total billed charges,14% of total billed charges,8.22,837.71,
11102 Shave Biopsy,3428674,CDM,761,RC,11102,HCPCS,Outpatient,,,75.62,37.81,,56.72,75,,,percent of total billed charges,75% of total billed charges,56.72,75,,,percent of total billed charges,75% of total billed charges,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,63.33,102,,,Fee Schedule,102% of WV Medicaid Rate,280.12,165,,,Fee Schedule,165% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,487.65,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,668.77,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,837.71,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,62.09,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,10.59,14,,,percent of total billed charges,14% of total billed charges,10.59,837.71,
11103 Additional Shave Biopsy,3428675,CDM,761,RC,11103,HCPCS,Outpatient,,,43.84,21.92,,32.88,75,,,percent of total billed charges,75% of total billed charges,32.88,75,,,percent of total billed charges,75% of total billed charges,14.03,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.14,14,,,percent of total billed charges,14% of total billed charges,6.14,32.88,
11104 Punch Biopsy with Suture,3428676,CDM,761,RC,11104,HCPCS,Outpatient,,,94.4,47.2,,70.8,75,,,percent of total billed charges,75% of total billed charges,70.8,75,,,percent of total billed charges,75% of total billed charges,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,78.36,102,,,Fee Schedule,102% of WV Medicaid Rate,578.72,165,,,Fee Schedule,165% of CMS OPPS Rate,363.51,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1007.47,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1381.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1730.67,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,76.82,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,363.51,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,13.22,14,,,percent of total billed charges,14% of total billed charges,13.22,1730.67,
11105 Add'l Punch Biospy with suture,3428677,CDM,761,RC,11105,HCPCS,Outpatient,,,51.75,25.88,,38.81,75,,,percent of total billed charges,75% of total billed charges,38.81,75,,,percent of total billed charges,75% of total billed charges,16.56,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.25,14,,,percent of total billed charges,14% of total billed charges,7.25,38.81,
11106 Wedge Biopsy with Suture,3428678,CDM,761,RC,11106,HCPCS,Outpatient,,,114.16,57.08,,85.62,75,,,percent of total billed charges,75% of total billed charges,85.62,75,,,percent of total billed charges,75% of total billed charges,546.17,100,,,Fee Schedule,100% of CMS OPPS Rate,97.45,102,,,Fee Schedule,102% of WV Medicaid Rate,901.2,165,,,Fee Schedule,165% of CMS OPPS Rate,566.07,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1568.84,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2151.55,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,2695.04,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,95.54,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,546.17,100,,,Fee Schedule,100% of CMS OPPS Rate,566.07,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,15.98,14,,,percent of total billed charges,14% of total billed charges,15.98,2695.04,
11107 Add'l Wedge Biopsy with suture,3428679,CDM,761,RC,11107,HCPCS,Outpatient,,,61.9,30.95,,46.43,75,,,percent of total billed charges,75% of total billed charges,46.43,75,,,percent of total billed charges,75% of total billed charges,19.81,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.67,14,,,percent of total billed charges,14% of total billed charges,8.67,46.43,
11200- Remove skin tags </= 15,3431493,CDM,761,RC,11200,HCPCS,Outpatient,,,149.01,74.51,,111.76,75,,,percent of total billed charges,75% of total billed charges,111.76,75,,,percent of total billed charges,75% of total billed charges,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,280.12,165,,,Fee Schedule,165% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,487.65,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,668.78,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,837.71,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,20.86,14,,,percent of total billed charges,14% of total billed charges,20.86,837.71,
11200-PF REMOVAL SKN TAGS MLT FIBRQ TAGS ANY AREA UPW/15,4321320,CDM,981,RC,11200,HCPCS,Outpatient,,,149.01,74.51,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
11201- Remove skin tags/ea add 10 lesions,3431494,CDM,761,RC,11201,HCPCS,Outpatient,,,32.48,16.24,,24.36,75,,,percent of total billed charges,75% of total billed charges,24.36,75,,,percent of total billed charges,75% of total billed charges,10.39,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.55,14,,,percent of total billed charges,14% of total billed charges,4.55,24.36,
"11300- Shave Skin Lesion,0.5Cm Or Less",3431495,CDM,761,RC,11300,HCPCS,Outpatient,,,68.48,34.24,,51.36,75,,,percent of total billed charges,75% of total billed charges,51.36,75,,,percent of total billed charges,75% of total billed charges,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,578.73,165,,,Fee Schedule,165% of CMS OPPS Rate,363.52,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1007.47,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1381.67,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1730.68,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,363.52,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,9.59,14,,,percent of total billed charges,14% of total billed charges,9.59,1730.68,
"11301- Shave Skin Lesion,0.6-1.0Cm",3431496,CDM,761,RC,11301,HCPCS,Outpatient,,,102.84,51.42,,77.13,75,,,percent of total billed charges,75% of total billed charges,77.13,75,,,percent of total billed charges,75% of total billed charges,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,280.12,165,,,Fee Schedule,165% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,487.65,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,668.78,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,837.71,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,14.4,14,,,percent of total billed charges,14% of total billed charges,14.4,837.71,
11301-PF SHVG SKIN LESION 1 TRUNK/ARM/LEG DIAM 0.6-1.0 CM,4321322,CDM,981,RC,11301,HCPCS,Outpatient,,,102.84,51.42,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
"11302- Shave Skin Lesion,1.1-2.0Cm",3431497,CDM,761,RC,11302,HCPCS,Outpatient,,,119.57,59.79,,89.68,75,,,percent of total billed charges,75% of total billed charges,89.68,75,,,percent of total billed charges,75% of total billed charges,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,280.12,165,,,Fee Schedule,165% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,487.65,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,668.78,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,837.71,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,16.74,14,,,percent of total billed charges,14% of total billed charges,16.74,837.71,
11303- Shave epi/derm sng lesion/trunk/arm/leg/>2.0cm,3431498,CDM,761,RC,11303,HCPCS,Outpatient,,,142.8,71.4,,107.1,75,,,percent of total billed charges,75% of total billed charges,107.1,75,,,percent of total billed charges,75% of total billed charges,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,578.73,165,,,Fee Schedule,165% of CMS OPPS Rate,363.52,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1007.47,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1381.67,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1730.68,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,363.52,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,19.99,14,,,percent of total billed charges,14% of total billed charges,19.99,1730.68,
"11305- Shave Skin Lesion, .5Cm Or Less",3431499,CDM,761,RC,11305,HCPCS,Outpatient,,,76.36,38.18,,57.27,75,,,percent of total billed charges,75% of total billed charges,57.27,75,,,percent of total billed charges,75% of total billed charges,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,280.12,165,,,Fee Schedule,165% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,487.65,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,668.78,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,837.71,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,10.69,14,,,percent of total billed charges,14% of total billed charges,10.69,837.71,
"11306- Shave Skin Lesion,0.6-1.0 Cm",3431500,CDM,761,RC,11306,HCPCS,Outpatient,,,98.9,49.45,,74.18,75,,,percent of total billed charges,75% of total billed charges,74.18,75,,,percent of total billed charges,75% of total billed charges,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,280.12,165,,,Fee Schedule,165% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,487.65,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,668.78,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,837.71,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,13.85,14,,,percent of total billed charges,14% of total billed charges,13.85,837.71,
"11307- Shave Skin Lesion,1.1-2.0 Cm",3431501,CDM,761,RC,11307,HCPCS,Outpatient,,,126.12,63.06,,94.59,75,,,percent of total billed charges,75% of total billed charges,94.59,75,,,percent of total billed charges,75% of total billed charges,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,73.31,102,,,Fee Schedule,102% of WV Medicaid Rate,280.12,165,,,Fee Schedule,165% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,487.65,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,668.77,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,837.71,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,71.87,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,17.66,14,,,percent of total billed charges,14% of total billed charges,17.66,837.71,
11308- Shave epi/derm sng lesion/scalp/neck/hnd/ft/genit/>2.0cm,3431502,CDM,761,RC,11308,HCPCS,Outpatient,,,142.1,71.05,,106.58,75,,,percent of total billed charges,75% of total billed charges,106.58,75,,,percent of total billed charges,75% of total billed charges,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,578.73,165,,,Fee Schedule,165% of CMS OPPS Rate,363.52,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1007.47,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1381.67,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1730.68,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,363.52,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,19.89,14,,,percent of total billed charges,14% of total billed charges,19.89,1730.68,
11310- Shave epi/derm sng lesion/face/ear/lid/nose/lip/0.5cm or <,3431503,CDM,761,RC,11310,HCPCS,Outpatient,,,91.39,45.7,,68.54,75,,,percent of total billed charges,75% of total billed charges,68.54,75,,,percent of total billed charges,75% of total billed charges,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,70.98,102,,,Fee Schedule,102% of WV Medicaid Rate,280.12,165,,,Fee Schedule,165% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,487.65,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,668.77,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,837.71,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,69.59,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,12.79,14,,,percent of total billed charges,14% of total billed charges,12.79,837.71,
11311- Shave epi/derm sng lesion/face/ear/lid/nose/lip/0.6-1.0cm,3431504,CDM,761,RC,11311,HCPCS,Outpatient,,,125.76,62.88,,94.32,75,,,percent of total billed charges,75% of total billed charges,94.32,75,,,percent of total billed charges,75% of total billed charges,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,73.31,102,,,Fee Schedule,102% of WV Medicaid Rate,280.12,165,,,Fee Schedule,165% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,487.65,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,668.77,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,837.71,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,71.87,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,17.61,14,,,percent of total billed charges,14% of total billed charges,17.61,837.71,
11312- Shave epi/derm sng lesion/face/ear/lid/nose/lip/1.1-2.0cm,3431505,CDM,761,RC,11312,HCPCS,Outpatient,,,148.68,74.34,,111.51,75,,,percent of total billed charges,75% of total billed charges,111.51,75,,,percent of total billed charges,75% of total billed charges,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,88.18,102,,,Fee Schedule,102% of WV Medicaid Rate,578.72,165,,,Fee Schedule,165% of CMS OPPS Rate,363.51,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1007.47,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1381.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1730.67,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,86.45,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,363.51,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,20.82,14,,,percent of total billed charges,14% of total billed charges,20.82,1730.67,
11313- Shave epi/derm sng lesion/face/ear/lid/nose/lip/>2.0cm,3431506,CDM,761,RC,11313,HCPCS,Outpatient,,,192.84,96.42,,144.63,75,,,percent of total billed charges,75% of total billed charges,144.63,75,,,percent of total billed charges,75% of total billed charges,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,97.19,102,,,Fee Schedule,102% of WV Medicaid Rate,578.72,165,,,Fee Schedule,165% of CMS OPPS Rate,363.51,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1007.47,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1381.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1730.67,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,95.28,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,363.51,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,27,14,,,percent of total billed charges,14% of total billed charges,27,1730.67,
11400- Exc Tr-Ext Benign+Marg 0.5 < Cm,3431507,CDM,761,RC,11400,HCPCS,Outpatient,,,165.13,82.57,,123.85,75,,,percent of total billed charges,75% of total billed charges,123.85,75,,,percent of total billed charges,75% of total billed charges,610.13,100,,,Fee Schedule,100% of CMS OPPS Rate,76.7,102,,,Fee Schedule,102% of WV Medicaid Rate,1006.72,165,,,Fee Schedule,165% of CMS OPPS Rate,632.35,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1752.53,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2403.46,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,3010.58,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,75.2,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,610.13,100,,,Fee Schedule,100% of CMS OPPS Rate,632.35,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,23.12,14,,,percent of total billed charges,14% of total billed charges,23.12,3010.58,
11400-PF EXC B9 LESION MRGN XCP SK TG T/A/L 0.5 CM/<,4321304,CDM,981,RC,11400,HCPCS,Outpatient,,,165.13,82.57,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
11401- Exc tr-ext benign+marg 0.6-1 cm,3431508,CDM,761,RC,11401,HCPCS,Outpatient,,,208.37,104.19,,156.28,75,,,percent of total billed charges,75% of total billed charges,156.28,75,,,percent of total billed charges,75% of total billed charges,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,87.9,102,,,Fee Schedule,102% of WV Medicaid Rate,578.72,165,,,Fee Schedule,165% of CMS OPPS Rate,363.51,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1007.47,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1381.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1730.67,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,86.18,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,363.51,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,29.17,14,,,percent of total billed charges,14% of total billed charges,29.17,1730.67,
11402 - PF Exc B9 Lesion Mrgn XCP SK TG T/ A/ L 1.1-2.0 cm,4311468,CDM,960,RC,11402,HCPCS,Outpatient,,,261.28,130.64,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
11402- Exc tr-ext benign+marg 1.1-2 cm,3431509,CDM,761,RC,11402,HCPCS,Outpatient,,,228.94,114.47,,171.71,75,,,percent of total billed charges,75% of total billed charges,171.71,75,,,percent of total billed charges,75% of total billed charges,610.13,100,,,Fee Schedule,100% of CMS OPPS Rate,95.28,102,,,Fee Schedule,102% of WV Medicaid Rate,1006.72,165,,,Fee Schedule,165% of CMS OPPS Rate,632.35,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1752.53,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2403.46,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,3010.58,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,93.41,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,610.13,100,,,Fee Schedule,100% of CMS OPPS Rate,632.35,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,32.05,14,,,percent of total billed charges,14% of total billed charges,32.05,3010.58,
11403 - PF Exc B9 Lesion Mrgn XCP SK TG T/ A/ L 2.1-3.0 cm,4311469,CDM,960,RC,11403,HCPCS,Outpatient,,,296.93,148.47,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
11403- Exc tr-ext bengin+marg 2.1-3cm,3431510,CDM,761,RC,11403,HCPCS,Outpatient,,,296.93,148.47,,222.7,75,,,percent of total billed charges,75% of total billed charges,222.7,75,,,percent of total billed charges,75% of total billed charges,610.13,100,,,Fee Schedule,100% of CMS OPPS Rate,103.73,102,,,Fee Schedule,102% of WV Medicaid Rate,1006.72,165,,,Fee Schedule,165% of CMS OPPS Rate,632.35,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1752.53,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2403.46,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,3010.58,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,101.7,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,610.13,100,,,Fee Schedule,100% of CMS OPPS Rate,632.35,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,41.57,14,,,percent of total billed charges,14% of total billed charges,41.57,3010.58,
11404- Exc tr-ext benign+marg 3.1-4 cm,3431511,CDM,761,RC,11404,HCPCS,Outpatient,,,329.05,164.53,,246.79,75,,,percent of total billed charges,75% of total billed charges,246.79,75,,,percent of total billed charges,75% of total billed charges,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,479.67,102,,,Fee Schedule,102% of WV Medicaid Rate,2326.19,165,,,Fee Schedule,165% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4049.52,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5553.61,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6956.46,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,470.26,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,46.07,14,,,percent of total billed charges,14% of total billed charges,46.07,6956.46,
11406 - PF Exc B9 Lesion Mrgn XCP SK TG T/ A/ L >4.0 cm,4311470,CDM,960,RC,11406,HCPCS,Outpatient,,,503.48,251.74,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
11406- Exc tr-ext bengin+marg >4.0 cm,3431512,CDM,761,RC,11406,HCPCS,Outpatient,,,503.48,251.74,,377.61,75,,,percent of total billed charges,75% of total billed charges,377.61,75,,,percent of total billed charges,75% of total billed charges,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,479.67,102,,,Fee Schedule,102% of WV Medicaid Rate,2326.19,165,,,Fee Schedule,165% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4049.52,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5553.61,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6956.46,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,470.26,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,70.49,14,,,percent of total billed charges,14% of total billed charges,70.49,6956.46,
11420- Exc h-f-nk-sp benign+marg 0.5/<,3431513,CDM,761,RC,11420,HCPCS,Outpatient,,,161.54,80.77,,121.16,75,,,percent of total billed charges,75% of total billed charges,121.16,75,,,percent of total billed charges,75% of total billed charges,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,73.15,102,,,Fee Schedule,102% of WV Medicaid Rate,2326.19,165,,,Fee Schedule,165% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4049.52,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5553.61,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6956.46,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,71.72,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,22.62,14,,,percent of total billed charges,14% of total billed charges,22.62,6956.46,
11420-PF EXC B9 LESION MRGN XCP SK TG S/N/H/F/G 0.5 CM/<,4321324,CDM,981,RC,11420,HCPCS,Outpatient,,,161.54,80.77,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
11420PF Exc h-f-nk-sp benign+marg 0.5/<,4267403,CDM,960,RC,11420,HCPCS,Outpatient,,,161.54,80.77,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
11421- Exc h-f-nk-sp benign+marg 0.6-1,3431514,CDM,761,RC,11421,HCPCS,Outpatient,,,216.52,108.26,,162.39,75,,,percent of total billed charges,75% of total billed charges,162.39,75,,,percent of total billed charges,75% of total billed charges,610.13,100,,,Fee Schedule,100% of CMS OPPS Rate,85.45,102,,,Fee Schedule,102% of WV Medicaid Rate,1006.72,165,,,Fee Schedule,165% of CMS OPPS Rate,632.35,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1752.53,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2403.46,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,3010.58,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,83.77,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,610.13,100,,,Fee Schedule,100% of CMS OPPS Rate,632.35,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,30.31,14,,,percent of total billed charges,14% of total billed charges,30.31,3010.58,
11421-PF EXC B9 LESION MRGN XCP SK TG S/N/H/F/G 0.6-1.0CM,4321325,CDM,981,RC,11421,HCPCS,Outpatient,,,216.52,108.26,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
11422 - PF Exc B9 Lesion Mrgn XCP SK TG S/ N/ H/ F/ G 1.1-2.0 cm,4311471,CDM,960,RC,11422,HCPCS,Outpatient,,,268.29,134.15,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
11422- Exc h-f-nk-sp benign1.1-2,3431515,CDM,761,RC,11422,HCPCS,Outpatient,,,268.29,134.15,,201.22,75,,,percent of total billed charges,75% of total billed charges,201.22,75,,,percent of total billed charges,75% of total billed charges,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,94.45,102,,,Fee Schedule,102% of WV Medicaid Rate,2326.19,165,,,Fee Schedule,165% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4049.52,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5553.61,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6956.46,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,92.6,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,37.56,14,,,percent of total billed charges,14% of total billed charges,37.56,6956.46,
11423- Exc h-f-nk-sp benign+marg 2.1-3,3431516,CDM,761,RC,11423,HCPCS,Outpatient,,,312.19,156.1,,234.14,75,,,percent of total billed charges,75% of total billed charges,234.14,75,,,percent of total billed charges,75% of total billed charges,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,102.92,102,,,Fee Schedule,102% of WV Medicaid Rate,2326.19,165,,,Fee Schedule,165% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4049.52,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5553.61,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6956.46,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,100.9,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,43.71,14,,,percent of total billed charges,14% of total billed charges,43.71,6956.46,
11424- Exc benign les/see area/3.1-4.0cm,3431517,CDM,761,RC,11424,HCPCS,Outpatient,,,362.56,181.28,,271.92,75,,,percent of total billed charges,75% of total billed charges,271.92,75,,,percent of total billed charges,75% of total billed charges,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,479.67,102,,,Fee Schedule,102% of WV Medicaid Rate,2326.19,165,,,Fee Schedule,165% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4049.52,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5553.61,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6956.46,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,470.26,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,50.76,14,,,percent of total billed charges,14% of total billed charges,50.76,6956.46,
11426- Exc h-f-nk-sp benign+marg >4 cm,3431518,CDM,761,RC,11426,HCPCS,Outpatient,,,542.08,271.04,,406.56,75,,,percent of total billed charges,75% of total billed charges,406.56,75,,,percent of total billed charges,75% of total billed charges,2428.67,100,,,Fee Schedule,100% of CMS OPPS Rate,803.83,102,,,Fee Schedule,102% of WV Medicaid Rate,4007.32,165,,,Fee Schedule,165% of CMS OPPS Rate,2517.11,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,6976.06,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,9567.11,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,11983.78,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,788.07,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2428.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2517.11,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,75.89,14,,,percent of total billed charges,14% of total billed charges,75.89,11983.78,
11440- Exc face-mm benign+marg 0.5 cm/<,3431519,CDM,761,RC,11440,HCPCS,Outpatient,,,207.53,103.77,,155.65,75,,,percent of total billed charges,75% of total billed charges,155.65,75,,,percent of total billed charges,75% of total billed charges,610.13,100,,,Fee Schedule,100% of CMS OPPS Rate,85.17,102,,,Fee Schedule,102% of WV Medicaid Rate,1006.72,165,,,Fee Schedule,165% of CMS OPPS Rate,632.35,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1752.53,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2403.46,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,3010.58,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,83.5,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,610.13,100,,,Fee Schedule,100% of CMS OPPS Rate,632.35,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,29.05,14,,,percent of total billed charges,14% of total billed charges,29.05,3010.58,
11440-PF EXC B9 LESION MRGN XCP SK TG F/E/E/N/L/M 0.5CM/<,4321306,CDM,981,RC,11440,HCPCS,Outpatient,,,207.53,103.77,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
11441- Exc face-mm benign+marg 0.6-1 cm,3431520,CDM,761,RC,11441,HCPCS,Outpatient,,,262.35,131.18,,196.76,75,,,percent of total billed charges,75% of total billed charges,196.76,75,,,percent of total billed charges,75% of total billed charges,610.13,100,,,Fee Schedule,100% of CMS OPPS Rate,94.72,102,,,Fee Schedule,102% of WV Medicaid Rate,1006.72,165,,,Fee Schedule,165% of CMS OPPS Rate,632.35,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1752.53,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2403.46,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,3010.58,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,92.86,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,610.13,100,,,Fee Schedule,100% of CMS OPPS Rate,632.35,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,36.73,14,,,percent of total billed charges,14% of total billed charges,36.73,3010.58,
11442- Exc face-mm benign+marg 1.1-2 cm,3431521,CDM,761,RC,11442,HCPCS,Outpatient,,,290.48,145.24,,217.86,75,,,percent of total billed charges,75% of total billed charges,217.86,75,,,percent of total billed charges,75% of total billed charges,610.13,100,,,Fee Schedule,100% of CMS OPPS Rate,102.37,102,,,Fee Schedule,102% of WV Medicaid Rate,1006.72,165,,,Fee Schedule,165% of CMS OPPS Rate,632.35,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1752.53,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2403.46,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,3010.58,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,100.36,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,610.13,100,,,Fee Schedule,100% of CMS OPPS Rate,632.35,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,40.67,14,,,percent of total billed charges,14% of total billed charges,40.67,3010.58,
11443- Exc face-mm benign+marg 2.1-3 cm,3431522,CDM,761,RC,11443,HCPCS,Outpatient,,,356.01,178.01,,267.01,75,,,percent of total billed charges,75% of total billed charges,267.01,75,,,percent of total billed charges,75% of total billed charges,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,112.74,102,,,Fee Schedule,102% of WV Medicaid Rate,2326.19,165,,,Fee Schedule,165% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4049.52,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5553.61,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6956.46,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,110.53,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,49.84,14,,,percent of total billed charges,14% of total billed charges,49.84,6956.46,
11444- Exc/benign les/see area/3.1-4.0cm,3431523,CDM,761,RC,11444,HCPCS,Outpatient,,,451.24,225.62,,338.43,75,,,percent of total billed charges,75% of total billed charges,338.43,75,,,percent of total billed charges,75% of total billed charges,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,479.67,102,,,Fee Schedule,102% of WV Medicaid Rate,2326.19,165,,,Fee Schedule,165% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4049.52,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5553.61,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6956.46,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,470.26,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,63.17,14,,,percent of total billed charges,14% of total billed charges,63.17,6956.46,
11446- Exc benign lesion/see area/>4.0cm,3431524,CDM,761,RC,11446,HCPCS,Outpatient,,,638.48,319.24,,478.86,75,,,percent of total billed charges,75% of total billed charges,478.86,75,,,percent of total billed charges,75% of total billed charges,2428.67,100,,,Fee Schedule,100% of CMS OPPS Rate,803.83,102,,,Fee Schedule,102% of WV Medicaid Rate,4007.32,165,,,Fee Schedule,165% of CMS OPPS Rate,2517.11,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,6976.06,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,9567.11,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,11983.78,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,788.07,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2428.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2517.11,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,89.39,14,,,percent of total billed charges,14% of total billed charges,89.39,11983.78,
11450- Exc/hidradenitis/axilla/smp/im rpr,3431525,CDM,761,RC,11450,HCPCS,Outpatient,,,530.15,265.08,,397.61,75,,,percent of total billed charges,75% of total billed charges,397.61,75,,,percent of total billed charges,75% of total billed charges,2428.67,100,,,Fee Schedule,100% of CMS OPPS Rate,803.83,102,,,Fee Schedule,102% of WV Medicaid Rate,4007.32,165,,,Fee Schedule,165% of CMS OPPS Rate,2517.11,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,6976.06,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,9567.11,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,11983.78,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,788.07,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2428.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2517.11,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,74.22,14,,,percent of total billed charges,14% of total billed charges,74.22,11983.78,
11451- Exc/hidradenitis/axilla/comp rpr,3431526,CDM,761,RC,11451,HCPCS,Outpatient,,,673.08,336.54,,504.81,75,,,percent of total billed charges,75% of total billed charges,504.81,75,,,percent of total billed charges,75% of total billed charges,2428.67,100,,,Fee Schedule,100% of CMS OPPS Rate,803.83,102,,,Fee Schedule,102% of WV Medicaid Rate,4007.32,165,,,Fee Schedule,165% of CMS OPPS Rate,2517.11,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,6976.06,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,9567.11,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,11983.78,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,788.07,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2428.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2517.11,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,94.23,14,,,percent of total billed charges,14% of total billed charges,94.23,11983.78,
11462- Exc/hidradenitis/ingun/smp/imt rpr,3431527,CDM,761,RC,11462,HCPCS,Outpatient,,,503.35,251.68,,377.51,75,,,percent of total billed charges,75% of total billed charges,377.51,75,,,percent of total billed charges,75% of total billed charges,2428.67,100,,,Fee Schedule,100% of CMS OPPS Rate,803.83,102,,,Fee Schedule,102% of WV Medicaid Rate,4007.32,165,,,Fee Schedule,165% of CMS OPPS Rate,2517.11,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,6976.06,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,9567.11,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,11983.78,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,788.07,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2428.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2517.11,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,70.47,14,,,percent of total billed charges,14% of total billed charges,70.47,11983.78,
11463- Exc/hidradenitis/inguinal/comp rpr,3431528,CDM,761,RC,11463,HCPCS,Outpatient,,,674.75,337.38,,506.06,75,,,percent of total billed charges,75% of total billed charges,506.06,75,,,percent of total billed charges,75% of total billed charges,2428.67,100,,,Fee Schedule,100% of CMS OPPS Rate,803.83,102,,,Fee Schedule,102% of WV Medicaid Rate,4007.32,165,,,Fee Schedule,165% of CMS OPPS Rate,2517.11,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,6976.06,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,9567.11,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,11983.78,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,788.07,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2428.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2517.11,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,94.47,14,,,percent of total billed charges,14% of total billed charges,94.47,11983.78,
11470- Exc hidradenit/perianal/neal/sp/in,3431529,CDM,761,RC,11470,HCPCS,Outpatient,,,580.73,290.37,,435.55,75,,,percent of total billed charges,75% of total billed charges,435.55,75,,,percent of total billed charges,75% of total billed charges,2428.67,100,,,Fee Schedule,100% of CMS OPPS Rate,803.83,102,,,Fee Schedule,102% of WV Medicaid Rate,4007.32,165,,,Fee Schedule,165% of CMS OPPS Rate,2517.11,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,6976.06,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,9567.11,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,11983.78,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,788.07,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2428.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2517.11,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,81.3,14,,,percent of total billed charges,14% of total billed charges,81.3,11983.78,
11471- Exc hidradenitis/perianal/neal/com,3431530,CDM,761,RC,11471,HCPCS,Outpatient,,,712.09,356.05,,534.07,75,,,percent of total billed charges,75% of total billed charges,534.07,75,,,percent of total billed charges,75% of total billed charges,2428.67,100,,,Fee Schedule,100% of CMS OPPS Rate,803.83,102,,,Fee Schedule,102% of WV Medicaid Rate,4007.32,165,,,Fee Schedule,165% of CMS OPPS Rate,2517.11,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,6976.06,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,9567.11,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,11983.78,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,788.07,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2428.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2517.11,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,99.69,14,,,percent of total billed charges,14% of total billed charges,99.69,11983.78,
11600- Exc/malig/trunk/arms/legs <0.5cm,3431531,CDM,761,RC,11600,HCPCS,Outpatient,,,243.02,121.51,,182.27,75,,,percent of total billed charges,75% of total billed charges,182.27,75,,,percent of total billed charges,75% of total billed charges,610.13,100,,,Fee Schedule,100% of CMS OPPS Rate,111.11,102,,,Fee Schedule,102% of WV Medicaid Rate,1006.72,165,,,Fee Schedule,165% of CMS OPPS Rate,632.35,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1752.53,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2403.46,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,3010.58,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,108.93,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,610.13,100,,,Fee Schedule,100% of CMS OPPS Rate,632.35,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,34.02,14,,,percent of total billed charges,14% of total billed charges,34.02,3010.58,
11601- Exc malig/trunk/arm/leg 0.6-1.0cm,3431532,CDM,761,RC,11601,HCPCS,Outpatient,,,294.28,147.14,,220.71,75,,,percent of total billed charges,75% of total billed charges,220.71,75,,,percent of total billed charges,75% of total billed charges,610.13,100,,,Fee Schedule,100% of CMS OPPS Rate,122.57,102,,,Fee Schedule,102% of WV Medicaid Rate,1006.72,165,,,Fee Schedule,165% of CMS OPPS Rate,632.35,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1752.53,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2403.46,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,3010.58,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,120.17,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,610.13,100,,,Fee Schedule,100% of CMS OPPS Rate,632.35,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,41.2,14,,,percent of total billed charges,14% of total billed charges,41.2,3010.58,
11602 - PF Excision MAL Lesion Trunk/ Arm/ Leg 1.1-2.0 cm,4311472,CDM,960,RC,11602,HCPCS,Outpatient,,,318.93,159.47,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
11602- Exc tr-ext mal+marg 1.1-2 cm,3431533,CDM,761,RC,11602,HCPCS,Outpatient,,,318.93,159.47,,239.2,75,,,percent of total billed charges,75% of total billed charges,239.2,75,,,percent of total billed charges,75% of total billed charges,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,129.4,102,,,Fee Schedule,102% of WV Medicaid Rate,578.72,165,,,Fee Schedule,165% of CMS OPPS Rate,363.51,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1007.47,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1381.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1730.67,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,126.86,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,363.51,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,44.65,14,,,percent of total billed charges,14% of total billed charges,44.65,1730.67,
11603- Exc tr-ext mal+marg 2.1-3 cm,3431534,CDM,761,RC,11603,HCPCS,Outpatient,,,383.4,191.7,,287.55,75,,,percent of total billed charges,75% of total billed charges,287.55,75,,,percent of total billed charges,75% of total billed charges,610.13,100,,,Fee Schedule,100% of CMS OPPS Rate,139.5,102,,,Fee Schedule,102% of WV Medicaid Rate,1006.72,165,,,Fee Schedule,165% of CMS OPPS Rate,632.35,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1752.53,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2403.46,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,3010.58,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,136.76,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,610.13,100,,,Fee Schedule,100% of CMS OPPS Rate,632.35,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,53.68,14,,,percent of total billed charges,14% of total billed charges,53.68,3010.58,
11604- Exc tr-ext mal+marg 3.1-4 cm,3431535,CDM,761,RC,11604,HCPCS,Outpatient,,,424.06,212.03,,318.05,75,,,percent of total billed charges,75% of total billed charges,318.05,75,,,percent of total billed charges,75% of total billed charges,610.13,100,,,Fee Schedule,100% of CMS OPPS Rate,254,102,,,Fee Schedule,102% of WV Medicaid Rate,1006.72,165,,,Fee Schedule,165% of CMS OPPS Rate,632.35,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1752.53,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2403.46,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,3010.58,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,249.02,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,610.13,100,,,Fee Schedule,100% of CMS OPPS Rate,632.35,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,59.37,14,,,percent of total billed charges,14% of total billed charges,59.37,3010.58,
11606- Exc tr-ext mal+marg >4 cm,3431536,CDM,761,RC,11606,HCPCS,Outpatient,,,642.59,321.3,,481.94,75,,,percent of total billed charges,75% of total billed charges,481.94,75,,,percent of total billed charges,75% of total billed charges,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,479.67,102,,,Fee Schedule,102% of WV Medicaid Rate,2326.19,165,,,Fee Schedule,165% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4049.52,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5553.61,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6956.46,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,470.26,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,89.96,14,,,percent of total billed charges,14% of total billed charges,89.96,6956.46,
11620- Exc/malig/see area/0.5cm or less,3431537,CDM,761,RC,11620,HCPCS,Outpatient,,,245.22,122.61,,183.92,75,,,percent of total billed charges,75% of total billed charges,183.92,75,,,percent of total billed charges,75% of total billed charges,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,111.37,102,,,Fee Schedule,102% of WV Medicaid Rate,2326.19,165,,,Fee Schedule,165% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4049.52,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5553.61,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6956.46,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,109.19,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,34.33,14,,,percent of total billed charges,14% of total billed charges,34.33,6956.46,
11621- Exc H-F-Nk-Sp Mlg+Marg 0.6-1.0 Cm,3431538,CDM,761,RC,11621,HCPCS,Outpatient,,,295.91,147.96,,221.93,75,,,percent of total billed charges,75% of total billed charges,221.93,75,,,percent of total billed charges,75% of total billed charges,610.13,100,,,Fee Schedule,100% of CMS OPPS Rate,122.85,102,,,Fee Schedule,102% of WV Medicaid Rate,1006.72,165,,,Fee Schedule,165% of CMS OPPS Rate,632.35,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1752.53,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2403.46,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,3010.58,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,120.44,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,610.13,100,,,Fee Schedule,100% of CMS OPPS Rate,632.35,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,41.43,14,,,percent of total billed charges,14% of total billed charges,41.43,3010.58,
11622- Exc s/n/h/f/g mal+mrg 1.1-2,3431539,CDM,761,RC,11622,HCPCS,Outpatient,,,335.96,167.98,,251.97,75,,,percent of total billed charges,75% of total billed charges,251.97,75,,,percent of total billed charges,75% of total billed charges,610.13,100,,,Fee Schedule,100% of CMS OPPS Rate,131.58,102,,,Fee Schedule,102% of WV Medicaid Rate,1006.72,165,,,Fee Schedule,165% of CMS OPPS Rate,632.35,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1752.53,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2403.46,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,3010.58,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,129,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,610.13,100,,,Fee Schedule,100% of CMS OPPS Rate,632.35,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,47.03,14,,,percent of total billed charges,14% of total billed charges,47.03,3010.58,
11623- Exc H-F-Nk-Sp Mlg+Marg 2.1-3 Cm,3431540,CDM,761,RC,11623,HCPCS,Outpatient,,,416.86,208.43,,312.65,75,,,percent of total billed charges,75% of total billed charges,312.65,75,,,percent of total billed charges,75% of total billed charges,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,144.41,102,,,Fee Schedule,102% of WV Medicaid Rate,2326.19,165,,,Fee Schedule,165% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4049.52,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5553.61,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6956.46,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,141.58,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,58.36,14,,,percent of total billed charges,14% of total billed charges,58.36,6956.46,
11624- Exc s/n/h/f/g mal+mrg 3.1-4,3431541,CDM,761,RC,11624,HCPCS,Outpatient,,,477.13,238.57,,357.85,75,,,percent of total billed charges,75% of total billed charges,357.85,75,,,percent of total billed charges,75% of total billed charges,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,479.67,102,,,Fee Schedule,102% of WV Medicaid Rate,2326.19,165,,,Fee Schedule,165% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4049.52,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5553.61,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6956.46,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,470.26,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,66.8,14,,,percent of total billed charges,14% of total billed charges,66.8,6956.46,
11626- Exc s/n/h/f/g mal+mrg >4 cm,3431542,CDM,761,RC,11626,HCPCS,Outpatient,,,589.34,294.67,,442.01,75,,,percent of total billed charges,75% of total billed charges,442.01,75,,,percent of total billed charges,75% of total billed charges,2428.67,100,,,Fee Schedule,100% of CMS OPPS Rate,803.83,102,,,Fee Schedule,102% of WV Medicaid Rate,4007.32,165,,,Fee Schedule,165% of CMS OPPS Rate,2517.11,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,6976.06,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,9567.11,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,11983.78,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,788.07,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2428.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2517.11,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,82.51,14,,,percent of total billed charges,14% of total billed charges,82.51,11983.78,
11640- Exc/malg/fac/ear/lid/nos/lip<0.5cm,3431543,CDM,761,RC,11640,HCPCS,Outpatient,,,250.84,125.42,,188.13,75,,,percent of total billed charges,75% of total billed charges,188.13,75,,,percent of total billed charges,75% of total billed charges,610.13,100,,,Fee Schedule,100% of CMS OPPS Rate,114.38,102,,,Fee Schedule,102% of WV Medicaid Rate,1006.72,165,,,Fee Schedule,165% of CMS OPPS Rate,632.35,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1752.53,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2403.46,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,3010.58,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,112.14,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,610.13,100,,,Fee Schedule,100% of CMS OPPS Rate,632.35,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,35.12,14,,,percent of total billed charges,14% of total billed charges,35.12,3010.58,
11641- Exc f/e/e/n/l mal+mrg 0.6-1,3431544,CDM,761,RC,11641,HCPCS,Outpatient,,,308.46,154.23,,231.35,75,,,percent of total billed charges,75% of total billed charges,231.35,75,,,percent of total billed charges,75% of total billed charges,610.13,100,,,Fee Schedule,100% of CMS OPPS Rate,126.11,102,,,Fee Schedule,102% of WV Medicaid Rate,1006.72,165,,,Fee Schedule,165% of CMS OPPS Rate,632.35,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1752.53,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2403.46,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,3010.58,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,123.64,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,610.13,100,,,Fee Schedule,100% of CMS OPPS Rate,632.35,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,43.18,14,,,percent of total billed charges,14% of total billed charges,43.18,3010.58,
11642- Exc Face-Mm Malig+Marg 1.1-2,3431545,CDM,761,RC,11642,HCPCS,Outpatient,,,362.33,181.17,,271.75,75,,,percent of total billed charges,75% of total billed charges,271.75,75,,,percent of total billed charges,75% of total billed charges,610.13,100,,,Fee Schedule,100% of CMS OPPS Rate,137.04,102,,,Fee Schedule,102% of WV Medicaid Rate,1006.72,165,,,Fee Schedule,165% of CMS OPPS Rate,632.35,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1752.53,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2403.46,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,3010.58,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,134.35,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,610.13,100,,,Fee Schedule,100% of CMS OPPS Rate,632.35,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,50.73,14,,,percent of total billed charges,14% of total billed charges,50.73,3010.58,
11643- Exc f/e/e/n/l mal+mrg 2.1-3,3431546,CDM,761,RC,11643,HCPCS,Outpatient,,,454.1,227.05,,340.58,75,,,percent of total billed charges,75% of total billed charges,340.58,75,,,percent of total billed charges,75% of total billed charges,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,150.14,102,,,Fee Schedule,102% of WV Medicaid Rate,2326.19,165,,,Fee Schedule,165% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4049.52,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5553.61,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6956.46,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,147.2,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,63.57,14,,,percent of total billed charges,14% of total billed charges,63.57,6956.46,
11644- Exc Face-Mm Malig+Marg 3.1-4.0,3431547,CDM,761,RC,11644,HCPCS,Outpatient,,,565.09,282.55,,423.82,75,,,percent of total billed charges,75% of total billed charges,423.82,75,,,percent of total billed charges,75% of total billed charges,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,479.67,102,,,Fee Schedule,102% of WV Medicaid Rate,2326.19,165,,,Fee Schedule,165% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4049.52,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5553.61,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6956.46,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,470.26,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,79.11,14,,,percent of total billed charges,14% of total billed charges,79.11,6956.46,
11646- Exc/malig/fac/ear/lid/nose/lip>4cm,3431548,CDM,761,RC,11646,HCPCS,Outpatient,,,787.05,393.53,,590.29,75,,,percent of total billed charges,75% of total billed charges,590.29,75,,,percent of total billed charges,75% of total billed charges,2428.67,100,,,Fee Schedule,100% of CMS OPPS Rate,803.83,102,,,Fee Schedule,102% of WV Medicaid Rate,4007.32,165,,,Fee Schedule,165% of CMS OPPS Rate,2517.11,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,6976.06,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,9567.11,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,11983.78,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,788.07,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2428.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2517.11,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,110.19,14,,,percent of total billed charges,14% of total billed charges,110.19,11983.78,
11719- Trim nondystrophic nails,3431549,CDM,510,RC,11719,HCPCS,Outpatient,,,34.92,17.46,,26.19,75,,,percent of total billed charges,75% of total billed charges,26.19,75,,,percent of total billed charges,75% of total billed charges,54.04,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,89.16,165,,,Fee Schedule,165% of CMS OPPS Rate,56,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,155.22,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,212.87,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,266.65,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,54.04,100,,,Fee Schedule,100% of CMS OPPS Rate,56,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4.89,14,,,percent of total billed charges,14% of total billed charges,4.89,266.65,
11719-PF TRIMMING NONDYSTROPHIC NAILS ANY NUMBER,4321327,CDM,981,RC,11719,HCPCS,Outpatient,,,14.72,7.36,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
11720- Debride/nails/any method/1 to 5,3431550,CDM,510,RC,11720,HCPCS,Outpatient,,,81.24,40.62,,60.93,75,,,percent of total billed charges,75% of total billed charges,60.93,75,,,percent of total billed charges,75% of total billed charges,54.04,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,89.16,165,,,Fee Schedule,165% of CMS OPPS Rate,56,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,155.22,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,212.87,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,266.65,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,54.04,100,,,Fee Schedule,100% of CMS OPPS Rate,56,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,11.37,14,,,percent of total billed charges,14% of total billed charges,11.37,266.65,
11720-PF DEBRIDEMENT NAIL ANY METHOD 1-5,4321329,CDM,981,RC,11720,HCPCS,Outpatient,,,29.2,14.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
11721 - DEB NAIL 6 OR MORE Profee,3435765,CDM,510,RC,11721,HCPCS,Outpatient,,,110.94,55.47,,83.21,75,,,percent of total billed charges,75% of total billed charges,83.21,75,,,percent of total billed charges,75% of total billed charges,54.04,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,89.16,165,,,Fee Schedule,165% of CMS OPPS Rate,56,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,155.22,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,212.87,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,266.65,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,54.04,100,,,Fee Schedule,100% of CMS OPPS Rate,56,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,15.53,14,,,percent of total billed charges,14% of total billed charges,15.53,266.65,
11721- Debride/nails/any method/6 or more,3431551,CDM,761,RC,11721,HCPCS,Outpatient,,,48.36,24.18,,36.27,75,,,percent of total billed charges,75% of total billed charges,36.27,75,,,percent of total billed charges,75% of total billed charges,54.04,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,89.16,165,,,Fee Schedule,165% of CMS OPPS Rate,56,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,155.22,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,212.87,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,266.65,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,54.04,100,,,Fee Schedule,100% of CMS OPPS Rate,56,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,6.77,14,,,percent of total billed charges,14% of total billed charges,6.77,266.65,
11721-PF DEBRIDEMENT NAIL ANY METHOD 6/>,4321330,CDM,981,RC,11721,HCPCS,Outpatient,,,48.36,24.18,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
11730- Avulsion/nail plate/simple/single,3431552,CDM,761,RC,11730,HCPCS,Outpatient,,,108.73,54.37,,81.55,75,,,percent of total billed charges,75% of total billed charges,81.55,75,,,percent of total billed charges,75% of total billed charges,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,280.12,165,,,Fee Schedule,165% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,487.65,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,668.78,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,837.71,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,15.22,14,,,percent of total billed charges,14% of total billed charges,15.22,837.71,
11730-PF AVULSION NAIL PLATE PARTIAL/COMPLETE SIMPLE 1,4321332,CDM,981,RC,11730,HCPCS,Outpatient,,,108.73,54.37,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
11732- Avulsion/nail plate/simple/ea add,3431553,CDM,761,RC,11732,HCPCS,Outpatient,,,34.53,17.27,,25.9,75,,,percent of total billed charges,75% of total billed charges,25.9,75,,,percent of total billed charges,75% of total billed charges,11.05,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.83,14,,,percent of total billed charges,14% of total billed charges,4.83,25.9,
11732-PF AVULSION NAIL PLATE PARTIAL/COMP SIMPLE EA ADDL,4321333,CDM,981,RC,11732,HCPCS,Outpatient,,,34.53,17.27,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
11740- Evacuation of Subungual Hematoma,3431554,CDM,510,RC,11740,HCPCS,Outpatient,,,140.32,70.16,,105.24,75,,,percent of total billed charges,75% of total billed charges,105.24,75,,,percent of total billed charges,75% of total billed charges,109.16,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,180.11,165,,,Fee Schedule,165% of CMS OPPS Rate,113.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,313.55,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,430.01,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,538.63,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,109.16,100,,,Fee Schedule,100% of CMS OPPS Rate,113.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,19.64,14,,,percent of total billed charges,14% of total billed charges,19.64,538.63,
11740-PF EVACUATION SUBUNGUAL HEMATOM,4321334,CDM,981,RC,11740,HCPCS,Outpatient,,,59.98,29.99,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
EVAC SUBUNGUAL HEMATOMA,3428427,CDM,981,RC,11740,HCPCS,Outpatient,,,140.32,70.16,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
11750- Excise/nail/matrix/perm removal,3431555,CDM,761,RC,11750,HCPCS,Outpatient,,,400.26,200.13,,300.2,75,,,percent of total billed charges,75% of total billed charges,300.2,75,,,percent of total billed charges,75% of total billed charges,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,83.53,102,,,Fee Schedule,102% of WV Medicaid Rate,578.72,165,,,Fee Schedule,165% of CMS OPPS Rate,363.51,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1007.47,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1381.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1730.67,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,81.89,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,363.51,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,56.04,14,,,percent of total billed charges,14% of total billed charges,56.04,1730.67,
11750-PF EXCISION NAIL MATRIX PERMANENT REMOVAL,4321336,CDM,981,RC,11750,HCPCS,Outpatient,,,192.56,96.28,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
11755- Biopsy of nail unit,3431556,CDM,510,RC,11755,HCPCS,Outpatient,,,309.26,154.63,,231.95,75,,,percent of total billed charges,75% of total billed charges,231.95,75,,,percent of total billed charges,75% of total billed charges,610.13,100,,,Fee Schedule,100% of CMS OPPS Rate,63.33,102,,,Fee Schedule,102% of WV Medicaid Rate,1006.72,165,,,Fee Schedule,165% of CMS OPPS Rate,632.35,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1752.53,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2403.46,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,3010.58,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,62.09,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,610.13,100,,,Fee Schedule,100% of CMS OPPS Rate,632.35,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,43.3,14,,,percent of total billed charges,14% of total billed charges,43.3,3010.58,
11760- Repair of nail bed,3431557,CDM,510,RC,11760,HCPCS,Outpatient,,,472.11,236.06,,354.08,75,,,percent of total billed charges,75% of total billed charges,354.08,75,,,percent of total billed charges,75% of total billed charges,546.17,100,,,Fee Schedule,100% of CMS OPPS Rate,103.73,102,,,Fee Schedule,102% of WV Medicaid Rate,901.2,165,,,Fee Schedule,165% of CMS OPPS Rate,566.07,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1568.84,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2151.55,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,2695.04,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,101.7,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,546.17,100,,,Fee Schedule,100% of CMS OPPS Rate,566.07,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,66.1,14,,,percent of total billed charges,14% of total billed charges,66.1,2695.04,
11760-PF REPAIR NAIL BED,4321337,CDM,981,RC,11760,HCPCS,Outpatient,,,212.46,106.23,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
11762- Reconstruct/nail bed/graft,3431558,CDM,510,RC,11762,HCPCS,Outpatient,,,732.86,366.43,,549.65,75,,,percent of total billed charges,75% of total billed charges,549.65,75,,,percent of total billed charges,75% of total billed charges,1622.59,100,,,Fee Schedule,100% of CMS OPPS Rate,146.86,102,,,Fee Schedule,102% of WV Medicaid Rate,2677.27,165,,,Fee Schedule,165% of CMS OPPS Rate,1681.67,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4660.68,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,6391.75,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,8006.31,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,143.98,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1622.59,100,,,Fee Schedule,100% of CMS OPPS Rate,1681.67,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,102.6,14,,,percent of total billed charges,14% of total billed charges,102.6,8006.31,
11762-PF RECONSTRUCTION NAIL BED W/GRAFT,4321338,CDM,981,RC,11762,HCPCS,Outpatient,,,359.92,179.96,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
PHY-RECONSTRUCT NAIL BED WITH GRAFT,3428510,CDM,981,RC,11762,HCPCS,Outpatient,,,732.86,366.43,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
11765- Wedge excision/skin of nail fold,3431559,CDM,510,RC,11765,HCPCS,Outpatient,,,409.94,204.97,,307.46,75,,,percent of total billed charges,75% of total billed charges,307.46,75,,,percent of total billed charges,75% of total billed charges,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,578.73,165,,,Fee Schedule,165% of CMS OPPS Rate,363.52,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1007.47,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1381.67,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1730.68,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,363.52,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,57.39,14,,,percent of total billed charges,14% of total billed charges,57.39,1730.68,
11765-PF WEDGE EXCISION SKIN NAIL FOLD,4321343,CDM,981,RC,11765,HCPCS,Outpatient,,,174.04,87.02,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
11770- Exc/pilonidal cyst/sinus/simple,3431560,CDM,510,RC,11770,HCPCS,Outpatient,,,915.8,457.9,,686.85,75,,,percent of total billed charges,75% of total billed charges,686.85,75,,,percent of total billed charges,75% of total billed charges,2428.67,100,,,Fee Schedule,100% of CMS OPPS Rate,803.83,102,,,Fee Schedule,102% of WV Medicaid Rate,4007.32,165,,,Fee Schedule,165% of CMS OPPS Rate,2517.11,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,6976.06,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,9567.11,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,11983.78,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,788.07,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2428.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2517.11,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,128.21,14,,,percent of total billed charges,14% of total billed charges,128.21,11983.78,
11771 - PF Excision Pilonidal Cyst/ Sinus Extensive,4311473,CDM,960,RC,11771,HCPCS,Outpatient,,,1046.47,523.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
11771- Exc/pilonidal cyst/sinus/extensive,3431561,CDM,510,RC,11771,HCPCS,Outpatient,,,1625.21,812.61,,1218.91,75,,,percent of total billed charges,75% of total billed charges,1218.91,75,,,percent of total billed charges,75% of total billed charges,2428.67,100,,,Fee Schedule,100% of CMS OPPS Rate,803.83,102,,,Fee Schedule,102% of WV Medicaid Rate,4007.32,165,,,Fee Schedule,165% of CMS OPPS Rate,2517.11,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,6976.06,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,9567.11,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,11983.78,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,788.07,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2428.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2517.11,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,227.53,14,,,percent of total billed charges,14% of total billed charges,227.53,11983.78,
11772 - PF Excision Pilonidal Cyst/ Sinus Complicated,4311474,CDM,960,RC,11772,HCPCS,Outpatient,,,1338.05,669.03,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
11772- Exc/pilonidal cyst/sinus/comp,3431562,CDM,510,RC,11772,HCPCS,Outpatient,,,1995.38,997.69,,1496.54,75,,,percent of total billed charges,75% of total billed charges,1496.54,75,,,percent of total billed charges,75% of total billed charges,2428.67,100,,,Fee Schedule,100% of CMS OPPS Rate,803.83,102,,,Fee Schedule,102% of WV Medicaid Rate,4007.32,165,,,Fee Schedule,165% of CMS OPPS Rate,2517.11,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,6976.06,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,9567.11,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,11983.78,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,788.07,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2428.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2517.11,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,279.35,14,,,percent of total billed charges,14% of total billed charges,279.35,11983.78,
11900- Intralesional injection/</=7,3431563,CDM,761,RC,11900,HCPCS,Outpatient,,,60.21,30.11,,45.16,75,,,percent of total billed charges,75% of total billed charges,45.16,75,,,percent of total billed charges,75% of total billed charges,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,280.12,165,,,Fee Schedule,165% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,487.65,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,668.78,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,837.71,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8.43,14,,,percent of total billed charges,14% of total billed charges,8.43,837.71,
11901- Inj/intralesional/> 7 lesions,3431564,CDM,761,RC,11901,HCPCS,Outpatient,,,91.05,45.53,,68.29,75,,,percent of total billed charges,75% of total billed charges,68.29,75,,,percent of total billed charges,75% of total billed charges,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,280.12,165,,,Fee Schedule,165% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,487.65,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,668.78,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,837.71,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,12.75,14,,,percent of total billed charges,14% of total billed charges,12.75,837.71,
11921- Tattooing/intraderm 6.1-20.0 sq cm,3431565,CDM,510,RC,11921,HCPCS,Outpatient,,,557,278.5,,417.75,75,,,percent of total billed charges,75% of total billed charges,417.75,75,,,percent of total billed charges,75% of total billed charges,546.17,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,901.2,165,,,Fee Schedule,165% of CMS OPPS Rate,566.07,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1568.84,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2151.55,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,2695.04,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,546.17,100,,,Fee Schedule,100% of CMS OPPS Rate,566.07,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,77.98,14,,,percent of total billed charges,14% of total billed charges,77.98,2695.04,
11950 - Subcutaneous injection filling material,3572729,CDM,983,RC,11950,HCPCS,Outpatient,,,202.51,101.26,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
11950- Subq inj/fill material/1cc or <,3431566,CDM,761,RC,11950,HCPCS,Outpatient,,,106.02,53.01,,79.52,75,,,percent of total billed charges,75% of total billed charges,79.52,75,,,percent of total billed charges,75% of total billed charges,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,37.94,102,,,Fee Schedule,102% of WV Medicaid Rate,280.12,165,,,Fee Schedule,165% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,487.65,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,668.77,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,837.71,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,37.2,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,14.84,14,,,percent of total billed charges,14% of total billed charges,14.84,837.71,
11951- Subq inj/fill material/1.1-5.0 cc,3431567,CDM,761,RC,11951,HCPCS,Outpatient,,,148.44,74.22,,111.33,75,,,percent of total billed charges,75% of total billed charges,111.33,75,,,percent of total billed charges,75% of total billed charges,546.17,100,,,Fee Schedule,100% of CMS OPPS Rate,48.32,102,,,Fee Schedule,102% of WV Medicaid Rate,901.2,165,,,Fee Schedule,165% of CMS OPPS Rate,566.07,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1568.84,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2151.55,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,2695.04,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,47.37,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,546.17,100,,,Fee Schedule,100% of CMS OPPS Rate,566.07,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,20.78,14,,,percent of total billed charges,14% of total billed charges,20.78,2695.04,
11971- Rmv tissue expander w/o prosthesis,3431568,CDM,510,RC,11971,HCPCS,Outpatient,,,1414.12,707.06,,1060.59,75,,,percent of total billed charges,75% of total billed charges,1060.59,75,,,percent of total billed charges,75% of total billed charges,2428.67,100,,,Fee Schedule,100% of CMS OPPS Rate,803.83,102,,,Fee Schedule,102% of WV Medicaid Rate,4007.33,165,,,Fee Schedule,165% of CMS OPPS Rate,2517.12,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,6976.06,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,9567.11,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,11983.78,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,788.07,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2428.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2517.12,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,197.98,14,,,percent of total billed charges,14% of total billed charges,197.98,11983.78,
11976- Rmv implant contraceptive capsule,3431569,CDM,510,RC,11976,HCPCS,Outpatient,,,370.77,185.39,,278.08,75,,,percent of total billed charges,75% of total billed charges,278.08,75,,,percent of total billed charges,75% of total billed charges,610.13,100,,,Fee Schedule,100% of CMS OPPS Rate,60.87,102,,,Fee Schedule,102% of WV Medicaid Rate,1006.73,165,,,Fee Schedule,165% of CMS OPPS Rate,632.35,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1752.54,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2403.47,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,3010.59,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,59.68,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,610.13,100,,,Fee Schedule,100% of CMS OPPS Rate,632.35,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,51.91,14,,,percent of total billed charges,14% of total billed charges,51.91,3010.59,
11976-PF REMOVAL IMPLANTABLE CONTRACEPTIVE CAPSULES,4321345,CDM,981,RC,11976,HCPCS,Outpatient,,,185.74,92.87,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
11980PF Hormone pellet implant/subq,4267404,CDM,960,RC,11980,HCPCS,Outpatient,,,132.8,66.4,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
11981- Insert/drug delivery implant,3431571,CDM,510,RC,11981,HCPCS,Outpatient,,,259.44,129.72,,194.58,75,,,percent of total billed charges,75% of total billed charges,194.58,75,,,percent of total billed charges,75% of total billed charges,109.16,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,180.11,165,,,Fee Schedule,165% of CMS OPPS Rate,113.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,313.55,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,430.01,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,538.63,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,109.16,100,,,Fee Schedule,100% of CMS OPPS Rate,113.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,36.32,14,,,percent of total billed charges,14% of total billed charges,36.32,538.63,
AMB IUD Implant Admin Charge:Insert Drug Implant Device 11981,3444230,CDM,960,RC,11981,HCPCS,Outpatient,,,259.44,129.72,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
11982- Remove/drug delivery implant,3431572,CDM,510,RC,11982,HCPCS,Outpatient,,,156.69,78.35,,117.52,75,,,percent of total billed charges,75% of total billed charges,117.52,75,,,percent of total billed charges,75% of total billed charges,354.97,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,585.71,165,,,Fee Schedule,165% of CMS OPPS Rate,367.9,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1019.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1398.33,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1751.55,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,354.97,100,,,Fee Schedule,100% of CMS OPPS Rate,367.9,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,21.94,14,,,percent of total billed charges,14% of total billed charges,21.94,1751.55,
11983- Remove/reinsert drug deliv implant,3431573,CDM,510,RC,11983,HCPCS,Outpatient,,,369.3,184.65,,276.98,75,,,percent of total billed charges,75% of total billed charges,276.98,75,,,percent of total billed charges,75% of total billed charges,354.97,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,585.71,165,,,Fee Schedule,165% of CMS OPPS Rate,367.9,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1019.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1398.33,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1751.55,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,354.97,100,,,Fee Schedule,100% of CMS OPPS Rate,367.9,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,51.7,14,,,percent of total billed charges,14% of total billed charges,51.7,1751.55,
12001 - PF Smpl Rpr Scalp/ Neck/ Ax/ Genit/ Trunk 2.5 cm/ <,4311475,CDM,960,RC,12001,HCPCS,Outpatient,,,93.47,46.74,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
12001 - SIMPLE REPAIR SCALP/NECK/AX/GENIT/TRUNK 2.5CM/<,4037467,CDM,510,RC,12001,HCPCS,Outpatient,,,93.47,46.74,,70.1,75,,,percent of total billed charges,75% of total billed charges,70.1,75,,,percent of total billed charges,75% of total billed charges,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,280.12,165,,,Fee Schedule,165% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,487.65,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,668.78,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,837.71,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,13.09,14,,,percent of total billed charges,14% of total billed charges,13.09,837.71,
12001- Rep Superfic Wound 2.5Cm Less,3431574,CDM,761,RC,12001,HCPCS,Outpatient,,,93.47,46.74,,70.1,75,,,percent of total billed charges,75% of total billed charges,70.1,75,,,percent of total billed charges,75% of total billed charges,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,280.12,165,,,Fee Schedule,165% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,487.65,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,668.78,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,837.71,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,13.09,14,,,percent of total billed charges,14% of total billed charges,13.09,837.71,
12001-PF SIMPLE REPAIR SCALP/NECK/AX/GENIT/TRUNK 2.5CM/<,4321346,CDM,981,RC,12001,HCPCS,Outpatient,,,93.47,46.74,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
12002- Rep Superfic Wound 2.6-7.5Cm,3431575,CDM,761,RC,12002,HCPCS,Outpatient,,,123.43,61.72,,92.57,75,,,percent of total billed charges,75% of total billed charges,92.57,75,,,percent of total billed charges,75% of total billed charges,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,280.12,165,,,Fee Schedule,165% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,487.65,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,668.78,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,837.71,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,17.28,14,,,percent of total billed charges,14% of total billed charges,17.28,837.71,
12002-PF SMPL REPAIR SCALP/NECK/AX/GENIT/TRUNK 2.6-7.5CM,4321348,CDM,981,RC,12002,HCPCS,Outpatient,,,123.43,61.72,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
12004- Rep Superific Wound 7.6-12.5 cm,3431576,CDM,761,RC,12004,HCPCS,Outpatient,,,154.93,77.47,,116.2,75,,,percent of total billed charges,75% of total billed charges,116.2,75,,,percent of total billed charges,75% of total billed charges,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,280.12,165,,,Fee Schedule,165% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,487.65,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,668.78,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,837.71,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,21.69,14,,,percent of total billed charges,14% of total billed charges,21.69,837.71,
12004-PF SIMPLE RPR SCALP/NECK/AX/GENIT/TRUNK 7.6-12.5CM,4321349,CDM,981,RC,12004,HCPCS,Outpatient,,,154.93,77.47,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
12005- Rep Superfic Wound 12.6-20.0Cm,3431577,CDM,761,RC,12005,HCPCS,Outpatient,,,201.29,100.65,,150.97,75,,,percent of total billed charges,75% of total billed charges,150.97,75,,,percent of total billed charges,75% of total billed charges,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,141.09,102,,,Fee Schedule,102% of WV Medicaid Rate,578.73,165,,,Fee Schedule,165% of CMS OPPS Rate,363.52,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1007.47,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1381.67,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1730.68,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,138.32,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,363.52,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,28.18,14,,,percent of total billed charges,14% of total billed charges,28.18,1730.68,
12005-PF SMPL RPR SCALP/NECK/AX/GENIT/TRUNK 12.6-20.0CM,4321351,CDM,981,RC,12005,HCPCS,Outpatient,,,201.29,100.65,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
"12006- Simple Repair, scalp/neck/axillae/trunk/genital/extrem, 2.5 - 7.5 cm",3428737,CDM,510,RC,12006,HCPCS,Outpatient,,,245.31,122.66,,183.98,75,,,percent of total billed charges,75% of total billed charges,183.98,75,,,percent of total billed charges,75% of total billed charges,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,141.09,102,,,Fee Schedule,102% of WV Medicaid Rate,578.73,165,,,Fee Schedule,165% of CMS OPPS Rate,363.52,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1007.47,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1381.67,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1730.68,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,138.32,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,363.52,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,34.34,14,,,percent of total billed charges,14% of total billed charges,34.34,1730.68,
12006-PF SMPL RPR SCALP/NECK/AX/GENIT/TRUNK 20.1-30.0CM,4321352,CDM,981,RC,12006,HCPCS,Outpatient,,,245.31,122.66,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
12007- Smpl rpr/scalp/neck/ax/ext genit/trnk/extrem/inc hnd/ft/>30cm,3431578,CDM,761,RC,12007,HCPCS,Outpatient,,,304.05,152.03,,228.04,75,,,percent of total billed charges,75% of total billed charges,228.04,75,,,percent of total billed charges,75% of total billed charges,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,73.31,102,,,Fee Schedule,102% of WV Medicaid Rate,280.12,165,,,Fee Schedule,165% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,487.65,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,668.77,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,837.71,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,71.87,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,42.57,14,,,percent of total billed charges,14% of total billed charges,42.57,837.71,
12007-PF SIMPLE REPAIR SCALP/NECK/AX/GENIT/TRUNK >30.0C,4321354,CDM,981,RC,12007,HCPCS,Outpatient,,,304.05,152.03,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
12011- PF Smpl Rpr F/ E/ E/ N/ L/ M 2.5 cm/ <,4311476,CDM,960,RC,12011,HCPCS,Outpatient,,,116.45,58.23,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
12011- Rep Superfic Wounds 2.5Cm Less,3431579,CDM,761,RC,12011,HCPCS,Outpatient,,,116.45,58.23,,87.34,75,,,percent of total billed charges,75% of total billed charges,87.34,75,,,percent of total billed charges,75% of total billed charges,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,280.12,165,,,Fee Schedule,165% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,487.65,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,668.78,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,837.71,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,16.3,14,,,percent of total billed charges,14% of total billed charges,16.3,837.71,
12011-EYE RPR SPR WND FACE <2.5CM,3428738,CDM,510,RC,12011,HCPCS,Outpatient,,,116.45,58.23,,87.34,75,,,percent of total billed charges,75% of total billed charges,87.34,75,,,percent of total billed charges,75% of total billed charges,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,280.12,165,,,Fee Schedule,165% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,487.65,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,668.78,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,837.71,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,16.3,14,,,percent of total billed charges,14% of total billed charges,16.3,837.71,
12011-OCC EYE RPR SPR WND FACE <2.5CM,3536972,CDM,983,RC,12011,HCPCS,Outpatient,,,119.35,59.68,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
12011-PF SIMPLE REPAIR F/E/E/N/L/M 2.5CM/<,4321355,CDM,981,RC,12011,HCPCS,Outpatient,,,116.45,58.23,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
12013- Rep Superfic Wounds 2.6-5.0Cm,3431580,CDM,761,RC,12013,HCPCS,Outpatient,,,123.04,61.52,,92.28,75,,,percent of total billed charges,75% of total billed charges,92.28,75,,,percent of total billed charges,75% of total billed charges,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,280.12,165,,,Fee Schedule,165% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,487.65,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,668.78,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,837.71,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,17.23,14,,,percent of total billed charges,14% of total billed charges,17.23,837.71,
12013-PF SIMPLE REPAIR F/E/E/N/L/M 2.6CM-5.0 CM,4321357,CDM,981,RC,12013,HCPCS,Outpatient,,,123.04,61.52,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
12014 - Simple repair of superficial wound of eyelid,3428739,CDM,983,RC,12014,HCPCS,Outpatient,,,368.19,184.1,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
12014-PF SIMPLE REPAIR F/E/E/N/L/M 5.1CM-7.5 CM,4321358,CDM,981,RC,12014,HCPCS,Outpatient,,,159.53,79.77,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
12015- Rep Superfic Wounds 7.6-12.5Cm,3431581,CDM,761,RC,12015,HCPCS,Outpatient,,,200.19,100.1,,150.14,75,,,percent of total billed charges,75% of total billed charges,150.14,75,,,percent of total billed charges,75% of total billed charges,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,73.31,102,,,Fee Schedule,102% of WV Medicaid Rate,280.12,165,,,Fee Schedule,165% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,487.65,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,668.78,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,837.71,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,71.87,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,28.03,14,,,percent of total billed charges,14% of total billed charges,28.03,837.71,
12015-PF SIMPLE REPAIR F/E/E/N/L/M 7.6CM-12.5 CM,4321360,CDM,981,RC,12015,HCPCS,Outpatient,,,200.19,100.1,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
12016- Smp rp fac/ear/no/lip/lid 12.6-20,3428740,CDM,510,RC,12016,HCPCS,Outpatient,,,271.32,135.66,,203.49,75,,,percent of total billed charges,75% of total billed charges,203.49,75,,,percent of total billed charges,75% of total billed charges,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,141.09,102,,,Fee Schedule,102% of WV Medicaid Rate,578.73,165,,,Fee Schedule,165% of CMS OPPS Rate,363.52,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1007.47,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1381.67,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1730.68,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,138.32,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,363.52,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,37.98,14,,,percent of total billed charges,14% of total billed charges,37.98,1730.68,
12016-PF SIMPLE REPAIR F/E/E/N/L/M 12.6CM-20.0 CM,4321361,CDM,981,RC,12016,HCPCS,Outpatient,,,271.32,135.66,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
12017-PF SIMPLE REPAIR F/E/E/N/L/M 20.1CM-30.0 CM,4321363,CDM,981,RC,12017,HCPCS,Outpatient,,,328.28,164.14,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
12018- Smpl rpr/face/ear/lid/nose/lip/>30.0cm,3431582,CDM,761,RC,12018,HCPCS,Outpatient,,,369.73,184.87,,277.3,75,,,percent of total billed charges,75% of total billed charges,277.3,75,,,percent of total billed charges,75% of total billed charges,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,73.31,102,,,Fee Schedule,102% of WV Medicaid Rate,280.12,165,,,Fee Schedule,165% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,487.65,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,668.78,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,837.71,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,71.87,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,51.76,14,,,percent of total billed charges,14% of total billed charges,51.76,837.71,
12018-PF SIMPLE REPAIR F/E/E/N/L/M >30.0 CM,4321364,CDM,981,RC,12018,HCPCS,Outpatient,,,369.73,184.87,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
12020 - Treatment of superficial wound dehiscence; simple cl,4231108,CDM,510,RC,12020,HCPCS,Outpatient,,,756.73,378.37,,567.55,75,,,percent of total billed charges,75% of total billed charges,567.55,75,,,percent of total billed charges,75% of total billed charges,546.17,100,,,Fee Schedule,100% of CMS OPPS Rate,213.77,102,,,Fee Schedule,102% of WV Medicaid Rate,901.2,165,,,Fee Schedule,165% of CMS OPPS Rate,566.07,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1568.84,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2151.55,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,2695.04,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,209.58,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,546.17,100,,,Fee Schedule,100% of CMS OPPS Rate,566.07,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,105.94,14,,,percent of total billed charges,14% of total billed charges,105.94,2695.04,
12020 -OCC CLOSURE OF SPLIT WOUND,3568838,CDM,983,RC,12020,HCPCS,Outpatient,,,756.8,378.4,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
12020- Tx superfic wnd dehise/smp close,3431583,CDM,761,RC,12020,HCPCS,Outpatient,,,378,189,,283.5,75,,,percent of total billed charges,75% of total billed charges,283.5,75,,,percent of total billed charges,75% of total billed charges,546.17,100,,,Fee Schedule,100% of CMS OPPS Rate,213.77,102,,,Fee Schedule,102% of WV Medicaid Rate,901.2,165,,,Fee Schedule,165% of CMS OPPS Rate,566.07,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1568.84,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2151.55,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,2695.04,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,209.58,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,546.17,100,,,Fee Schedule,100% of CMS OPPS Rate,566.07,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,52.92,14,,,percent of total billed charges,14% of total billed charges,52.92,2695.04,
12020-PF TX SUPERFICIAL WOUND DEHISCENCE SIMPLE CLOSURE,4321366,CDM,981,RC,12020,HCPCS,Outpatient,,,378,189,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
12021- Tx superficial wnd dehise/smp/pack,3431584,CDM,761,RC,12021,HCPCS,Outpatient,,,282.55,141.28,,211.91,75,,,percent of total billed charges,75% of total billed charges,211.91,75,,,percent of total billed charges,75% of total billed charges,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,141.09,102,,,Fee Schedule,102% of WV Medicaid Rate,578.72,165,,,Fee Schedule,165% of CMS OPPS Rate,363.51,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1007.47,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1381.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1730.67,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,138.32,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,363.51,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,39.56,14,,,percent of total billed charges,14% of total billed charges,39.56,1730.67,
12021-PF TX SUPERFICIAL WOUND DEHISCENCE W/PACKING,4321367,CDM,981,RC,12021,HCPCS,Outpatient,,,282.55,141.28,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
12031- Int rp scalp/ax/trunk/ext 2.5 or <,3428743,CDM,761,RC,12031,HCPCS,Outpatient,,,299,149.5,,224.25,75,,,percent of total billed charges,75% of total billed charges,224.25,75,,,percent of total billed charges,75% of total billed charges,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,141.09,102,,,Fee Schedule,102% of WV Medicaid Rate,578.72,165,,,Fee Schedule,165% of CMS OPPS Rate,363.51,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1007.47,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1381.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1730.67,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,138.32,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,363.51,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,41.86,14,,,percent of total billed charges,14% of total billed charges,41.86,1730.67,
12031-PF REPAIR INTERMEDIATE S/A/T/E 2.5 CM/<,4321369,CDM,981,RC,12031,HCPCS,Outpatient,,,299,149.5,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
"12032- Intermed Rpr, Scalp, Axillae, Trunk, Extremities 2.6-7.5cm",3431585,CDM,761,RC,12032,HCPCS,Outpatient,,,374.71,187.36,,281.03,75,,,percent of total billed charges,75% of total billed charges,281.03,75,,,percent of total billed charges,75% of total billed charges,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,141.09,102,,,Fee Schedule,102% of WV Medicaid Rate,578.72,165,,,Fee Schedule,165% of CMS OPPS Rate,363.51,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1007.47,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1381.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1730.67,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,138.32,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,363.51,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,52.46,14,,,percent of total billed charges,14% of total billed charges,52.46,1730.67,
12032-PF REPAIR INTERMEDIATE S/A/T/E 2.6-7.5 CM,4321378,CDM,981,RC,12032,HCPCS,Outpatient,,,374.71,187.36,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
12034- Itmed rpr/scalp/ax/trnk/extrem/exclu hnd/ft/7.6-12.5c,3431586,CDM,761,RC,12034,HCPCS,Outpatient,,,409.54,204.77,,307.16,75,,,percent of total billed charges,75% of total billed charges,307.16,75,,,percent of total billed charges,75% of total billed charges,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,141.09,102,,,Fee Schedule,102% of WV Medicaid Rate,578.72,165,,,Fee Schedule,165% of CMS OPPS Rate,363.51,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1007.47,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1381.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1730.67,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,138.32,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,363.51,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,57.34,14,,,percent of total billed charges,14% of total billed charges,57.34,1730.67,
12034-PF REPAIR INTERMEDIATE S/A/T/E 7.6-12.5 CM,4321386,CDM,981,RC,12034,HCPCS,Outpatient,,,409.54,204.77,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
12035- Int rp scalp/ax/trunk/ext 12.6-20,3428744,CDM,510,RC,12035,HCPCS,Outpatient,,,487.35,243.68,,365.51,75,,,percent of total billed charges,75% of total billed charges,365.51,75,,,percent of total billed charges,75% of total billed charges,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,141.09,102,,,Fee Schedule,102% of WV Medicaid Rate,578.72,165,,,Fee Schedule,165% of CMS OPPS Rate,363.51,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1007.47,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1381.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1730.67,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,138.32,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,363.51,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,68.23,14,,,percent of total billed charges,14% of total billed charges,68.23,1730.67,
12035-PF REPAIR INTERMEDIATE S/A/T/E 12.6-20.0CM,4321387,CDM,981,RC,12035,HCPCS,Outpatient,,,487.35,243.68,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
12036-PF REPAIR INTERMEDIATE S/A/T/E 20.1-30.0 CM,4321388,CDM,981,RC,12036,HCPCS,Outpatient,,,576.13,288.07,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
"12037 - PF Repair, intermediate, wounds of scalp, axillae, trunk and/or extremities (excluding hands",3715363,CDM,960,RC,12037,HCPCS,Outpatient,,,671.36,335.68,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
"12037 - Repair, intermediate, wounds of scalp, axillae, trunk and/or extremities (excluding hands an",3715279,CDM,510,RC,12037,HCPCS,Outpatient,,,671.36,335.68,,503.52,75,,,percent of total billed charges,75% of total billed charges,503.52,75,,,percent of total billed charges,75% of total billed charges,1622.59,100,,,Fee Schedule,100% of CMS OPPS Rate,699.11,102,,,Fee Schedule,102% of WV Medicaid Rate,2677.27,165,,,Fee Schedule,165% of CMS OPPS Rate,1681.67,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4660.68,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,6391.75,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,8006.31,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,685.4,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1622.59,100,,,Fee Schedule,100% of CMS OPPS Rate,1681.67,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,93.99,14,,,percent of total billed charges,14% of total billed charges,93.99,8006.31,
12037-PF REPAIR INTERMEDIATE S/A/T/E >30.0 CM,4321389,CDM,981,RC,12037,HCPCS,Outpatient,,,671.36,335.68,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
12041- Itmed rpr/neck/hand/ft/ext genit/2.5 cm or <,3431587,CDM,761,RC,12041,HCPCS,Outpatient,,,288.91,144.46,,216.68,75,,,percent of total billed charges,75% of total billed charges,216.68,75,,,percent of total billed charges,75% of total billed charges,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,141.09,102,,,Fee Schedule,102% of WV Medicaid Rate,578.73,165,,,Fee Schedule,165% of CMS OPPS Rate,363.52,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1007.47,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1381.67,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1730.68,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,138.32,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,363.52,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,40.45,14,,,percent of total billed charges,14% of total billed charges,40.45,1730.68,
12041-PF REPAIR INTERMEDIATE N/H/F/XTRNL GENT 2.5CM/<,4321390,CDM,981,RC,12041,HCPCS,Outpatient,,,288.91,144.46,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
12042 - PF Rpr Intrmdt N/ H/ F/ Xtrnl Gent 2.6-7.5 cm,4311477,CDM,960,RC,12042,HCPCS,Outpatient,,,388.17,194.09,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
12042- Itmed rpr/neck/hand/ft/ext genit/2.6-7.5 cm,3431588,CDM,761,RC,12042,HCPCS,Outpatient,,,388.17,194.09,,291.13,75,,,percent of total billed charges,75% of total billed charges,291.13,75,,,percent of total billed charges,75% of total billed charges,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,141.09,102,,,Fee Schedule,102% of WV Medicaid Rate,578.72,165,,,Fee Schedule,165% of CMS OPPS Rate,363.51,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1007.47,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1381.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1730.67,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,138.32,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,363.51,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,54.34,14,,,percent of total billed charges,14% of total billed charges,54.34,1730.67,
12042-PF REPAIR INTERMEDIATE N/H/F/XTRNL GENT 2.6-7.5 CM,4321391,CDM,981,RC,12042,HCPCS,Outpatient,,,388.17,194.09,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
12044- Int rp neck/hand/feet/gen 7.6-12.5,3428745,CDM,510,RC,12044,HCPCS,Outpatient,,,429.43,214.72,,322.07,75,,,percent of total billed charges,75% of total billed charges,322.07,75,,,percent of total billed charges,75% of total billed charges,546.17,100,,,Fee Schedule,100% of CMS OPPS Rate,213.77,102,,,Fee Schedule,102% of WV Medicaid Rate,901.2,165,,,Fee Schedule,165% of CMS OPPS Rate,566.07,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1568.84,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2151.55,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,2695.04,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,209.58,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,546.17,100,,,Fee Schedule,100% of CMS OPPS Rate,566.07,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,60.12,14,,,percent of total billed charges,14% of total billed charges,60.12,2695.04,
12044-PF REPAIR INTERMEDIATE N/H/F/XTRNL GENT 7.6-12.5CM,4321392,CDM,981,RC,12044,HCPCS,Outpatient,,,429.43,214.72,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
12045- Itmed rpr/neck/hnd/ft/ext genit/12.6-20.0cm,3431589,CDM,761,RC,12045,HCPCS,Outpatient,,,550.35,275.18,,412.76,75,,,percent of total billed charges,75% of total billed charges,412.76,75,,,percent of total billed charges,75% of total billed charges,546.17,100,,,Fee Schedule,100% of CMS OPPS Rate,213.77,102,,,Fee Schedule,102% of WV Medicaid Rate,901.2,165,,,Fee Schedule,165% of CMS OPPS Rate,566.07,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1568.84,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2151.55,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,2695.04,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,209.58,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,546.17,100,,,Fee Schedule,100% of CMS OPPS Rate,566.07,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,77.05,14,,,percent of total billed charges,14% of total billed charges,77.05,2695.04,
12045-PF REPAIR INTERMEDIATE N/H/F/XTRNL GENT 12.6-20 CM,4321393,CDM,981,RC,12045,HCPCS,Outpatient,,,550.35,275.18,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
12046- Itmed rpr/neck/hnd/ft/ext genit/20.1-30.0cm,3431590,CDM,761,RC,12046,HCPCS,Outpatient,,,651.05,325.53,,488.29,75,,,percent of total billed charges,75% of total billed charges,488.29,75,,,percent of total billed charges,75% of total billed charges,546.17,100,,,Fee Schedule,100% of CMS OPPS Rate,213.77,102,,,Fee Schedule,102% of WV Medicaid Rate,901.2,165,,,Fee Schedule,165% of CMS OPPS Rate,566.07,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1568.84,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2151.55,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,2695.04,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,209.58,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,546.17,100,,,Fee Schedule,100% of CMS OPPS Rate,566.07,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,91.15,14,,,percent of total billed charges,14% of total billed charges,91.15,2695.04,
12046-PF RPR INTERMEDIATE N/H/F/XTRNL GENT 20.1-30.0 CM,4321394,CDM,981,RC,12046,HCPCS,Outpatient,,,651.05,325.53,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
12047- Itmed rpr/neck/hnd/ft/ext genit/> 30.0 cm,3431591,CDM,761,RC,12047,HCPCS,Outpatient,,,724.43,362.22,,543.32,75,,,percent of total billed charges,75% of total billed charges,543.32,75,,,percent of total billed charges,75% of total billed charges,1622.59,100,,,Fee Schedule,100% of CMS OPPS Rate,699.11,102,,,Fee Schedule,102% of WV Medicaid Rate,2677.27,165,,,Fee Schedule,165% of CMS OPPS Rate,1681.67,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4660.68,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,6391.75,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,8006.31,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,685.4,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1622.59,100,,,Fee Schedule,100% of CMS OPPS Rate,1681.67,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,101.42,14,,,percent of total billed charges,14% of total billed charges,101.42,8006.31,
12047-PF REPAIR INTERMEDIATE N/H/F/XTRNL GENT >30.0 CM,4321395,CDM,981,RC,12047,HCPCS,Outpatient,,,724.43,362.22,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
12051- Itmed rpr/face/ear/lid/nose/lip/2.5 cm or<,3431592,CDM,761,RC,12051,HCPCS,Outpatient,,,336.44,168.22,,252.33,75,,,percent of total billed charges,75% of total billed charges,252.33,75,,,percent of total billed charges,75% of total billed charges,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,141.09,102,,,Fee Schedule,102% of WV Medicaid Rate,578.72,165,,,Fee Schedule,165% of CMS OPPS Rate,363.51,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1007.47,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1381.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1730.67,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,138.32,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,363.51,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,47.1,14,,,percent of total billed charges,14% of total billed charges,47.1,1730.67,
12051-PF REPAIR INTERMEDIATE F/E/E/N/L&/MUC 2.5 CM/<,4321396,CDM,981,RC,12051,HCPCS,Outpatient,,,336.44,168.22,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
12052- Itmed rpr/face/ear/lid/nose/lip/2.6-5.0 cm,3431593,CDM,761,RC,12052,HCPCS,Outpatient,,,396.16,198.08,,297.12,75,,,percent of total billed charges,75% of total billed charges,297.12,75,,,percent of total billed charges,75% of total billed charges,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,141.09,102,,,Fee Schedule,102% of WV Medicaid Rate,578.72,165,,,Fee Schedule,165% of CMS OPPS Rate,363.51,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1007.47,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1381.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1730.67,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,138.32,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,363.51,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,55.46,14,,,percent of total billed charges,14% of total billed charges,55.46,1730.67,
12052-PF REPAIR INTERMEDIATE F/E/E/N/L&/MUC 2.6-5.0 CM,4321397,CDM,981,RC,12052,HCPCS,Outpatient,,,396.16,198.08,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
12053- Int rp fac/ear/lid/nos/lip 5.1-7.5,3428750,CDM,761,RC,12053,HCPCS,Outpatient,,,428.81,214.41,,321.61,75,,,percent of total billed charges,75% of total billed charges,321.61,75,,,percent of total billed charges,75% of total billed charges,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,141.09,102,,,Fee Schedule,102% of WV Medicaid Rate,578.72,165,,,Fee Schedule,165% of CMS OPPS Rate,363.51,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1007.47,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1381.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1730.67,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,138.32,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,363.51,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,60.03,14,,,percent of total billed charges,14% of total billed charges,60.03,1730.67,
12053-PF REPAIR INTERMEDIATE F/E/E/N/L&/MUC 5.1-7.5 CM,4321400,CDM,981,RC,12053,HCPCS,Outpatient,,,428.81,214.41,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
12054- In rp fac/ear/lid/nos/lip 7.6-12.5,3428751,CDM,510,RC,12054,HCPCS,Outpatient,,,444.86,222.43,,333.65,75,,,percent of total billed charges,75% of total billed charges,333.65,75,,,percent of total billed charges,75% of total billed charges,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,141.09,102,,,Fee Schedule,102% of WV Medicaid Rate,578.73,165,,,Fee Schedule,165% of CMS OPPS Rate,363.52,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1007.47,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1381.67,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1730.68,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,138.32,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,363.52,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,62.28,14,,,percent of total billed charges,14% of total billed charges,62.28,1730.68,
12054-PF REPAIR INTERMEDIATE F/E/E/N/L&/MUC 7.6-12.5 CM,4321401,CDM,981,RC,12054,HCPCS,Outpatient,,,444.86,222.43,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
12055- Itmed rpr/face 2.6-20.0cm,3428752,CDM,510,RC,12055,HCPCS,Outpatient,,,611.13,305.57,,458.35,75,,,percent of total billed charges,75% of total billed charges,458.35,75,,,percent of total billed charges,75% of total billed charges,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,141.09,102,,,Fee Schedule,102% of WV Medicaid Rate,578.72,165,,,Fee Schedule,165% of CMS OPPS Rate,363.51,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1007.47,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1381.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1730.67,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,138.32,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,363.51,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,85.56,14,,,percent of total billed charges,14% of total billed charges,85.56,1730.67,
12055-PF REPAIR INTERMEDIATE F/E/E/N/L&/MUC 12.6-20.0CM,4321404,CDM,981,RC,12055,HCPCS,Outpatient,,,611.13,305.57,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
12056- Int rp fac/ear/lid/nos/lip 20.1-30,3428755,CDM,510,RC,12056,HCPCS,Outpatient,,,772.15,386.08,,579.11,75,,,percent of total billed charges,75% of total billed charges,579.11,75,,,percent of total billed charges,75% of total billed charges,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,141.09,102,,,Fee Schedule,102% of WV Medicaid Rate,578.73,165,,,Fee Schedule,165% of CMS OPPS Rate,363.52,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1007.47,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1381.67,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1730.68,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,138.32,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,363.52,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,108.1,14,,,percent of total billed charges,14% of total billed charges,108.1,1730.68,
12056-PF REPAIR INTERMEDIATE F/E/E/N/L&/MUC 20.1-30.0CM,4321406,CDM,981,RC,12056,HCPCS,Outpatient,,,772.15,386.08,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
12057- Itmed rpr/face/ear/lid/nose/lip/>30.0cm,3431594,CDM,761,RC,12057,HCPCS,Outpatient,,,846.26,423.13,,634.7,75,,,percent of total billed charges,75% of total billed charges,634.7,75,,,percent of total billed charges,75% of total billed charges,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,141.09,102,,,Fee Schedule,102% of WV Medicaid Rate,578.72,165,,,Fee Schedule,165% of CMS OPPS Rate,363.51,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1007.47,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1381.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1730.67,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,138.32,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,363.51,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,118.48,14,,,percent of total billed charges,14% of total billed charges,118.48,1730.67,
12057-PF REPAIR INTERMEDIATE F/E/E/N/L&/MUC >30.0 CM,4321407,CDM,981,RC,12057,HCPCS,Outpatient,,,846.26,423.13,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
13100-PF REPAIR COMPLEX TRUNK 1.1-2.5 CM,4321409,CDM,981,RC,13100,HCPCS,Outpatient,,,399.01,199.51,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
13101- Complex repair/trunk/2.6-7.5 cm,3431595,CDM,761,RC,13101,HCPCS,Outpatient,,,487.66,243.83,,365.75,75,,,percent of total billed charges,75% of total billed charges,365.75,75,,,percent of total billed charges,75% of total billed charges,546.17,100,,,Fee Schedule,100% of CMS OPPS Rate,213.77,102,,,Fee Schedule,102% of WV Medicaid Rate,901.2,165,,,Fee Schedule,165% of CMS OPPS Rate,566.07,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1568.84,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2151.55,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,2695.04,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,209.58,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,546.17,100,,,Fee Schedule,100% of CMS OPPS Rate,566.07,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,68.27,14,,,percent of total billed charges,14% of total billed charges,68.27,2695.04,
13101-PF REPAIR COMPLEX TRUNK 2.6-7.5 CM,4321410,CDM,981,RC,13101,HCPCS,Outpatient,,,487.66,243.83,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
"13102 - Repair, complex, trunk; each additional 5 cm or less",4037473,CDM,510,RC,13102,HCPCS,Outpatient,,,145.88,72.94,,109.41,75,,,percent of total billed charges,75% of total billed charges,109.41,75,,,percent of total billed charges,75% of total billed charges,46.68,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.42,14,,,percent of total billed charges,14% of total billed charges,20.42,109.41,
13102-PF REPAIR COMPLEX TRUNK EACH ADDITIONAL 5 CM/<,4321414,CDM,981,RC,13102,HCPCS,Outpatient,,,145.88,72.94,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
13120- Repair/comp/scalp/arm/leg/1.1-2.5c,3431596,CDM,761,RC,13120,HCPCS,Outpatient,,,457.5,228.75,,343.13,75,,,percent of total billed charges,75% of total billed charges,343.13,75,,,percent of total billed charges,75% of total billed charges,546.17,100,,,Fee Schedule,100% of CMS OPPS Rate,213.77,102,,,Fee Schedule,102% of WV Medicaid Rate,901.2,165,,,Fee Schedule,165% of CMS OPPS Rate,566.07,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1568.84,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2151.55,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,2695.04,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,209.58,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,546.17,100,,,Fee Schedule,100% of CMS OPPS Rate,566.07,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,64.05,14,,,percent of total billed charges,14% of total billed charges,64.05,2695.04,
13120-PF REPAIR COMPLEX SCALP/ARM/LEG 1.1-2.5 CM,4321415,CDM,981,RC,13120,HCPCS,Outpatient,,,457.5,228.75,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
13121- Cmplx rpr s/a/l 2.6-7.5 cm,3431597,CDM,761,RC,13121,HCPCS,Outpatient,,,513.25,256.63,,384.94,75,,,percent of total billed charges,75% of total billed charges,384.94,75,,,percent of total billed charges,75% of total billed charges,546.17,100,,,Fee Schedule,100% of CMS OPPS Rate,213.77,102,,,Fee Schedule,102% of WV Medicaid Rate,901.2,165,,,Fee Schedule,165% of CMS OPPS Rate,566.07,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1568.84,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2151.55,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,2695.04,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,209.58,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,546.17,100,,,Fee Schedule,100% of CMS OPPS Rate,566.07,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,71.86,14,,,percent of total billed charges,14% of total billed charges,71.86,2695.04,
13121-PF REPAIR COMPLEX SCALP/ARM/LEG 2.6-7.5 CM,4321417,CDM,981,RC,13121,HCPCS,Outpatient,,,513.25,256.63,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
"13122 - Repair, complex, scalp, arms, and/or legs; each additional 5 cm or less (List separately in",3715283,CDM,510,RC,13122,HCPCS,Outpatient,,,167.59,83.8,,125.69,75,,,percent of total billed charges,75% of total billed charges,125.69,75,,,percent of total billed charges,75% of total billed charges,53.63,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.46,14,,,percent of total billed charges,14% of total billed charges,23.46,125.69,
13122-PF REPAIR COMPLEX SCALP/ARM/LEG EA ADDL 5 CM/<,4321418,CDM,981,RC,13122,HCPCS,Outpatient,,,167.59,83.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
13131- Cmplx rpr f/c/c/m/n/ax/g/h/f; 1.1 cm to 2.5 cm,3431598,CDM,761,RC,13131,HCPCS,Outpatient,,,482.19,241.1,,361.64,75,,,percent of total billed charges,75% of total billed charges,361.64,75,,,percent of total billed charges,75% of total billed charges,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,141.09,102,,,Fee Schedule,102% of WV Medicaid Rate,578.72,165,,,Fee Schedule,165% of CMS OPPS Rate,363.51,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1007.47,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1381.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1730.67,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,138.32,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,363.51,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,67.51,14,,,percent of total billed charges,14% of total billed charges,67.51,1730.67,
13131-PF REPAIR COMPLEX F/C/C/M/N/AX/G/H/F 1.1-2.5 CM,4321420,CDM,981,RC,13131,HCPCS,Outpatient,,,482.19,241.1,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
13132- Cmplx rpr f/c/c/m/n/ax/g/h/f; 2.6 cm to 7.5 cm,3431599,CDM,761,RC,13132,HCPCS,Outpatient,,,602.31,301.16,,451.73,75,,,percent of total billed charges,75% of total billed charges,451.73,75,,,percent of total billed charges,75% of total billed charges,546.17,100,,,Fee Schedule,100% of CMS OPPS Rate,213.77,102,,,Fee Schedule,102% of WV Medicaid Rate,901.2,165,,,Fee Schedule,165% of CMS OPPS Rate,566.07,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1568.84,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2151.55,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,2695.04,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,209.58,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,546.17,100,,,Fee Schedule,100% of CMS OPPS Rate,566.07,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,84.32,14,,,percent of total billed charges,14% of total billed charges,84.32,2695.04,
13132-PF REPAIR COMPLEX F/C/C/M/N/AX/G/H/F 2.6-7.5 CM,4321423,CDM,981,RC,13132,HCPCS,Outpatient,,,602.31,301.16,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
13133-PF REPAIR COMPLEX F/C/C/M/N/AX/G/H/F EA ADDL 5 CM/<,4321425,CDM,981,RC,13133,HCPCS,Outpatient,,,253.06,126.53,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
13151- Cmplx rpr e/n/e/l; 1.1-2.5 cm,3431601,CDM,761,RC,13151,HCPCS,Outpatient,,,554.7,277.35,,416.03,75,,,percent of total billed charges,75% of total billed charges,416.03,75,,,percent of total billed charges,75% of total billed charges,546.17,100,,,Fee Schedule,100% of CMS OPPS Rate,213.77,102,,,Fee Schedule,102% of WV Medicaid Rate,901.2,165,,,Fee Schedule,165% of CMS OPPS Rate,566.07,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1568.84,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2151.55,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,2695.04,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,209.58,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,546.17,100,,,Fee Schedule,100% of CMS OPPS Rate,566.07,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,77.66,14,,,percent of total billed charges,14% of total billed charges,77.66,2695.04,
13151-PF REPAIR COMPLEX EYELID/NOSE/EAR/LIP 1.1-2.5 CM,4321427,CDM,981,RC,13151,HCPCS,Outpatient,,,554.7,277.35,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
13152- Cmplx rpr e/n/e/l; 2.6-7.5 cm,3431602,CDM,761,RC,13152,HCPCS,Outpatient,,,669.92,334.96,,502.44,75,,,percent of total billed charges,75% of total billed charges,502.44,75,,,percent of total billed charges,75% of total billed charges,546.17,100,,,Fee Schedule,100% of CMS OPPS Rate,213.77,102,,,Fee Schedule,102% of WV Medicaid Rate,901.2,165,,,Fee Schedule,165% of CMS OPPS Rate,566.07,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1568.84,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2151.55,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,2695.04,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,209.58,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,546.17,100,,,Fee Schedule,100% of CMS OPPS Rate,566.07,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,93.79,14,,,percent of total billed charges,14% of total billed charges,93.79,2695.04,
13152-PF REPAIR COMPLEX EYELID/NOSE/EAR/LIP 2.6-7.5 CM,4321430,CDM,981,RC,13152,HCPCS,Outpatient,,,669.92,334.96,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
13153-PF REPAIR COMPLX EYELID/NOSE/EAR/LIP EA ADDL 5 CM/<,4322014,CDM,981,RC,13153,HCPCS,Outpatient,,,277.23,138.62,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
13160 - PF 2ndry Clsr Surg Wound/ Dehsn Extsv/ Complic,4311478,CDM,960,RC,13160,HCPCS,Outpatient,,,1612.56,806.28,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
13160- Secondary clos/surg wound/ext/comp,3431603,CDM,761,RC,13160,HCPCS,Outpatient,,,1612.56,806.28,,1209.42,75,,,percent of total billed charges,75% of total billed charges,1209.42,75,,,percent of total billed charges,75% of total billed charges,1622.59,100,,,Fee Schedule,100% of CMS OPPS Rate,699.11,102,,,Fee Schedule,102% of WV Medicaid Rate,2677.27,165,,,Fee Schedule,165% of CMS OPPS Rate,1681.67,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4660.68,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,6391.75,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,8006.31,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,685.4,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1622.59,100,,,Fee Schedule,100% of CMS OPPS Rate,1681.67,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,225.76,14,,,percent of total billed charges,14% of total billed charges,225.76,8006.31,
13160-PF SECONDARY CLOSURE SURG WOUND/DEHSN EXTSV/COMPLIC,4322013,CDM,981,RC,13160,HCPCS,Outpatient,,,1612.56,806.28,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
"14000 - (PF) Adjacent tissue transfer or rearrangement, trunk; defect 10 sq cm or less",3634893,CDM,960,RC,14000,HCPCS,Outpatient,,,1007.83,503.92,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
14001- Skin Tiss Transfer 10.1-30Sq Cm,3431604,CDM,761,RC,14001,HCPCS,Outpatient,,,1314.46,657.23,,985.85,75,,,percent of total billed charges,75% of total billed charges,985.85,75,,,percent of total billed charges,75% of total billed charges,1622.59,100,,,Fee Schedule,100% of CMS OPPS Rate,699.11,102,,,Fee Schedule,102% of WV Medicaid Rate,2677.27,165,,,Fee Schedule,165% of CMS OPPS Rate,1681.67,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4660.68,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,6391.75,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,8006.31,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,685.4,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1622.59,100,,,Fee Schedule,100% of CMS OPPS Rate,1681.67,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,184.02,14,,,percent of total billed charges,14% of total billed charges,184.02,8006.31,
14020- Skin Tissue Trnfr 10Sq Cm Less,3431605,CDM,761,RC,14020,HCPCS,Outpatient,,,1124.34,562.17,,843.26,75,,,percent of total billed charges,75% of total billed charges,843.26,75,,,percent of total billed charges,75% of total billed charges,1622.59,100,,,Fee Schedule,100% of CMS OPPS Rate,699.11,102,,,Fee Schedule,102% of WV Medicaid Rate,2677.27,165,,,Fee Schedule,165% of CMS OPPS Rate,1681.67,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4660.68,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,6391.75,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,8006.31,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,685.4,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1622.59,100,,,Fee Schedule,100% of CMS OPPS Rate,1681.67,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,157.41,14,,,percent of total billed charges,14% of total billed charges,157.41,8006.31,
14021- Skin Tissue Trnfr 10.1-30Sq Cm,3431606,CDM,761,RC,14021,HCPCS,Outpatient,,,1410.33,705.17,,1057.75,75,,,percent of total billed charges,75% of total billed charges,1057.75,75,,,percent of total billed charges,75% of total billed charges,1622.59,100,,,Fee Schedule,100% of CMS OPPS Rate,699.11,102,,,Fee Schedule,102% of WV Medicaid Rate,2677.27,165,,,Fee Schedule,165% of CMS OPPS Rate,1681.67,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4660.68,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,6391.75,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,8006.31,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,685.4,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1622.59,100,,,Fee Schedule,100% of CMS OPPS Rate,1681.67,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,197.45,14,,,percent of total billed charges,14% of total billed charges,197.45,8006.31,
14040- Tis trnfr f/c/c/m/n/a/g/h/f; defect 10 sq cm or less,3431607,CDM,761,RC,14040,HCPCS,Outpatient,,,1239.78,619.89,,929.84,75,,,percent of total billed charges,75% of total billed charges,929.84,75,,,percent of total billed charges,75% of total billed charges,1622.59,100,,,Fee Schedule,100% of CMS OPPS Rate,699.11,102,,,Fee Schedule,102% of WV Medicaid Rate,2677.27,165,,,Fee Schedule,165% of CMS OPPS Rate,1681.67,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4660.68,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,6391.75,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,8006.31,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,685.4,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1622.59,100,,,Fee Schedule,100% of CMS OPPS Rate,1681.67,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,173.57,14,,,percent of total billed charges,14% of total billed charges,173.57,8006.31,
14041- Adj tis trans/see area/10.1-30sqcm,3431608,CDM,761,RC,14041,HCPCS,Outpatient,,,1514.25,757.13,,1135.69,75,,,percent of total billed charges,75% of total billed charges,1135.69,75,,,percent of total billed charges,75% of total billed charges,1622.59,100,,,Fee Schedule,100% of CMS OPPS Rate,699.11,102,,,Fee Schedule,102% of WV Medicaid Rate,2677.27,165,,,Fee Schedule,165% of CMS OPPS Rate,1681.67,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4660.68,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,6391.75,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,8006.31,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,685.4,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1622.59,100,,,Fee Schedule,100% of CMS OPPS Rate,1681.67,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,212,14,,,percent of total billed charges,14% of total billed charges,212,8006.31,
14060- Tis trnfr e/n/e/l 10 sq cm/<,3431609,CDM,761,RC,14060,HCPCS,Outpatient,,,1514.25,757.13,,1135.69,75,,,percent of total billed charges,75% of total billed charges,1135.69,75,,,percent of total billed charges,75% of total billed charges,1622.59,100,,,Fee Schedule,100% of CMS OPPS Rate,699.11,102,,,Fee Schedule,102% of WV Medicaid Rate,2677.27,165,,,Fee Schedule,165% of CMS OPPS Rate,1681.67,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4660.68,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,6391.75,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,8006.31,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,685.4,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1622.59,100,,,Fee Schedule,100% of CMS OPPS Rate,1681.67,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,212,14,,,percent of total billed charges,14% of total billed charges,212,8006.31,
14350- Filleted/fng/toe/recip site prep,3431610,CDM,510,RC,14350,HCPCS,Outpatient,,,1760.71,880.36,,1320.53,75,,,percent of total billed charges,75% of total billed charges,1320.53,75,,,percent of total billed charges,75% of total billed charges,1622.59,100,,,Fee Schedule,100% of CMS OPPS Rate,699.11,102,,,Fee Schedule,102% of WV Medicaid Rate,2677.27,165,,,Fee Schedule,165% of CMS OPPS Rate,1681.67,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4660.68,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,6391.75,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,8006.31,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,685.4,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1622.59,100,,,Fee Schedule,100% of CMS OPPS Rate,1681.67,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,246.5,14,,,percent of total billed charges,14% of total billed charges,246.5,8006.31,
"15002- Wnd Prep,Ch/Inf,Trk/Arm/Lg",3431611,CDM,510,RC,15002,HCPCS,Outpatient,,,889.22,444.61,,666.92,75,,,percent of total billed charges,75% of total billed charges,666.92,75,,,percent of total billed charges,75% of total billed charges,1622.59,100,,,Fee Schedule,100% of CMS OPPS Rate,699.11,102,,,Fee Schedule,102% of WV Medicaid Rate,2677.27,165,,,Fee Schedule,165% of CMS OPPS Rate,1681.67,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4660.68,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,6391.75,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,8006.31,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,685.4,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1622.59,100,,,Fee Schedule,100% of CMS OPPS Rate,1681.67,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,124.49,14,,,percent of total billed charges,14% of total billed charges,124.49,8006.31,
"15003- Wnd Prep,Ch/Inf Addl 100 Cm",3431612,CDM,510,RC,15003,HCPCS,Outpatient,,,181.13,90.57,,135.85,75,,,percent of total billed charges,75% of total billed charges,135.85,75,,,percent of total billed charges,75% of total billed charges,57.96,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.36,14,,,percent of total billed charges,14% of total billed charges,25.36,135.85,
"15004- Wnd Prep Ch/Inf,F/N/Hf/G",3431613,CDM,960,RC,15004,HCPCS,Outpatient,,,525.51,262.76,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
"15040 - Harvest of skin for tissue cultured skin autograft, 100 sq cm or less",3715286,CDM,510,RC,15040,HCPCS,Outpatient,,,255.71,127.86,,191.78,75,,,percent of total billed charges,75% of total billed charges,191.78,75,,,percent of total billed charges,75% of total billed charges,1622.59,100,,,Fee Schedule,100% of CMS OPPS Rate,699.11,102,,,Fee Schedule,102% of WV Medicaid Rate,2677.27,165,,,Fee Schedule,165% of CMS OPPS Rate,1681.67,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4660.68,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,6391.75,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,8006.31,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,685.4,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1622.59,100,,,Fee Schedule,100% of CMS OPPS Rate,1681.67,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,35.8,14,,,percent of total billed charges,14% of total billed charges,35.8,8006.31,
15100PF Split-Thickness Autograft Trunk/Arms/Legs First 100s,4281204,CDM,960,RC,15100,HCPCS,Outpatient,,,1445.06,722.53,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
15101- Skin Split Graft Addl 100Sq Cm,3431614,CDM,761,RC,15101,HCPCS,Outpatient,,,226.37,113.19,,169.78,75,,,percent of total billed charges,75% of total billed charges,169.78,75,,,percent of total billed charges,75% of total billed charges,72.44,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.69,14,,,percent of total billed charges,14% of total billed charges,31.69,169.78,
15110- Epidrm Autogrft Trnk/Arm/Leg,3431615,CDM,761,RC,15110,HCPCS,Outpatient,,,1459.07,729.54,,1094.3,75,,,percent of total billed charges,75% of total billed charges,1094.3,75,,,percent of total billed charges,75% of total billed charges,1622.59,100,,,Fee Schedule,100% of CMS OPPS Rate,699.11,102,,,Fee Schedule,102% of WV Medicaid Rate,2677.27,165,,,Fee Schedule,165% of CMS OPPS Rate,1681.67,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4660.68,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,6391.75,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,8006.31,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,685.4,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1622.59,100,,,Fee Schedule,100% of CMS OPPS Rate,1681.67,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,204.27,14,,,percent of total billed charges,14% of total billed charges,204.27,8006.31,
15111- Epiderm autograft/specified areas/ea add 100sq cm/ea add 1% body area infant/child,3431616,CDM,761,RC,15111,HCPCS,Outpatient,,,212.17,106.09,,159.13,75,,,percent of total billed charges,75% of total billed charges,159.13,75,,,percent of total billed charges,75% of total billed charges,67.89,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.7,14,,,percent of total billed charges,14% of total billed charges,29.7,159.13,
15115- Epiderm autograft/specified areas/first 100sq cm or </1% body area/infant/child,3431617,CDM,761,RC,15115,HCPCS,Outpatient,,,1415.57,707.79,,1061.68,75,,,percent of total billed charges,75% of total billed charges,1061.68,75,,,percent of total billed charges,75% of total billed charges,1622.59,100,,,Fee Schedule,100% of CMS OPPS Rate,699.11,102,,,Fee Schedule,102% of WV Medicaid Rate,2677.27,165,,,Fee Schedule,165% of CMS OPPS Rate,1681.67,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4660.68,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,6391.75,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,8006.31,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,685.4,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1622.59,100,,,Fee Schedule,100% of CMS OPPS Rate,1681.67,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,198.18,14,,,percent of total billed charges,14% of total billed charges,198.18,8006.31,
15120 - SPLIT AGRFT F/S/N/H/F/G/M/D GT 1ST 100 CM/,4037474,CDM,510,RC,15120,HCPCS,Outpatient,,,1392.29,696.15,,1044.22,75,,,percent of total billed charges,75% of total billed charges,1044.22,75,,,percent of total billed charges,75% of total billed charges,3058.39,100,,,Fee Schedule,100% of CMS OPPS Rate,1437.27,102,,,Fee Schedule,102% of WV Medicaid Rate,5046.34,165,,,Fee Schedule,165% of CMS OPPS Rate,3169.76,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8784.82,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,12047.69,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,15090.95,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1409.09,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,3058.39,100,,,Fee Schedule,100% of CMS OPPS Rate,3169.76,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,194.92,14,,,percent of total billed charges,14% of total billed charges,194.92,15090.95,
15200- Full thick graft/trunk/</=20 sq cm,3431619,CDM,761,RC,15200,HCPCS,Outpatient,,,1353.32,676.66,,1014.99,75,,,percent of total billed charges,75% of total billed charges,1014.99,75,,,percent of total billed charges,75% of total billed charges,1622.59,100,,,Fee Schedule,100% of CMS OPPS Rate,699.11,102,,,Fee Schedule,102% of WV Medicaid Rate,2677.27,165,,,Fee Schedule,165% of CMS OPPS Rate,1681.67,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4660.68,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,6391.75,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,8006.31,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,685.4,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1622.59,100,,,Fee Schedule,100% of CMS OPPS Rate,1681.67,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,189.46,14,,,percent of total billed charges,14% of total billed charges,189.46,8006.31,
15220- Full thick gft/scalp/arm/leg/20sqcm or<,3431620,CDM,761,RC,15220,HCPCS,Outpatient,,,1213.83,606.92,,910.37,75,,,percent of total billed charges,75% of total billed charges,910.37,75,,,percent of total billed charges,75% of total billed charges,1622.59,100,,,Fee Schedule,100% of CMS OPPS Rate,699.11,102,,,Fee Schedule,102% of WV Medicaid Rate,2677.27,165,,,Fee Schedule,165% of CMS OPPS Rate,1681.67,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4660.68,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,6391.75,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,8006.31,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,685.4,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1622.59,100,,,Fee Schedule,100% of CMS OPPS Rate,1681.67,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,169.94,14,,,percent of total billed charges,14% of total billed charges,169.94,8006.31,
15221- Full thick gft/scalp/arm/leg/add 20sqcm,3431621,CDM,761,RC,15221,HCPCS,Outpatient,,,140.94,70.47,,105.71,75,,,percent of total billed charges,75% of total billed charges,105.71,75,,,percent of total billed charges,75% of total billed charges,45.1,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.73,14,,,percent of total billed charges,14% of total billed charges,19.73,105.71,
15240- Full Thick Graft w/close donor site face/neck/ax/genit/hnd/ft <=20sqcm,3431622,CDM,761,RC,15240,HCPCS,Outpatient,,,1578.13,789.07,,1183.6,75,,,percent of total billed charges,75% of total billed charges,1183.6,75,,,percent of total billed charges,75% of total billed charges,1622.59,100,,,Fee Schedule,100% of CMS OPPS Rate,699.11,102,,,Fee Schedule,102% of WV Medicaid Rate,2677.27,165,,,Fee Schedule,165% of CMS OPPS Rate,1681.67,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4660.68,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,6391.75,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,8006.31,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,685.4,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1622.59,100,,,Fee Schedule,100% of CMS OPPS Rate,1681.67,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,220.94,14,,,percent of total billed charges,14% of total billed charges,220.94,8006.31,
15241- Skin Full Graft Add 20Sq Cm,3431623,CDM,761,RC,15241,HCPCS,Outpatient,,,218.23,109.12,,163.67,75,,,percent of total billed charges,75% of total billed charges,163.67,75,,,percent of total billed charges,75% of total billed charges,69.83,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.55,14,,,percent of total billed charges,14% of total billed charges,30.55,163.67,
15260- Full thick gft/nose/ear/lid/lip/20sqcm or<,3431624,CDM,761,RC,15260,HCPCS,Outpatient,,,1673.85,836.93,,1255.39,75,,,percent of total billed charges,75% of total billed charges,1255.39,75,,,percent of total billed charges,75% of total billed charges,1622.59,100,,,Fee Schedule,100% of CMS OPPS Rate,699.11,102,,,Fee Schedule,102% of WV Medicaid Rate,2677.27,165,,,Fee Schedule,165% of CMS OPPS Rate,1681.67,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4660.68,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,6391.75,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,8006.31,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,685.4,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1622.59,100,,,Fee Schedule,100% of CMS OPPS Rate,1681.67,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,234.34,14,,,percent of total billed charges,14% of total billed charges,234.34,8006.31,
15261- Skin Full Graft Add 20 Sq Cm,3431625,CDM,761,RC,15261,HCPCS,Outpatient,,,272.7,136.35,,204.53,75,,,percent of total billed charges,75% of total billed charges,204.53,75,,,percent of total billed charges,75% of total billed charges,87.26,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.18,14,,,percent of total billed charges,14% of total billed charges,38.18,204.53,
15271 - PF AppSkn Sub Grft T/A/L Area/100sq cm/<1st 25,4309233,CDM,960,RC,15271,HCPCS,Outpatient,,,171.15,85.58,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
15273- Skin Sub Grft Trnk Arm Lg Child,3431626,CDM,761,RC,15273,HCPCS,Outpatient,,,401.51,200.76,,301.13,75,,,percent of total billed charges,75% of total billed charges,301.13,75,,,percent of total billed charges,75% of total billed charges,3058.39,100,,,Fee Schedule,100% of CMS OPPS Rate,1437.27,102,,,Fee Schedule,102% of WV Medicaid Rate,5046.34,165,,,Fee Schedule,165% of CMS OPPS Rate,3169.76,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8784.82,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,12047.69,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,15090.95,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1409.09,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,3058.39,100,,,Fee Schedule,100% of CMS OPPS Rate,3169.76,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,56.21,14,,,percent of total billed charges,14% of total billed charges,56.21,15090.95,
"15275 Application of skin substitute graft to face, scalp, eyelids, mouth, neck, ears, orbits, genit",3621205,CDM,510,RC,15275,HCPCS,Outpatient,,,189.49,94.75,,142.12,75,,,percent of total billed charges,75% of total billed charges,142.12,75,,,percent of total billed charges,75% of total billed charges,1622.59,100,,,Fee Schedule,100% of CMS OPPS Rate,699.11,102,,,Fee Schedule,102% of WV Medicaid Rate,2677.27,165,,,Fee Schedule,165% of CMS OPPS Rate,1681.67,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4660.68,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,6391.75,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,8006.31,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,685.4,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1622.59,100,,,Fee Schedule,100% of CMS OPPS Rate,1681.67,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,26.53,14,,,percent of total billed charges,14% of total billed charges,26.53,8006.31,
15275-OCC Skin sub graft face/nk/hf/g,3536971,CDM,983,RC,15275,HCPCS,Outpatient,,,246.52,123.26,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
15576 - FRMJ DIRECT/TUBED PEDICLE W/WOTR E/N/E/L/NTRORAL,3997179,CDM,960,RC,15576,HCPCS,Outpatient,,,1289.43,644.72,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
15730 - PF Midface Flap w/ Preservation of Vascular Pedicle(s),4333233,CDM,960,RC,15730,HCPCS,Outpatient,,,1716.32,858.16,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
"15734 - Muscle, myocutaneous, or fasciocutaneous flap; trunk",3572796,CDM,960,RC,15734,HCPCS,Outpatient,,,3076.46,1538.23,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
15760- Composite graft/pri close/don area,3431628,CDM,761,RC,15760,HCPCS,Outpatient,,,1394.05,697.03,,1045.54,75,,,percent of total billed charges,75% of total billed charges,1045.54,75,,,percent of total billed charges,75% of total billed charges,1622.59,100,,,Fee Schedule,100% of CMS OPPS Rate,699.11,102,,,Fee Schedule,102% of WV Medicaid Rate,2677.27,165,,,Fee Schedule,165% of CMS OPPS Rate,1681.67,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4660.68,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,6391.75,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,8006.31,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,685.4,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1622.59,100,,,Fee Schedule,100% of CMS OPPS Rate,1681.67,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,195.17,14,,,percent of total billed charges,14% of total billed charges,195.17,8006.31,
"15769 - PF Grafting of autologous soft tissue, other, harvested by direct excision (eg, fat, dermis,",3712907,CDM,960,RC,15769,HCPCS,Outpatient,,,971.64,485.82,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
15770 - PF Graft; derma-fat-fascia,3712908,CDM,960,RC,15770,HCPCS,Outpatient,,,1348.55,674.28,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
15777 - Acellular Derm Matrix Implt Bio for Soft Tiss Reinfo,3898973,CDM,983,RC,15777,HCPCS,Outpatient,,,570.85,285.43,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
15778- IMPL ABSRB MESH/PRSTH DLYD CLSR DFCT INFCTJ/TRMA,4199248,CDM,960,RC,15778,HCPCS,Outpatient,,,899.49,449.75,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
"15788 - Chemical peel, facial; epidermal",3715288,CDM,510,RC,15788,HCPCS,Outpatient,,,419.21,209.61,,314.41,75,,,percent of total billed charges,75% of total billed charges,314.41,75,,,percent of total billed charges,75% of total billed charges,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,578.73,165,,,Fee Schedule,165% of CMS OPPS Rate,363.52,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1007.47,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1381.67,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1730.68,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,363.52,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,58.69,14,,,percent of total billed charges,14% of total billed charges,58.69,1730.68,
"15789 - Chemical peel, facial; dermal",3715293,CDM,510,RC,15789,HCPCS,Outpatient,,,805.26,402.63,,603.95,75,,,percent of total billed charges,75% of total billed charges,603.95,75,,,percent of total billed charges,75% of total billed charges,546.17,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,901.2,165,,,Fee Schedule,165% of CMS OPPS Rate,566.07,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1568.84,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2151.55,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,2695.04,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,546.17,100,,,Fee Schedule,100% of CMS OPPS Rate,566.07,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,112.74,14,,,percent of total billed charges,14% of total billed charges,112.74,2695.04,
"15792 -Chemical peel, nonfacial; epidermal",3715294,CDM,510,RC,15792,HCPCS,Outpatient,,,406.23,203.12,,304.67,75,,,percent of total billed charges,75% of total billed charges,304.67,75,,,percent of total billed charges,75% of total billed charges,546.17,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,901.21,165,,,Fee Schedule,165% of CMS OPPS Rate,566.07,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1568.85,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2151.55,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,2695.04,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,546.17,100,,,Fee Schedule,100% of CMS OPPS Rate,566.07,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,56.87,14,,,percent of total billed charges,14% of total billed charges,56.87,2695.04,
"15793 - Chemical peel, nonfacial; dermal",3715296,CDM,510,RC,15793,HCPCS,Outpatient,,,699.07,349.54,,524.3,75,,,percent of total billed charges,75% of total billed charges,524.3,75,,,percent of total billed charges,75% of total billed charges,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,578.73,165,,,Fee Schedule,165% of CMS OPPS Rate,363.52,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1007.47,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1381.67,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1730.68,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,363.52,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,97.87,14,,,percent of total billed charges,14% of total billed charges,97.87,1730.68,
"15820 - Blepharoplasty, lower eyelid;",3712914,CDM,510,RC,15820,HCPCS,Outpatient,,,1002.38,501.19,,751.79,75,,,percent of total billed charges,75% of total billed charges,751.79,75,,,percent of total billed charges,75% of total billed charges,1622.59,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,2677.27,165,,,Fee Schedule,165% of CMS OPPS Rate,1681.67,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4660.68,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,6391.75,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,8006.31,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,1622.59,100,,,Fee Schedule,100% of CMS OPPS Rate,1681.67,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,140.33,14,,,percent of total billed charges,14% of total billed charges,140.33,8006.31,
"15820 - PF Blepharoplasty, lower eyelid;",3712911,CDM,960,RC,15820,HCPCS,Outpatient,,,1002.38,501.19,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
"15821 Blepharoplasty, lower eyelid; with extensive herniated fat pad",3622066,CDM,960,RC,15821,HCPCS,Outpatient,,,1074.37,537.19,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
"15822 - Blepharoplasty, upper eyelid",3572797,CDM,960,RC,15822,HCPCS,Outpatient,,,778.72,389.36,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
"15823 -Blepharoplasty, upper eyelid; with excessive skin weighting down lid",3566780,CDM,960,RC,15823,HCPCS,Outpatient,,,1073.06,536.53,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
15830-MA EXC SKIN ABD,3428767,CDM,510,RC,15830,HCPCS,Outpatient,,,3066.16,1533.08,,2299.62,75,,,percent of total billed charges,75% of total billed charges,2299.62,75,,,percent of total billed charges,75% of total billed charges,5587.54,100,,,Fee Schedule,100% of CMS OPPS Rate,1819.46,102,,,Fee Schedule,102% of WV Medicaid Rate,9219.44,165,,,Fee Schedule,165% of CMS OPPS Rate,5791.01,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,16049.47,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,22010.56,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,27570.47,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1783.78,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,5587.54,100,,,Fee Schedule,100% of CMS OPPS Rate,5791.01,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,429.26,14,,,percent of total billed charges,14% of total billed charges,429.26,27570.47,
"15851 - Removal of sutures under anesthesia (other than local), other surgeon",3715463,CDM,510,RC,15851,HCPCS,Outpatient,,,131.14,65.57,,98.36,75,,,percent of total billed charges,75% of total billed charges,98.36,75,,,percent of total billed charges,75% of total billed charges,1622.59,100,,,Fee Schedule,100% of CMS OPPS Rate,61.42,102,,,Fee Schedule,102% of WV Medicaid Rate,2677.27,165,,,Fee Schedule,165% of CMS OPPS Rate,1681.67,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4660.68,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,6391.75,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,8006.31,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,60.22,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1622.59,100,,,Fee Schedule,100% of CMS OPPS Rate,1681.67,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,18.36,14,,,percent of total billed charges,14% of total billed charges,18.36,8006.31,
15851-PF REMOVAL SUTURES UNDER ANESTHESIA OTHER SURGEON,4322012,CDM,981,RC,15851,HCPCS,Outpatient,,,131.14,65.57,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
15852-PF DRESSING CHANGE UNDER ANESTHESIA,4322011,CDM,981,RC,15852,HCPCS,Outpatient,,,92.41,46.21,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
"15999PF Unlisted procedure, excision pressure ulcer",4281203,CDM,960,RC,15999,HCPCS,Outpatient,,,131.14,65.57,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
16000-PF INITIAL TX 1ST DEGREE BURN LOCAL TX,4322010,CDM,981,RC,16000,HCPCS,Outpatient,,,94.49,47.25,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
16020- Dress/debride pt-thick burn/<5% BS,3431631,CDM,761,RC,16020,HCPCS,Outpatient,,,111.26,55.63,,83.45,75,,,percent of total billed charges,75% of total billed charges,83.45,75,,,percent of total billed charges,75% of total billed charges,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,280.12,165,,,Fee Schedule,165% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,487.65,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,668.78,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,837.71,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,15.58,14,,,percent of total billed charges,14% of total billed charges,15.58,837.71,
16020-PF DRS&/DBRDMT PRTL-THKNS BURNS 1ST/SBSQ SMALL,4322009,CDM,981,RC,16020,HCPCS,Outpatient,,,111.26,55.63,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
16025- Dress/debride pt-tck burn/5-10% BS,3431632,CDM,761,RC,16025,HCPCS,Outpatient,,,226.01,113.01,,169.51,75,,,percent of total billed charges,75% of total billed charges,169.51,75,,,percent of total billed charges,75% of total billed charges,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,73.31,102,,,Fee Schedule,102% of WV Medicaid Rate,280.12,165,,,Fee Schedule,165% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,487.65,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,668.77,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,837.71,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,71.87,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,31.64,14,,,percent of total billed charges,14% of total billed charges,31.64,837.71,
16025-PF DRS&/DBRDMT PRTL-THKNS BURNS 1ST/SBSQ MEDIUM,4322008,CDM,981,RC,16025,HCPCS,Outpatient,,,226.01,113.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
16030 - PF Dress/ Debrid Prtl-Thkns Burns 1st/ Subq Lg,4311479,CDM,960,RC,16030,HCPCS,Outpatient,,,270.02,135.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
16030-PF DRS&/DBRDMT PRTL-THKNS BURNS 1ST/SBSQ LARGE,4322007,CDM,981,RC,16030,HCPCS,Outpatient,,,270.02,135.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
16035-PF ESCHAROTOMY FIRST INCISION,4321310,CDM,981,RC,16035,HCPCS,Outpatient,,,386.08,193.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
16036-PF ESCHAROTOMY EACH ADDITIONAL INCISION,4321312,CDM,981,RC,16036,HCPCS,Outpatient,,,165.56,82.78,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
17000- Destruct premalig lesion/1st les,3431633,CDM,761,RC,17000,HCPCS,Outpatient,,,107.14,53.57,,80.36,75,,,percent of total billed charges,75% of total billed charges,80.36,75,,,percent of total billed charges,75% of total billed charges,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,280.12,165,,,Fee Schedule,165% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,487.65,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,668.78,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,837.71,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,15,14,,,percent of total billed charges,14% of total billed charges,15,837.71,
17003- DERM DESTRUCT PREMALG LES 2-14,3514645,CDM,761,RC,17003,HCPCS,Outpatient,,,3.96,1.98,,2.97,75,,,percent of total billed charges,75% of total billed charges,2.97,75,,,percent of total billed charges,75% of total billed charges,1.27,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.27,2.97,
17004- Destroy premal lesions 15/>,3428770,CDM,510,RC,17004,HCPCS,Outpatient,,,194.55,97.28,,145.91,75,,,percent of total billed charges,75% of total billed charges,145.91,75,,,percent of total billed charges,75% of total billed charges,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,95.82,102,,,Fee Schedule,102% of WV Medicaid Rate,578.72,165,,,Fee Schedule,165% of CMS OPPS Rate,363.51,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1007.47,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1381.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1730.67,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,93.94,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,363.51,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,27.24,14,,,percent of total billed charges,14% of total billed charges,27.24,1730.67,
17110- Destruct benign lesion 1-14,3431075,CDM,761,RC,17110,HCPCS,Outpatient,,,132.86,66.43,,99.65,75,,,percent of total billed charges,75% of total billed charges,99.65,75,,,percent of total billed charges,75% of total billed charges,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,280.12,165,,,Fee Schedule,165% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,487.65,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,668.78,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,837.71,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,18.6,14,,,percent of total billed charges,14% of total billed charges,18.6,837.71,
17110-PF DESTRUCTION BENIGN LESIONS UP TO 14,4321314,CDM,981,RC,17110,HCPCS,Outpatient,,,132.86,66.43,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
17111- Destruct lesion 15 or more,3431076,CDM,761,RC,17111,HCPCS,Outpatient,,,162.75,81.38,,122.06,75,,,percent of total billed charges,75% of total billed charges,122.06,75,,,percent of total billed charges,75% of total billed charges,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,280.12,165,,,Fee Schedule,165% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,487.65,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,668.78,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,837.71,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,22.79,14,,,percent of total billed charges,14% of total billed charges,22.79,837.71,
17111-PF DESTRUCTION BENIGN LESIONS 15/>,4321316,CDM,981,RC,17111,HCPCS,Outpatient,,,162.75,81.38,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
17250- Chemical cautery of granulated tissue,3431077,CDM,761,RC,17250,HCPCS,Outpatient,,,75.03,37.52,,56.27,75,,,percent of total billed charges,75% of total billed charges,56.27,75,,,percent of total billed charges,75% of total billed charges,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,280.12,165,,,Fee Schedule,165% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,487.65,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,668.78,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,837.71,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,10.5,14,,,percent of total billed charges,14% of total billed charges,10.5,837.71,
17250-PF CHEMICAL CAUTERIZATION OF GRANULATION TISSUE,4322006,CDM,981,RC,17250,HCPCS,Outpatient,,,75.03,37.52,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
17260- Destruction of skin lesions,3431078,CDM,761,RC,17260,HCPCS,Outpatient,,,139.33,69.67,,104.5,75,,,percent of total billed charges,75% of total billed charges,104.5,75,,,percent of total billed charges,75% of total billed charges,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,280.12,165,,,Fee Schedule,165% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,487.65,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,668.78,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,837.71,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,19.51,14,,,percent of total billed charges,14% of total billed charges,19.51,837.71,
17261- Destruction of skin lesions,3431079,CDM,761,RC,17261,HCPCS,Outpatient,,,172.72,86.36,,129.54,75,,,percent of total billed charges,75% of total billed charges,129.54,75,,,percent of total billed charges,75% of total billed charges,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,280.12,165,,,Fee Schedule,165% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,487.65,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,668.78,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,837.71,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,24.18,14,,,percent of total billed charges,14% of total billed charges,24.18,837.71,
17262- Destruction of skin lesions,3431080,CDM,761,RC,17262,HCPCS,Outpatient,,,219.23,109.62,,164.42,75,,,percent of total billed charges,75% of total billed charges,164.42,75,,,percent of total billed charges,75% of total billed charges,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,280.12,165,,,Fee Schedule,165% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,487.65,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,668.78,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,837.71,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,30.69,14,,,percent of total billed charges,14% of total billed charges,30.69,837.71,
17263- Destruction of skin lesions,3431081,CDM,761,RC,17263,HCPCS,Outpatient,,,242.85,121.43,,182.14,75,,,percent of total billed charges,75% of total billed charges,182.14,75,,,percent of total billed charges,75% of total billed charges,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,280.12,165,,,Fee Schedule,165% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,487.65,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,668.78,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,837.71,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,34,14,,,percent of total billed charges,14% of total billed charges,34,837.71,
17264- Destruction of skin lesions,3431082,CDM,761,RC,17264,HCPCS,Outpatient,,,259.89,129.95,,194.92,75,,,percent of total billed charges,75% of total billed charges,194.92,75,,,percent of total billed charges,75% of total billed charges,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,107.56,102,,,Fee Schedule,102% of WV Medicaid Rate,578.72,165,,,Fee Schedule,165% of CMS OPPS Rate,363.51,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1007.47,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1381.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1730.67,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,105.45,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,363.51,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,36.38,14,,,percent of total billed charges,14% of total billed charges,36.38,1730.67,
17266- Destruction of skin lesions,3431083,CDM,761,RC,17266,HCPCS,Outpatient,,,305.13,152.57,,228.85,75,,,percent of total billed charges,75% of total billed charges,228.85,75,,,percent of total billed charges,75% of total billed charges,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,118.47,102,,,Fee Schedule,102% of WV Medicaid Rate,578.72,165,,,Fee Schedule,165% of CMS OPPS Rate,363.51,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1007.47,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1381.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1730.67,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,116.15,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,363.51,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,42.72,14,,,percent of total billed charges,14% of total billed charges,42.72,1730.67,
17270- Destruction of skin lesions,3431084,CDM,761,RC,17270,HCPCS,Outpatient,,,189.76,94.88,,142.32,75,,,percent of total billed charges,75% of total billed charges,142.32,75,,,percent of total billed charges,75% of total billed charges,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,73.31,102,,,Fee Schedule,102% of WV Medicaid Rate,280.12,165,,,Fee Schedule,165% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,487.65,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,668.77,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,837.71,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,71.87,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,26.57,14,,,percent of total billed charges,14% of total billed charges,26.57,837.71,
17271- Destruction of skin lesions,3431085,CDM,761,RC,17271,HCPCS,Outpatient,,,208.48,104.24,,156.36,75,,,percent of total billed charges,75% of total billed charges,156.36,75,,,percent of total billed charges,75% of total billed charges,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,73.31,102,,,Fee Schedule,102% of WV Medicaid Rate,280.12,165,,,Fee Schedule,165% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,487.65,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,668.77,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,837.71,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,71.87,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,29.19,14,,,percent of total billed charges,14% of total billed charges,29.19,837.71,
17272- Destruction of skin lesions,3431086,CDM,761,RC,17272,HCPCS,Outpatient,,,240.85,120.43,,180.64,75,,,percent of total billed charges,75% of total billed charges,180.64,75,,,percent of total billed charges,75% of total billed charges,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,280.12,165,,,Fee Schedule,165% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,487.65,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,668.78,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,837.71,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,33.72,14,,,percent of total billed charges,14% of total billed charges,33.72,837.71,
17273- Destruction of skin lesions,3431087,CDM,761,RC,17273,HCPCS,Outpatient,,,272.65,136.33,,204.49,75,,,percent of total billed charges,75% of total billed charges,204.49,75,,,percent of total billed charges,75% of total billed charges,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,105.92,102,,,Fee Schedule,102% of WV Medicaid Rate,578.72,165,,,Fee Schedule,165% of CMS OPPS Rate,363.51,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1007.47,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1381.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1730.67,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,103.84,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,363.51,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,38.17,14,,,percent of total billed charges,14% of total billed charges,38.17,1730.67,
17274- Destruction of skin lesions,3431088,CDM,761,RC,17274,HCPCS,Outpatient,,,333.31,166.66,,249.98,75,,,percent of total billed charges,75% of total billed charges,249.98,75,,,percent of total billed charges,75% of total billed charges,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,118.47,102,,,Fee Schedule,102% of WV Medicaid Rate,578.72,165,,,Fee Schedule,165% of CMS OPPS Rate,363.51,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1007.47,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1381.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1730.67,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,116.15,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,363.51,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,46.66,14,,,percent of total billed charges,14% of total billed charges,46.66,1730.67,
17276- Destruction of skin lesions,3431089,CDM,761,RC,17276,HCPCS,Outpatient,,,403.39,201.7,,302.54,75,,,percent of total billed charges,75% of total billed charges,302.54,75,,,percent of total billed charges,75% of total billed charges,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,131.86,102,,,Fee Schedule,102% of WV Medicaid Rate,578.72,165,,,Fee Schedule,165% of CMS OPPS Rate,363.51,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1007.47,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1381.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1730.67,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,129.27,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,363.51,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,56.47,14,,,percent of total billed charges,14% of total billed charges,56.47,1730.67,
17280- Destruction of skin lesions,3431090,CDM,761,RC,17280,HCPCS,Outpatient,,,172.12,86.06,,129.09,75,,,percent of total billed charges,75% of total billed charges,129.09,75,,,percent of total billed charges,75% of total billed charges,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,280.12,165,,,Fee Schedule,165% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,487.65,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,668.78,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,837.71,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,24.1,14,,,percent of total billed charges,14% of total billed charges,24.1,837.71,
17281- Destruction of skin lesions,3431091,CDM,761,RC,17281,HCPCS,Outpatient,,,235,117.5,,176.25,75,,,percent of total billed charges,75% of total billed charges,176.25,75,,,percent of total billed charges,75% of total billed charges,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,92.27,102,,,Fee Schedule,102% of WV Medicaid Rate,578.72,165,,,Fee Schedule,165% of CMS OPPS Rate,363.51,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1007.47,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1381.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1730.67,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,90.46,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,363.51,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,32.9,14,,,percent of total billed charges,14% of total billed charges,32.9,1730.67,
17282- Destruction of skin lesions,3431092,CDM,761,RC,17282,HCPCS,Outpatient,,,271.36,135.68,,203.52,75,,,percent of total billed charges,75% of total billed charges,203.52,75,,,percent of total billed charges,75% of total billed charges,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,103.47,102,,,Fee Schedule,102% of WV Medicaid Rate,578.72,165,,,Fee Schedule,165% of CMS OPPS Rate,363.51,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1007.47,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1381.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1730.67,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,101.44,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,363.51,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,37.99,14,,,percent of total billed charges,14% of total billed charges,37.99,1730.67,
"17283- Destruct Skin Lesions,2.1-3.0 cm",3431634,CDM,761,RC,17283,HCPCS,Outpatient,,,340.43,170.22,,255.32,75,,,percent of total billed charges,75% of total billed charges,255.32,75,,,percent of total billed charges,75% of total billed charges,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,115.46,102,,,Fee Schedule,102% of WV Medicaid Rate,578.72,165,,,Fee Schedule,165% of CMS OPPS Rate,363.51,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1007.47,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1381.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1730.67,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,113.2,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,363.51,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,47.66,14,,,percent of total billed charges,14% of total billed charges,47.66,1730.67,
17284- Destruction of skin lesions,3431093,CDM,761,RC,17284,HCPCS,Outpatient,,,396.61,198.31,,297.46,75,,,percent of total billed charges,75% of total billed charges,297.46,75,,,percent of total billed charges,75% of total billed charges,546.17,100,,,Fee Schedule,100% of CMS OPPS Rate,126.94,102,,,Fee Schedule,102% of WV Medicaid Rate,901.2,165,,,Fee Schedule,165% of CMS OPPS Rate,566.07,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1568.84,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2151.55,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,2695.04,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,124.45,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,546.17,100,,,Fee Schedule,100% of CMS OPPS Rate,566.07,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,55.53,14,,,percent of total billed charges,14% of total billed charges,55.53,2695.04,
17286- Destruction of skin lesions,3431094,CDM,761,RC,17286,HCPCS,Outpatient,,,539.99,270,,404.99,75,,,percent of total billed charges,75% of total billed charges,404.99,75,,,percent of total billed charges,75% of total billed charges,546.17,100,,,Fee Schedule,100% of CMS OPPS Rate,151.24,102,,,Fee Schedule,102% of WV Medicaid Rate,901.2,165,,,Fee Schedule,165% of CMS OPPS Rate,566.07,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1568.84,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2151.55,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,2695.04,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,148.27,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,546.17,100,,,Fee Schedule,100% of CMS OPPS Rate,566.07,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,75.6,14,,,percent of total billed charges,14% of total billed charges,75.6,2695.04,
17340 Cryotherapy of skin,3428315,CDM,983,RC,17340,HCPCS,Outpatient,,,98.28,49.14,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
"17999 Unlisted procedure, skin, mucous membrane and subcutan",3623321,CDM,510,RC,17999,HCPCS,Outpatient,,,340,170,,255,75,,,percent of total billed charges,75% of total billed charges,255,75,,,percent of total billed charges,75% of total billed charges,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,280.12,165,,,Fee Schedule,165% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,487.65,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,668.78,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,837.71,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,47.6,14,,,percent of total billed charges,14% of total billed charges,47.6,837.71,
19000- Drainage Of Breast Lesion,3431635,CDM,360,RC,19000,HCPCS,Outpatient,,,257.32,128.66,,192.99,75,,,percent of total billed charges,75% of total billed charges,192.99,75,,,percent of total billed charges,75% of total billed charges,610.13,100,,,Fee Schedule,100% of CMS OPPS Rate,58.43,102,,,Fee Schedule,102% of WV Medicaid Rate,1006.72,165,,,Fee Schedule,165% of CMS OPPS Rate,632.35,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1752.53,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2403.46,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,3010.58,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,57.28,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,610.13,100,,,Fee Schedule,100% of CMS OPPS Rate,632.35,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,36.02,14,,,percent of total billed charges,14% of total billed charges,36.02,3010.58,
US add Aspiration Breast Cyst,645158,CDM,320,RC,19000,HCPCS,Outpatient,,,250.9,125.45,,188.18,75,,,percent of total billed charges,75% of total billed charges,188.18,75,,,percent of total billed charges,75% of total billed charges,610.13,100,,,Fee Schedule,100% of CMS OPPS Rate,58.43,102,,,Fee Schedule,102% of WV Medicaid Rate,1006.72,165,,,Fee Schedule,165% of CMS OPPS Rate,632.35,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1752.53,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2403.46,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,3010.58,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,57.28,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,610.13,100,,,Fee Schedule,100% of CMS OPPS Rate,632.35,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,35.13,14,,,percent of total billed charges,14% of total billed charges,35.13,3010.58,
19001- Punc asp breast cyst ea additional,3428771,CDM,360,RC,19001,HCPCS,Outpatient,,,69.44,34.72,,52.08,75,,,percent of total billed charges,75% of total billed charges,52.08,75,,,percent of total billed charges,75% of total billed charges,22.22,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.72,14,,,percent of total billed charges,14% of total billed charges,9.72,52.08,
19020-,3428772,CDM,361,RC,19020,HCPCS,Outpatient,,,1196.78,598.39,,897.59,75,,,percent of total billed charges,75% of total billed charges,897.59,75,,,percent of total billed charges,75% of total billed charges,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,479.67,102,,,Fee Schedule,102% of WV Medicaid Rate,2326.19,165,,,Fee Schedule,165% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4049.52,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5553.61,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6956.46,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,470.26,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,167.55,14,,,percent of total billed charges,14% of total billed charges,167.55,6956.46,
19020-PF MASTOTOMY W/EXPLORATION/DRAINAGE ABSCESS DEEP,4322005,CDM,981,RC,19020,HCPCS,Outpatient,,,609.88,304.94,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
MA rad inj Ductogram/Galactogram,3922894,CDM,320,RC,19030,HCPCS,Outpatient,,,408.5,204.25,,306.38,75,,,percent of total billed charges,75% of total billed charges,306.38,75,,,percent of total billed charges,75% of total billed charges,130.72,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,57.19,14,,,percent of total billed charges,14% of total billed charges,57.19,306.38,
19081- Bx breast 1st lesion w/o US,3428775,CDM,320,RC,19081,HCPCS,Outpatient,,,1264.59,632.3,,948.44,75,,,percent of total billed charges,75% of total billed charges,948.44,75,,,percent of total billed charges,75% of total billed charges,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,479.67,102,,,Fee Schedule,102% of WV Medicaid Rate,2326.19,165,,,Fee Schedule,165% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4049.52,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5553.61,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6956.46,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,470.26,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,177.04,14,,,percent of total billed charges,14% of total billed charges,177.04,6956.46,
MA Stereostatic Bilat Breast Biopsy,3310457,CDM,320,RC,19081,HCPCS,Outpatient,,,1226.1,613.05,,919.58,75,,,percent of total billed charges,75% of total billed charges,919.58,75,,,percent of total billed charges,75% of total billed charges,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,479.67,102,,,Fee Schedule,102% of WV Medicaid Rate,2326.19,165,,,Fee Schedule,165% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4049.52,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5553.61,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6956.46,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,470.26,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,171.65,14,,,percent of total billed charges,14% of total billed charges,171.65,6956.46,
MA Stereostatic Lt Breast Biopsy,3310459,CDM,320,RC,19081,HCPCS,Outpatient,,,1226.1,613.05,,919.58,75,,,percent of total billed charges,75% of total billed charges,919.58,75,,,percent of total billed charges,75% of total billed charges,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,479.67,102,,,Fee Schedule,102% of WV Medicaid Rate,2326.19,165,,,Fee Schedule,165% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4049.52,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5553.61,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6956.46,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,470.26,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,171.65,14,,,percent of total billed charges,14% of total billed charges,171.65,6956.46,
MA Stereostatic Rt Breast Biopsy,3310461,CDM,320,RC,19081,HCPCS,Outpatient,,,1226.1,613.05,,919.58,75,,,percent of total billed charges,75% of total billed charges,919.58,75,,,percent of total billed charges,75% of total billed charges,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,479.67,102,,,Fee Schedule,102% of WV Medicaid Rate,2326.19,165,,,Fee Schedule,165% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4049.52,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5553.61,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6956.46,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,470.26,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,171.65,14,,,percent of total billed charges,14% of total billed charges,171.65,6956.46,
MA Stereotactic Lt Breast Biopsy:Read,603846,CDM,972,RC,19081,HCPCS,Outpatient,,,1226.1,613.05,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
"19082 Biopsy, breast, with placement of breast localization device(s) (eg, clip, metallic pellet), w",3621196,CDM,510,RC,19082,HCPCS,Outpatient,,,976,488,,732,75,,,percent of total billed charges,75% of total billed charges,732,75,,,percent of total billed charges,75% of total billed charges,312.32,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,136.64,14,,,percent of total billed charges,14% of total billed charges,136.64,732,
MA Stereo Each Additional Placement,3310463,CDM,320,RC,19082,HCPCS,Outpatient,,,936.3,468.15,,702.23,75,,,percent of total billed charges,75% of total billed charges,702.23,75,,,percent of total billed charges,75% of total billed charges,299.62,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,131.08,14,,,percent of total billed charges,14% of total billed charges,131.08,702.23,
19083- Biopsy/breast/1st lesion/US guide,3431636,CDM,401,RC,19083,HCPCS,Outpatient,,,1276.8,638.4,,957.6,75,,,percent of total billed charges,75% of total billed charges,957.6,75,,,percent of total billed charges,75% of total billed charges,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,479.67,102,,,Fee Schedule,102% of WV Medicaid Rate,2326.19,165,,,Fee Schedule,165% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4049.52,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5553.61,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6956.46,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,470.26,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,178.75,14,,,percent of total billed charges,14% of total billed charges,178.75,6956.46,
Read,3317779,CDM,972,RC,19083,HCPCS,Outpatient,,,489.04,244.52,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
Read,3317786,CDM,972,RC,19083,HCPCS,Outpatient,,,489.04,244.52,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
Read,3317793,CDM,972,RC,19083,HCPCS,Outpatient,,,489.04,244.52,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
Read,3370945,CDM,402,RC,19083,HCPCS,Outpatient,,,489.04,244.52,,366.78,75,,,percent of total billed charges,75% of total billed charges,366.78,75,,,percent of total billed charges,75% of total billed charges,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,479.67,102,,,Fee Schedule,102% of WV Medicaid Rate,2326.19,165,,,Fee Schedule,165% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4049.52,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5553.61,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6956.46,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,470.26,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,68.47,14,,,percent of total billed charges,14% of total billed charges,68.47,6956.46,
US Breast Biopsy Bilateral,645152,CDM,320,RC,19083,HCPCS,Outpatient,,,1222.6,611.3,,916.95,75,,,percent of total billed charges,75% of total billed charges,916.95,75,,,percent of total billed charges,75% of total billed charges,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,479.67,102,,,Fee Schedule,102% of WV Medicaid Rate,2326.19,165,,,Fee Schedule,165% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4049.52,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5553.61,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6956.46,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,470.26,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,171.16,14,,,percent of total billed charges,14% of total billed charges,171.16,6956.46,
US Breast Biopsy Lt,3310496,CDM,320,RC,19083,HCPCS,Outpatient,,,1222.6,611.3,,916.95,75,,,percent of total billed charges,75% of total billed charges,916.95,75,,,percent of total billed charges,75% of total billed charges,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,479.67,102,,,Fee Schedule,102% of WV Medicaid Rate,2326.19,165,,,Fee Schedule,165% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4049.52,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5553.61,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6956.46,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,470.26,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,171.16,14,,,percent of total billed charges,14% of total billed charges,171.16,6956.46,
US Breast Biopsy Rt,3310542,CDM,320,RC,19083,HCPCS,Outpatient,,,1222.6,611.3,,916.95,75,,,percent of total billed charges,75% of total billed charges,916.95,75,,,percent of total billed charges,75% of total billed charges,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,479.67,102,,,Fee Schedule,102% of WV Medicaid Rate,2326.19,165,,,Fee Schedule,165% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4049.52,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5553.61,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6956.46,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,470.26,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,171.16,14,,,percent of total billed charges,14% of total billed charges,171.16,6956.46,
US Vacuum Assist biopsy,652800,CDM,401,RC,19083,HCPCS,Outpatient,,,1222.6,611.3,,916.95,75,,,percent of total billed charges,75% of total billed charges,916.95,75,,,percent of total billed charges,75% of total billed charges,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,479.67,102,,,Fee Schedule,102% of WV Medicaid Rate,2326.19,165,,,Fee Schedule,165% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4049.52,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5553.61,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6956.46,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,470.26,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,171.16,14,,,percent of total billed charges,14% of total billed charges,171.16,6956.46,
"19084 Biopsy, breast, with placement of breast localization device(s)",3621149,CDM,510,RC,19084,HCPCS,Outpatient,,,963.48,481.74,,722.61,75,,,percent of total billed charges,75% of total billed charges,722.61,75,,,percent of total billed charges,75% of total billed charges,308.31,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,134.89,14,,,percent of total billed charges,14% of total billed charges,134.89,722.61,
"19084 Biopsy, breast, with placement of breast localization device(s) ProFee",3621150,CDM,510,RC,19084,HCPCS,Outpatient,,,202.3,101.15,,151.73,75,,,percent of total billed charges,75% of total billed charges,151.73,75,,,percent of total billed charges,75% of total billed charges,64.74,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.32,14,,,percent of total billed charges,14% of total billed charges,28.32,151.73,
US Breast Biopsy Each Additional,3310548,CDM,401,RC,19084,HCPCS,Outpatient,,,921.54,460.77,,691.16,75,,,percent of total billed charges,75% of total billed charges,691.16,75,,,percent of total billed charges,75% of total billed charges,294.89,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,129.02,14,,,percent of total billed charges,14% of total billed charges,129.02,691.16,
19100- Bx breast percut w/o image,3428778,CDM,401,RC,19100,HCPCS,Outpatient,,,393.47,196.74,,295.1,75,,,percent of total billed charges,75% of total billed charges,295.1,75,,,percent of total billed charges,75% of total billed charges,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,479.67,102,,,Fee Schedule,102% of WV Medicaid Rate,2326.19,165,,,Fee Schedule,165% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4049.52,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5553.61,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6956.46,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,470.26,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,55.09,14,,,percent of total billed charges,14% of total billed charges,55.09,6956.46,
19101-MSA BIOPSY OF BREAST OPEN,3428779,CDM,360,RC,19101,HCPCS,Outpatient,,,855.9,427.95,,641.93,75,,,percent of total billed charges,75% of total billed charges,641.93,75,,,percent of total billed charges,75% of total billed charges,3232.09,100,,,Fee Schedule,100% of CMS OPPS Rate,950.21,102,,,Fee Schedule,102% of WV Medicaid Rate,5332.96,165,,,Fee Schedule,165% of CMS OPPS Rate,3349.79,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,9283.77,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,12731.95,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,15948.06,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,931.58,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,3232.09,100,,,Fee Schedule,100% of CMS OPPS Rate,3349.79,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,119.83,14,,,percent of total billed charges,14% of total billed charges,119.83,15948.06,
"19110 Nipple exploration, with or without excision of a solitary lactiferous duct or a papilloma lac",3621652,CDM,510,RC,19110,HCPCS,Outpatient,,,1254.75,627.38,,941.06,75,,,percent of total billed charges,75% of total billed charges,941.06,75,,,percent of total billed charges,75% of total billed charges,3232.09,100,,,Fee Schedule,100% of CMS OPPS Rate,950.21,102,,,Fee Schedule,102% of WV Medicaid Rate,5332.96,165,,,Fee Schedule,165% of CMS OPPS Rate,3349.79,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,9283.77,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,12731.95,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,15948.06,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,931.58,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,3232.09,100,,,Fee Schedule,100% of CMS OPPS Rate,3349.79,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,175.67,14,,,percent of total billed charges,14% of total billed charges,175.67,15948.06,
19120- Removal of breast lesion,3428780,CDM,360,RC,19120,HCPCS,Outpatient,,,1349.16,674.58,,1011.87,75,,,percent of total billed charges,75% of total billed charges,1011.87,75,,,percent of total billed charges,75% of total billed charges,3232.09,100,,,Fee Schedule,100% of CMS OPPS Rate,950.21,102,,,Fee Schedule,102% of WV Medicaid Rate,5332.96,165,,,Fee Schedule,165% of CMS OPPS Rate,3349.79,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,9283.77,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,12731.95,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,15948.06,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,931.58,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,3232.09,100,,,Fee Schedule,100% of CMS OPPS Rate,3349.79,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,188.88,14,,,percent of total billed charges,14% of total billed charges,188.88,15948.06,
19125 - PF Exc Breast Les Preop Plmt Rad Marker Open 1 Les PF,4305374,CDM,960,RC,19125,HCPCS,Outpatient,,,1228.24,614.12,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
19125- Excision breast lesion,3428781,CDM,960,RC,19125,HCPCS,Outpatient,,,1228.24,614.12,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
19126 - PF Exc Brst Les Preop Plmt Rad Marker Opn Ea Addl PF,4305371,CDM,960,RC,19126,HCPCS,Outpatient,,,343.95,171.98,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
Read,603866,CDM,972,RC,19281,HCPCS,Outpatient,,,236.95,118.48,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
Read,603868,CDM,972,RC,19281,HCPCS,Outpatient,,,236.95,118.48,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
Read,603870,CDM,972,RC,19281,HCPCS,Outpatient,,,236.95,118.48,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
MA Mammo Each Additional Loc,603408,CDM,320,RC,19282,HCPCS,Outpatient,,,414.73,207.37,,311.05,75,,,percent of total billed charges,75% of total billed charges,311.05,75,,,percent of total billed charges,75% of total billed charges,132.71,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,58.06,14,,,percent of total billed charges,14% of total billed charges,58.06,311.05,
US add Needle Localization,652878,CDM,320,RC,19285,HCPCS,Outpatient,,,895.22,447.61,,671.42,75,,,percent of total billed charges,75% of total billed charges,671.42,75,,,percent of total billed charges,75% of total billed charges,610.13,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1006.73,165,,,Fee Schedule,165% of CMS OPPS Rate,632.35,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1752.54,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2403.47,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,3010.59,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,610.13,100,,,Fee Schedule,100% of CMS OPPS Rate,632.35,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,125.33,14,,,percent of total billed charges,14% of total billed charges,125.33,3010.59,
19300 - Mastectomy for gynecomastia,3898978,CDM,983,RC,19300,HCPCS,Outpatient,,,1495.53,747.77,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
19301 Partial Mastectomy,3550405,CDM,510,RC,19301,HCPCS,Outpatient,,,1769.31,884.66,,1326.98,75,,,percent of total billed charges,75% of total billed charges,1326.98,75,,,percent of total billed charges,75% of total billed charges,3232.09,100,,,Fee Schedule,100% of CMS OPPS Rate,950.21,102,,,Fee Schedule,102% of WV Medicaid Rate,5332.96,165,,,Fee Schedule,165% of CMS OPPS Rate,3349.79,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,9283.77,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,12731.95,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,15948.06,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,931.58,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,3232.09,100,,,Fee Schedule,100% of CMS OPPS Rate,3349.79,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,247.7,14,,,percent of total billed charges,14% of total billed charges,247.7,15948.06,
"19303- Mastectomy, simple, complete",3569390,CDM,510,RC,19303,HCPCS,Outpatient,,,2571.8,1285.9,,1928.85,75,,,percent of total billed charges,75% of total billed charges,1928.85,75,,,percent of total billed charges,75% of total billed charges,5587.54,100,,,Fee Schedule,100% of CMS OPPS Rate,1819.46,102,,,Fee Schedule,102% of WV Medicaid Rate,9219.44,165,,,Fee Schedule,165% of CMS OPPS Rate,5791.01,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,16049.47,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,22010.56,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,27570.47,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1783.78,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,5587.54,100,,,Fee Schedule,100% of CMS OPPS Rate,5791.01,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,360.05,14,,,percent of total billed charges,14% of total billed charges,360.05,27570.47,
"19307 - Mastectomy, modified radical, including axillary lymph nodes, with or without pectoralis min",3572798,CDM,960,RC,19307,HCPCS,Outpatient,,,3161.49,1580.75,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
19316- Mastopexy,3431639,CDM,510,RC,19316,HCPCS,Outpatient,,,2063.18,1031.59,,1547.39,75,,,percent of total billed charges,75% of total billed charges,1547.39,75,,,percent of total billed charges,75% of total billed charges,5587.54,100,,,Fee Schedule,100% of CMS OPPS Rate,1819.46,102,,,Fee Schedule,102% of WV Medicaid Rate,9219.44,165,,,Fee Schedule,165% of CMS OPPS Rate,5791.01,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,16049.47,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,22010.56,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,27570.47,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1783.78,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,5587.54,100,,,Fee Schedule,100% of CMS OPPS Rate,5791.01,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.85,14,,,percent of total billed charges,14% of total billed charges,288.85,27570.47,
20101- Explore penetrating wound/chest,3434642,CDM,510,RC,20101,HCPCS,Outpatient,,,1494.22,747.11,,1120.67,75,,,percent of total billed charges,75% of total billed charges,1120.67,75,,,percent of total billed charges,75% of total billed charges,1622.59,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,2677.27,165,,,Fee Schedule,165% of CMS OPPS Rate,1681.67,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4660.68,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,6391.75,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,8006.31,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,1622.59,100,,,Fee Schedule,100% of CMS OPPS Rate,1681.67,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,209.19,14,,,percent of total billed charges,14% of total billed charges,209.19,8006.31,
20103 - PF Exploration Penetrating Wound Spx Extremity,4311480,CDM,960,RC,20103,HCPCS,Outpatient,,,804.9,402.45,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
20103- Explore penetrating wnd/extremity,3434643,CDM,510,RC,20103,HCPCS,Outpatient,,,1439.15,719.58,,1079.36,75,,,percent of total billed charges,75% of total billed charges,1079.36,75,,,percent of total billed charges,75% of total billed charges,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,2326.19,165,,,Fee Schedule,165% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4049.52,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5553.61,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6956.46,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,201.48,14,,,percent of total billed charges,14% of total billed charges,201.48,6956.46,
20103-PF EXPLORATION PENETRATING WOUND SPX EXTREMITY,4322004,CDM,981,RC,20103,HCPCS,Outpatient,,,677.98,338.99,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
20200- Biopsy/muscle/superficial,3434644,CDM,510,RC,20200,HCPCS,Outpatient,,,554.34,277.17,,415.76,75,,,percent of total billed charges,75% of total billed charges,415.76,75,,,percent of total billed charges,75% of total billed charges,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,479.67,102,,,Fee Schedule,102% of WV Medicaid Rate,2326.19,165,,,Fee Schedule,165% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4049.52,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5553.61,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6956.46,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,470.26,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,77.61,14,,,percent of total billed charges,14% of total billed charges,77.61,6956.46,
20205 - PF Biopsy Muscle Deep,4311481,CDM,960,RC,20205,HCPCS,Outpatient,,,366.71,183.36,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
20205- Biopsy/muscle/deep,3434645,CDM,510,RC,20205,HCPCS,Outpatient,,,776.55,388.28,,582.41,75,,,percent of total billed charges,75% of total billed charges,582.41,75,,,percent of total billed charges,75% of total billed charges,2428.67,100,,,Fee Schedule,100% of CMS OPPS Rate,803.83,102,,,Fee Schedule,102% of WV Medicaid Rate,4007.32,165,,,Fee Schedule,165% of CMS OPPS Rate,2517.11,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,6976.06,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,9567.11,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,11983.78,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,788.07,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2428.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2517.11,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,108.72,14,,,percent of total billed charges,14% of total billed charges,108.72,11983.78,
CT add Needle Bx Bone Superficial,645132,CDM,350,RC,20220,HCPCS,Outpatient,,,574.5,287.25,,430.88,75,,,percent of total billed charges,75% of total billed charges,430.88,75,,,percent of total billed charges,75% of total billed charges,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,479.67,102,,,Fee Schedule,102% of WV Medicaid Rate,2326.19,165,,,Fee Schedule,165% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4049.52,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5553.61,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6956.46,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,470.26,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,80.43,14,,,percent of total billed charges,14% of total billed charges,80.43,6956.46,
Read,4181194,CDM,972,RC,20220,HCPCS,Outpatient,,,229.8,114.9,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
20225- Biopsy/bone/trocar/needle,3434646,CDM,360,RC,20225,HCPCS,Outpatient,,,974.9,487.45,,731.18,75,,,percent of total billed charges,75% of total billed charges,731.18,75,,,percent of total billed charges,75% of total billed charges,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,479.67,102,,,Fee Schedule,102% of WV Medicaid Rate,2326.19,165,,,Fee Schedule,165% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4049.52,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5553.61,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6956.46,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,470.26,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,136.49,14,,,percent of total billed charges,14% of total billed charges,136.49,6956.46,
CT add Needle Bx Bone Deep,645134,CDM,360,RC,20225,HCPCS,Outpatient,,,936.54,468.27,,702.41,75,,,percent of total billed charges,75% of total billed charges,702.41,75,,,percent of total billed charges,75% of total billed charges,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,479.67,102,,,Fee Schedule,102% of WV Medicaid Rate,2326.19,165,,,Fee Schedule,165% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4049.52,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5553.61,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6956.46,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,470.26,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,131.12,14,,,percent of total billed charges,14% of total billed charges,131.12,6956.46,
Read,4181192,CDM,972,RC,20225,HCPCS,Outpatient,,,374.61,187.31,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
20245- Biopsy/bone/open/deep,3434647,CDM,510,RC,20245,HCPCS,Outpatient,,,918.24,459.12,,688.68,75,,,percent of total billed charges,75% of total billed charges,688.68,75,,,percent of total billed charges,75% of total billed charges,2428.67,100,,,Fee Schedule,100% of CMS OPPS Rate,803.83,102,,,Fee Schedule,102% of WV Medicaid Rate,4007.32,165,,,Fee Schedule,165% of CMS OPPS Rate,2517.11,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,6976.06,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,9567.11,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,11983.78,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,788.07,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2428.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2517.11,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,128.55,14,,,percent of total billed charges,14% of total billed charges,128.55,11983.78,
20520- Rmv/FB/muscle/tendon sheath/simple,3434648,CDM,510,RC,20520,HCPCS,Outpatient,,,546.51,273.26,,409.88,75,,,percent of total billed charges,75% of total billed charges,409.88,75,,,percent of total billed charges,75% of total billed charges,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,118.2,102,,,Fee Schedule,102% of WV Medicaid Rate,2326.19,165,,,Fee Schedule,165% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4049.52,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5553.61,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6956.46,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,115.88,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,76.51,14,,,percent of total billed charges,14% of total billed charges,76.51,6956.46,
20520-PF REMOVAL FOREIGN BODY MUSCLE/TENDON SHEATH SIMPL,4322003,CDM,981,RC,20520,HCPCS,Outpatient,,,281.92,140.96,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
20525- Rmv FB/musc/tend/sheath/deep/comp,3434649,CDM,510,RC,20525,HCPCS,Outpatient,,,1172.53,586.27,,879.4,75,,,percent of total billed charges,75% of total billed charges,879.4,75,,,percent of total billed charges,75% of total billed charges,2428.67,100,,,Fee Schedule,100% of CMS OPPS Rate,803.83,102,,,Fee Schedule,102% of WV Medicaid Rate,4007.32,165,,,Fee Schedule,165% of CMS OPPS Rate,2517.11,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,6976.06,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,9567.11,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,11983.78,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,788.07,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2428.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2517.11,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,164.15,14,,,percent of total billed charges,14% of total billed charges,164.15,11983.78,
20525-PF RMVL FOREIGN BODY MUSCLE/TENDON SHEATH DEEP/COMP,4322002,CDM,981,RC,20525,HCPCS,Outpatient,,,482.2,241.1,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
20526- Inj/therapeutic/carpal tunnel,3434650,CDM,510,RC,20526,HCPCS,Outpatient,,,210.6,105.3,,157.95,75,,,percent of total billed charges,75% of total billed charges,157.95,75,,,percent of total billed charges,75% of total billed charges,255.61,100,,,Fee Schedule,100% of CMS OPPS Rate,36.04,102,,,Fee Schedule,102% of WV Medicaid Rate,421.75,165,,,Fee Schedule,165% of CMS OPPS Rate,264.92,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,734.23,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1006.94,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1261.29,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,35.33,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,255.61,100,,,Fee Schedule,100% of CMS OPPS Rate,264.92,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,29.48,14,,,percent of total billed charges,14% of total billed charges,29.48,1261.29,
20527- Inj/enzyme/palmar fascial cord,3434651,CDM,510,RC,20527,HCPCS,Outpatient,,,222.74,111.37,,167.06,75,,,percent of total billed charges,75% of total billed charges,167.06,75,,,percent of total billed charges,75% of total billed charges,255.61,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,421.75,165,,,Fee Schedule,165% of CMS OPPS Rate,264.92,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,734.23,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1006.94,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1261.29,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,255.61,100,,,Fee Schedule,100% of CMS OPPS Rate,264.92,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,31.18,14,,,percent of total billed charges,14% of total billed charges,31.18,1261.29,
20550- Inj/sng ten sheath/lig/aponeurosis,3434652,CDM,360,RC,20550,HCPCS,Outpatient,,,147.17,73.59,,110.38,75,,,percent of total billed charges,75% of total billed charges,110.38,75,,,percent of total billed charges,75% of total billed charges,255.61,100,,,Fee Schedule,100% of CMS OPPS Rate,23.21,102,,,Fee Schedule,102% of WV Medicaid Rate,421.75,165,,,Fee Schedule,165% of CMS OPPS Rate,264.92,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,734.23,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1006.94,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1261.29,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,22.75,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,255.61,100,,,Fee Schedule,100% of CMS OPPS Rate,264.92,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,20.6,14,,,percent of total billed charges,14% of total billed charges,20.6,1261.29,
20550-PF INJECTION 1 TENDON SHEATH/LIGAMENT APONEUROSIS,4321318,CDM,981,RC,20550,HCPCS,Outpatient,,,77.48,38.74,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
20551- Inj/single tendon origin/insertio,3434653,CDM,510,RC,20551,HCPCS,Outpatient,,,148.44,74.22,,111.33,75,,,percent of total billed charges,75% of total billed charges,111.33,75,,,percent of total billed charges,75% of total billed charges,255.61,100,,,Fee Schedule,100% of CMS OPPS Rate,24.02,102,,,Fee Schedule,102% of WV Medicaid Rate,421.75,165,,,Fee Schedule,165% of CMS OPPS Rate,264.92,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,734.23,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1006.94,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1261.29,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,23.55,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,255.61,100,,,Fee Schedule,100% of CMS OPPS Rate,264.92,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,20.78,14,,,percent of total billed charges,14% of total billed charges,20.78,1261.29,
20552- Inj/sng/mult trigger pnts/1/2 musc,3434654,CDM,360,RC,20552,HCPCS,Outpatient,,,136.98,68.49,,102.74,75,,,percent of total billed charges,75% of total billed charges,102.74,75,,,percent of total billed charges,75% of total billed charges,255.61,100,,,Fee Schedule,100% of CMS OPPS Rate,22.93,102,,,Fee Schedule,102% of WV Medicaid Rate,421.75,165,,,Fee Schedule,165% of CMS OPPS Rate,264.92,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,734.23,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1006.94,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1261.29,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,22.48,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,255.61,100,,,Fee Schedule,100% of CMS OPPS Rate,264.92,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,19.18,14,,,percent of total billed charges,14% of total billed charges,19.18,1261.29,
20552-PF INJECTION SINGLE/MLT TRIGGER POINT 1/2 MUSCLE,4322001,CDM,981,RC,20552,HCPCS,Outpatient,,,72.58,36.29,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
20553- Inj/sng/mult trigger pnts/3/> musc,3434655,CDM,510,RC,20553,HCPCS,Outpatient,,,157.43,78.72,,118.07,75,,,percent of total billed charges,75% of total billed charges,118.07,75,,,percent of total billed charges,75% of total billed charges,255.61,100,,,Fee Schedule,100% of CMS OPPS Rate,26.75,102,,,Fee Schedule,102% of WV Medicaid Rate,421.75,165,,,Fee Schedule,165% of CMS OPPS Rate,264.92,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,734.23,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1006.94,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1261.29,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,26.23,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,255.61,100,,,Fee Schedule,100% of CMS OPPS Rate,264.92,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,22.04,14,,,percent of total billed charges,14% of total billed charges,22.04,1261.29,
20553-PF INJECTION SINGLE/MLT TRIGGER POINT 3/> MUSCLES,4321321,CDM,981,RC,20553,HCPCS,Outpatient,,,83.3,41.65,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
20600- Arthrocentesis/sm jnt/bursa/w/o US,3434656,CDM,360,RC,20600,HCPCS,Outpatient,,,135.42,67.71,,101.57,75,,,percent of total billed charges,75% of total billed charges,101.57,75,,,percent of total billed charges,75% of total billed charges,255.61,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,421.75,165,,,Fee Schedule,165% of CMS OPPS Rate,264.92,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,734.23,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1006.94,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1261.29,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,255.61,100,,,Fee Schedule,100% of CMS OPPS Rate,264.92,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,18.96,14,,,percent of total billed charges,14% of total billed charges,18.96,1261.29,
20600-PF ARTHROCENTESIS ASPIR&/INJ SMALL JT/BURSA W/O US,4322000,CDM,981,RC,20600,HCPCS,Outpatient,,,69.66,34.83,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
20605- Arthrocentes/intm jnt/bursa/w/o US,3434658,CDM,360,RC,20605,HCPCS,Outpatient,,,139.61,69.81,,104.71,75,,,percent of total billed charges,75% of total billed charges,104.71,75,,,percent of total billed charges,75% of total billed charges,255.61,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,421.75,165,,,Fee Schedule,165% of CMS OPPS Rate,264.92,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,734.23,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1006.94,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1261.29,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,255.61,100,,,Fee Schedule,100% of CMS OPPS Rate,264.92,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,19.55,14,,,percent of total billed charges,14% of total billed charges,19.55,1261.29,
20605-PF ARTHROCENTESIS ASPIR&/INJ INTERM JT/BURS W/O U,4321999,CDM,981,RC,20605,HCPCS,Outpatient,,,73.32,36.66,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
20606-PF ARTHROCENTESIS ASPIR&/INJ INTERM JT/BURS W/US,4321323,CDM,981,RC,20606,HCPCS,Outpatient,,,102.56,51.28,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
20610- Arthrocentes/maj jnt/bursa/w/o US,3434660,CDM,360,RC,20610,HCPCS,Outpatient,,,165.68,82.84,,124.26,75,,,percent of total billed charges,75% of total billed charges,124.26,75,,,percent of total billed charges,75% of total billed charges,255.61,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,421.75,165,,,Fee Schedule,165% of CMS OPPS Rate,264.92,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,734.23,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1006.94,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1261.29,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,255.61,100,,,Fee Schedule,100% of CMS OPPS Rate,264.92,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,23.2,14,,,percent of total billed charges,14% of total billed charges,23.2,1261.29,
20610- Arthrocentesis/inject/major joint,3434636,CDM,320,RC,20610,HCPCS,Outpatient,,,165.68,82.84,,124.26,75,,,percent of total billed charges,75% of total billed charges,124.26,75,,,percent of total billed charges,75% of total billed charges,255.61,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,421.75,165,,,Fee Schedule,165% of CMS OPPS Rate,264.92,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,734.23,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1006.94,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1261.29,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,255.61,100,,,Fee Schedule,100% of CMS OPPS Rate,264.92,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,23.2,14,,,percent of total billed charges,14% of total billed charges,23.2,1261.29,
20610-PF ARTHROCENTESIS ASPIR&/INJ MAJOR JT/BURSA W/O US,4321998,CDM,981,RC,20610,HCPCS,Outpatient,,,88.9,44.45,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
Read,602055,CDM,972,RC,20610,HCPCS,Outpatient,,,111.57,55.79,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
20611- Arthrocentesis Aspir+/Injection Major Jt/Bursa with US,3434661,CDM,510,RC,20611,HCPCS,Outpatient,,,251.68,125.84,,188.76,75,,,percent of total billed charges,75% of total billed charges,188.76,75,,,percent of total billed charges,75% of total billed charges,255.61,100,,,Fee Schedule,100% of CMS OPPS Rate,46.69,102,,,Fee Schedule,102% of WV Medicaid Rate,421.75,165,,,Fee Schedule,165% of CMS OPPS Rate,264.92,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,734.23,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1006.94,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1261.29,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,45.77,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,255.61,100,,,Fee Schedule,100% of CMS OPPS Rate,264.92,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,35.24,14,,,percent of total billed charges,14% of total billed charges,35.24,1261.29,
20670- Remove implant/superficial,3434664,CDM,510,RC,20670,HCPCS,Outpatient,,,885.43,442.72,,664.07,75,,,percent of total billed charges,75% of total billed charges,664.07,75,,,percent of total billed charges,75% of total billed charges,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,479.67,102,,,Fee Schedule,102% of WV Medicaid Rate,2326.21,165,,,Fee Schedule,165% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4049.53,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5553.61,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6956.46,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,470.26,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,123.96,14,,,percent of total billed charges,14% of total billed charges,123.96,6956.46,
20680- Remove implant/deep,3434665,CDM,510,RC,20680,HCPCS,Outpatient,,,1530.14,765.07,,1147.61,75,,,percent of total billed charges,75% of total billed charges,1147.61,75,,,percent of total billed charges,75% of total billed charges,2428.67,100,,,Fee Schedule,100% of CMS OPPS Rate,803.83,102,,,Fee Schedule,102% of WV Medicaid Rate,4007.33,165,,,Fee Schedule,165% of CMS OPPS Rate,2517.12,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,6976.06,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,9567.11,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,11983.78,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,788.07,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2428.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2517.12,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,214.22,14,,,percent of total billed charges,14% of total billed charges,214.22,11983.78,
20950-PF MNTR INTERSTITIAL FLUID PRESSURE CMPRT SYNDROME,4321326,CDM,981,RC,20950,HCPCS,Outpatient,,,170.14,85.07,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
21011- Ex SQ tumor/face or scalp < 2 cm,3434682,CDM,510,RC,21011,HCPCS,Outpatient,,,518.64,259.32,,388.98,75,,,percent of total billed charges,75% of total billed charges,388.98,75,,,percent of total billed charges,75% of total billed charges,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,208.83,102,,,Fee Schedule,102% of WV Medicaid Rate,2326.19,165,,,Fee Schedule,165% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4049.52,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5553.61,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6956.46,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,204.74,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,72.61,14,,,percent of total billed charges,14% of total billed charges,72.61,6956.46,
21012- Ex SQ tumor/face or scalp 2 cm/>,3434683,CDM,510,RC,21012,HCPCS,Outpatient,,,688.11,344.06,,516.08,75,,,percent of total billed charges,75% of total billed charges,516.08,75,,,percent of total billed charges,75% of total billed charges,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,479.67,102,,,Fee Schedule,102% of WV Medicaid Rate,2326.19,165,,,Fee Schedule,165% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4049.52,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5553.61,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6956.46,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,470.26,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,96.34,14,,,percent of total billed charges,14% of total billed charges,96.34,6956.46,
21013- Exc IM tumor/face & scalp < 2 cm,3434684,CDM,510,RC,21013,HCPCS,Outpatient,,,811.54,405.77,,608.66,75,,,percent of total billed charges,75% of total billed charges,608.66,75,,,percent of total billed charges,75% of total billed charges,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,263.15,102,,,Fee Schedule,102% of WV Medicaid Rate,2326.19,165,,,Fee Schedule,165% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4049.52,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5553.61,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6956.46,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,257.99,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,113.62,14,,,percent of total billed charges,14% of total billed charges,113.62,6956.46,
21015- Rad res sft tis tum/face/scalp/<2c,3434685,CDM,960,RC,21015,HCPCS,Outpatient,,,1407.68,703.84,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
21016- Rad resect/tumor/face/scalp/2cm/>,3434686,CDM,960,RC,21016,HCPCS,Outpatient,,,2053.77,1026.89,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
21315-PF CLOSED TX NASAL BONE FX W/MNPJ W/O STABILIZATION,4321328,CDM,981,RC,21315,HCPCS,Outpatient,,,118.7,59.35,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
21320-PF CLOSED TX NASAL BONE FX W/MNPJ W/STABILIZATION,4321997,CDM,981,RC,21320,HCPCS,Outpatient,,,186.36,93.18,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
21440-PF CLTX MANDIBULAR/MAXILLARY ALVEOLAR RIDGE FX SPX,4321331,CDM,981,RC,21440,HCPCS,Outpatient,,,1012.12,506.06,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
21480-PF CLOSED TX TEMPOROMANDIBULAR DISLOCATION 1ST/SBSQ,4321996,CDM,981,RC,21480,HCPCS,Outpatient,,,63.3,31.65,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
21485-PF CLOSED TX TEMPOROMANDIBULAR DISLC COMP 1ST/SBSQ,4321335,CDM,981,RC,21485,HCPCS,Outpatient,,,1448.9,724.45,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
21501- I&D deep abscess/hema/neck/thorax,3434703,CDM,510,RC,21501,HCPCS,Outpatient,,,1227.97,613.99,,920.98,75,,,percent of total billed charges,75% of total billed charges,920.98,75,,,percent of total billed charges,75% of total billed charges,2428.67,100,,,Fee Schedule,100% of CMS OPPS Rate,803.83,102,,,Fee Schedule,102% of WV Medicaid Rate,4007.32,165,,,Fee Schedule,165% of CMS OPPS Rate,2517.11,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,6976.06,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,9567.11,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,11983.78,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,788.07,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2428.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2517.11,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,171.92,14,,,percent of total billed charges,14% of total billed charges,171.92,11983.78,
21552 - PF Exc Tumor Soft Tis Neck/Ant Thorax Subq 3cm/>,4301617,CDM,960,RC,21552,HCPCS,Outpatient,,,938.8,469.4,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
21554- Exc IM tum/neck/ant thorax 5cm/>,3434706,CDM,510,RC,21554,HCPCS,Outpatient,,,1937.32,968.66,,1452.99,75,,,percent of total billed charges,75% of total billed charges,1452.99,75,,,percent of total billed charges,75% of total billed charges,2428.67,100,,,Fee Schedule,100% of CMS OPPS Rate,803.83,102,,,Fee Schedule,102% of WV Medicaid Rate,4007.32,165,,,Fee Schedule,165% of CMS OPPS Rate,2517.11,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,6976.06,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,9567.11,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,11983.78,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,788.07,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2428.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2517.11,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,271.22,14,,,percent of total billed charges,14% of total billed charges,271.22,11983.78,
21555- Exc SQ tum/neck or ant thorax <3cm,3434707,CDM,510,RC,21555,HCPCS,Outpatient,,,623.3,311.65,,467.48,75,,,percent of total billed charges,75% of total billed charges,467.48,75,,,percent of total billed charges,75% of total billed charges,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,479.67,102,,,Fee Schedule,102% of WV Medicaid Rate,2326.19,165,,,Fee Schedule,165% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4049.52,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5553.61,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6956.46,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,470.26,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,87.26,14,,,percent of total billed charges,14% of total billed charges,87.26,6956.46,
21555- PF Exc Tumor Sft Tiss Neck/ Ant Thorax Subq <3 cm,4311482,CDM,960,RC,21555,HCPCS,Outpatient,,,623.3,311.65,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
21556- Exc IM tum/neck or ant thorax <5cm,3434708,CDM,510,RC,21556,HCPCS,Outpatient,,,1394,697,,1045.5,75,,,percent of total billed charges,75% of total billed charges,1045.5,75,,,percent of total billed charges,75% of total billed charges,2428.67,100,,,Fee Schedule,100% of CMS OPPS Rate,803.83,102,,,Fee Schedule,102% of WV Medicaid Rate,4007.32,165,,,Fee Schedule,165% of CMS OPPS Rate,2517.11,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,6976.06,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,9567.11,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,11983.78,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,788.07,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2428.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2517.11,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,195.16,14,,,percent of total billed charges,14% of total billed charges,195.16,11983.78,
21601-EXCISION OF CHEST WALL TUMOR,3430804,CDM,510,RC,21601,HCPCS,Outpatient,,,2698.29,1349.15,,2023.72,75,,,percent of total billed charges,75% of total billed charges,2023.72,75,,,percent of total billed charges,75% of total billed charges,2428.67,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,4007.32,165,,,Fee Schedule,165% of CMS OPPS Rate,2517.11,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,6976.06,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,9567.11,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,11983.78,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,2428.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2517.11,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,377.76,14,,,percent of total billed charges,14% of total billed charges,377.76,11983.78,
21620- Ostectomy of sternum/ partial,3434713,CDM,510,RC,21620,HCPCS,Outpatient,,,1336.08,668.04,,1002.06,75,,,percent of total billed charges,75% of total billed charges,1002.06,75,,,percent of total billed charges,75% of total billed charges,1336.08,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,1336.08,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1336.08,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1336.08,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1336.08,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1336.08,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,1336.08,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1336.08,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,187.05,14,,,percent of total billed charges,14% of total billed charges,187.05,1336.08,
21750- Close median sternotomy separation,3434714,CDM,510,RC,21750,HCPCS,Outpatient,,,1816.48,908.24,,1362.36,75,,,percent of total billed charges,75% of total billed charges,1362.36,75,,,percent of total billed charges,75% of total billed charges,1816.48,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,1816.48,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1816.48,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1816.48,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1816.48,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1816.48,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,1816.48,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1816.48,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,254.31,14,,,percent of total billed charges,14% of total billed charges,254.31,1816.48,
21825- Open tx/sternum fracture,3434716,CDM,510,RC,21825,HCPCS,Outpatient,,,1449.85,724.93,,1087.39,75,,,percent of total billed charges,75% of total billed charges,1087.39,75,,,percent of total billed charges,75% of total billed charges,1449.85,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,1449.85,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1449.85,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1449.85,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1449.85,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1449.85,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,1449.85,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1449.85,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,202.98,14,,,percent of total billed charges,14% of total billed charges,202.98,1449.85,
21930- Exc/tumor/back/flank/SQ/<3cm,3434718,CDM,510,RC,21930,HCPCS,Outpatient,,,1291,645.5,,968.25,75,,,percent of total billed charges,75% of total billed charges,968.25,75,,,percent of total billed charges,75% of total billed charges,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,479.67,102,,,Fee Schedule,102% of WV Medicaid Rate,2326.19,165,,,Fee Schedule,165% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4049.52,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5553.61,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6956.46,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,470.26,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,180.74,14,,,percent of total billed charges,14% of total billed charges,180.74,6956.46,
21931 - PF Exc Tumor Sft Tiss Back/ Flank Subq 3 cm/ >,4311483,CDM,960,RC,21931,HCPCS,Outpatient,,,1106.14,553.07,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
21931- Exc subq tumor/back/flank 3cm/>,3434719,CDM,510,RC,21931,HCPCS,Outpatient,,,1247.33,623.67,,935.5,75,,,percent of total billed charges,75% of total billed charges,935.5,75,,,percent of total billed charges,75% of total billed charges,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,479.67,102,,,Fee Schedule,102% of WV Medicaid Rate,2326.19,165,,,Fee Schedule,165% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4049.52,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5553.61,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6956.46,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,470.26,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,174.63,14,,,percent of total billed charges,14% of total billed charges,174.63,6956.46,
21932- Exc IM tumor/back/flank/ < 5 cm,3434720,CDM,510,RC,21932,HCPCS,Outpatient,,,1759.17,879.59,,1319.38,75,,,percent of total billed charges,75% of total billed charges,1319.38,75,,,percent of total billed charges,75% of total billed charges,2428.67,100,,,Fee Schedule,100% of CMS OPPS Rate,803.83,102,,,Fee Schedule,102% of WV Medicaid Rate,4007.32,165,,,Fee Schedule,165% of CMS OPPS Rate,2517.11,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,6976.06,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,9567.11,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,11983.78,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,788.07,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2428.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2517.11,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,246.28,14,,,percent of total billed charges,14% of total billed charges,246.28,11983.78,
21933- Exc IM tumor/back/flank/5 cm/>,3434721,CDM,510,RC,21933,HCPCS,Outpatient,,,1966.31,983.16,,1474.73,75,,,percent of total billed charges,75% of total billed charges,1474.73,75,,,percent of total billed charges,75% of total billed charges,2428.67,100,,,Fee Schedule,100% of CMS OPPS Rate,803.83,102,,,Fee Schedule,102% of WV Medicaid Rate,4007.32,165,,,Fee Schedule,165% of CMS OPPS Rate,2517.11,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,6976.06,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,9567.11,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,11983.78,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,788.07,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2428.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2517.11,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,275.28,14,,,percent of total billed charges,14% of total billed charges,275.28,11983.78,
22900 - PF Exc Tumor Sft Tiss Abdl Wall Subfascial <5 cm,4311484,CDM,960,RC,22900,HCPCS,Outpatient,,,1331.77,665.89,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
22900- Ex IM tumor/abdominal wall < 5 cm,3434786,CDM,510,RC,22900,HCPCS,Outpatient,,,1499.45,749.73,,1124.59,75,,,percent of total billed charges,75% of total billed charges,1124.59,75,,,percent of total billed charges,75% of total billed charges,2428.67,100,,,Fee Schedule,100% of CMS OPPS Rate,803.83,102,,,Fee Schedule,102% of WV Medicaid Rate,4007.32,165,,,Fee Schedule,165% of CMS OPPS Rate,2517.11,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,6976.06,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,9567.11,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,11983.78,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,788.07,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2428.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2517.11,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,209.92,14,,,percent of total billed charges,14% of total billed charges,209.92,11983.78,
22901-PF EXC TUMOR ABDOM WALL 5CM OR >,3428955,CDM,960,RC,22901,HCPCS,Outpatient,,,1781.38,890.69,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
22902 - PF Exc Tumor Sft Tiss Abdl Wall Subq <3 cm,4311485,CDM,960,RC,22902,HCPCS,Outpatient,,,777.16,388.58,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
22902- Excise subq tumor/abd wall <3 cm,3434787,CDM,510,RC,22902,HCPCS,Outpatient,,,1217.07,608.54,,912.8,75,,,percent of total billed charges,75% of total billed charges,912.8,75,,,percent of total billed charges,75% of total billed charges,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,479.67,102,,,Fee Schedule,102% of WV Medicaid Rate,2326.19,165,,,Fee Schedule,165% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4049.52,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5553.61,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6956.46,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,470.26,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,170.39,14,,,percent of total billed charges,14% of total billed charges,170.39,6956.46,
22903 - PF Exc Tumor Sft Tiss Abdl Wall Subq 3 cm/ >,4311486,CDM,960,RC,22903,HCPCS,Outpatient,,,1038.13,519.07,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
22903- Exc/abd soft tissue tumor/3cm or >,3434788,CDM,510,RC,22903,HCPCS,Outpatient,,,1169.41,584.71,,877.06,75,,,percent of total billed charges,75% of total billed charges,877.06,75,,,percent of total billed charges,75% of total billed charges,2428.67,100,,,Fee Schedule,100% of CMS OPPS Rate,803.83,102,,,Fee Schedule,102% of WV Medicaid Rate,4007.32,165,,,Fee Schedule,165% of CMS OPPS Rate,2517.11,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,6976.06,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,9567.11,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,11983.78,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,788.07,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2428.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2517.11,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,163.72,14,,,percent of total billed charges,14% of total billed charges,163.72,11983.78,
22904 - PF Rad Resection Tumor Soft Tissue Abdl Wall <5cm,4301627,CDM,960,RC,22904,HCPCS,Outpatient,,,2217.5,1108.75,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
22905-PF RESECT ABD TUM > 5 CM,3428961,CDM,510,RC,22905,HCPCS,Outpatient,,,3553.16,1776.58,,2664.87,75,,,percent of total billed charges,75% of total billed charges,2664.87,75,,,percent of total billed charges,75% of total billed charges,2428.67,100,,,Fee Schedule,100% of CMS OPPS Rate,803.83,102,,,Fee Schedule,102% of WV Medicaid Rate,4007.32,165,,,Fee Schedule,165% of CMS OPPS Rate,2517.11,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,6976.06,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,9567.11,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,11983.78,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,788.07,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2428.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2517.11,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,497.44,14,,,percent of total billed charges,14% of total billed charges,497.44,11983.78,
23071- Exc SQ tumor/shoulder area 3cm/>,3434794,CDM,510,RC,23071,HCPCS,Outpatient,,,1109.95,554.98,,832.46,75,,,percent of total billed charges,75% of total billed charges,832.46,75,,,percent of total billed charges,75% of total billed charges,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,479.67,102,,,Fee Schedule,102% of WV Medicaid Rate,2326.19,165,,,Fee Schedule,165% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4049.52,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5553.61,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6956.46,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,470.26,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,155.39,14,,,percent of total billed charges,14% of total billed charges,155.39,6956.46,
23073- Exc IM tumor/shoulder area 5cm/>,3434795,CDM,510,RC,23073,HCPCS,Outpatient,,,1841.54,920.77,,1381.16,75,,,percent of total billed charges,75% of total billed charges,1381.16,75,,,percent of total billed charges,75% of total billed charges,2428.67,100,,,Fee Schedule,100% of CMS OPPS Rate,803.83,102,,,Fee Schedule,102% of WV Medicaid Rate,4007.32,165,,,Fee Schedule,165% of CMS OPPS Rate,2517.11,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,6976.06,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,9567.11,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,11983.78,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,788.07,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2428.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2517.11,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,257.82,14,,,percent of total billed charges,14% of total billed charges,257.82,11983.78,
23410-PF OPEN REPAIR OF ROTATOR CUFF ACUTE,4321995,CDM,981,RC,23410,HCPCS,Outpatient,,,1609.06,804.53,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
23412-PF OPEN REPAIR OF ROTATOR CUFF CHRONIC,4321994,CDM,981,RC,23412,HCPCS,Outpatient,,,1672.58,836.29,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
23500-PF CLSD TX CLAVICULAR FRACTURE W/O MANIPULATION,4321993,CDM,981,RC,23500,HCPCS,Outpatient,,,444,222,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
23505-PF CLSD TX CLAVICULAR FRACTURE W/MANIPULATION,4321992,CDM,981,RC,23505,HCPCS,Outpatient,,,653.24,326.62,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
23515-PF OPEN TX CLAVICULAR FRACTURE INTERNAL FIXATION,4321991,CDM,981,RC,23515,HCPCS,Outpatient,,,1412.22,706.11,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
23520-PF CLSD TX STERNOCLAVICULAR DISLC W/O MANIPULATION,4321990,CDM,981,RC,23520,HCPCS,Outpatient,,,461.66,230.83,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
23525-PF CLOSED TX STERNOCLAVICULAR DISLC W/MANIPULATION,4321989,CDM,981,RC,23525,HCPCS,Outpatient,,,705.9,352.95,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
23530-PF OPEN TX STERNOCLAVICULAR DISLC ACUTE/CHRONIC,4321988,CDM,981,RC,23530,HCPCS,Outpatient,,,1129.88,564.94,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
23532-PF OPTX STRNCLAV DISLC ACUTE/CHRONIC W/FASCIAL GRF,4321987,CDM,981,RC,23532,HCPCS,Outpatient,,,1228.58,614.29,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
23540-PF CLSD TX ACROMIOCLAVICULAR DISLC W/O MANIPULATION,4321986,CDM,981,RC,23540,HCPCS,Outpatient,,,460.54,230.27,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
23545-PF CLSD TX ACROMIOCLAVICULAR DISLC W/ MANIPULATION,4321985,CDM,981,RC,23545,HCPCS,Outpatient,,,631.14,315.57,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
23550-PF OPEN TX ACROMIOCLAVICULAR DISLC ACUTE/CHRONIC,4321984,CDM,981,RC,23550,HCPCS,Outpatient,,,1121.42,560.71,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
23552-PF OPTX ACROMCLAV DISLC ACUTE/CHRONIC W/FASCIAL GRF,4321983,CDM,981,RC,23552,HCPCS,Outpatient,,,1270.3,635.15,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
23570-PF CLOSED TX SCAPULAR FRACTURE W/O MANIPULATION,4321982,CDM,981,RC,23570,HCPCS,Outpatient,,,469.32,234.66,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
23575-PF CLTX SCAPULAR FX W/MANJ W/WO SKELETAL TRACTION,4321981,CDM,981,RC,23575,HCPCS,Outpatient,,,740.54,370.27,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
23585-PF OPEN TX SCAPULAR FX W/INTERNAL FIXATION IF PFRMD,4321980,CDM,981,RC,23585,HCPCS,Outpatient,,,1919.92,959.96,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
23600-PF CLTX PROXIMAL HUMERAL FRACTURE W/O MANIPULATION,4321979,CDM,981,RC,23600,HCPCS,Outpatient,,,611.54,305.77,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
23605-PF CLTX PROX HUMRL FX W/MANJ W/WO SKELETAL TRAC,4321978,CDM,981,RC,23605,HCPCS,Outpatient,,,837.6,418.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
23615-PF OPEN TREATMENT PROXIMAL HUMERAL FRACTURE,4321977,CDM,981,RC,23615,HCPCS,Outpatient,,,1731.96,865.98,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
23616-PF OPEN PROX HUMERAL FRACTURE PROSTHETIC RPLCMT,4321976,CDM,981,RC,23616,HCPCS,Outpatient,,,2432.48,1216.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
23620-PF CLTX GREATER HUMERAL TUBEROSITY FX W/O MANJ,4321975,CDM,981,RC,23620,HCPCS,Outpatient,,,505.4,252.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
23625-PF CLTX GRTER HUMERAL TUBEROSITY FX W/MANIPULATION,4321974,CDM,981,RC,23625,HCPCS,Outpatient,,,697.36,348.68,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
23630-PF OPEN TREATMENT GRTER HUMERAL TUBEROSITY FRACTURE,4321973,CDM,981,RC,23630,HCPCS,Outpatient,,,1528.72,764.36,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
23650-PF CLSD TX SHOULDER DISLC W/MANIPULATION W/O ANE,4321972,CDM,981,RC,23650,HCPCS,Outpatient,,,590.12,295.06,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
23655-PF CLSD TX SHOULDER DISLC W/MANIPULATION REQ ANES,4321971,CDM,981,RC,23655,HCPCS,Outpatient,,,794.98,397.49,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
23660-PF OPEN TX ACUTE SHOULDER DISLOCATION,4321970,CDM,981,RC,23660,HCPCS,Outpatient,,,1149.4,574.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
23665-PF  CLTX SHOULDER DISLC W/FX HUMERAL TUBRST W/MANJ,4321969,CDM,981,RC,23665,HCPCS,Outpatient,,,781.52,390.76,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
23670-PF OPEN TX SHOULDER DISLC W/HUMERAL TUBEROSITY FX,4321968,CDM,981,RC,23670,HCPCS,Outpatient,,,1708.52,854.26,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
23675-PF CLTX SHOULDER DISLC W/SURG/ANTMCL NECK FX W/MANJ,4321967,CDM,981,RC,23675,HCPCS,Outpatient,,,980.48,490.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
23680-PF OPEN TX SHOULDER DISLOCATION W/NECK FRACTURE,4321966,CDM,981,RC,23680,HCPCS,Outpatient,,,1826.24,913.12,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
23930- I&D/upper arm/elbow/deep absc/hema,3434837,CDM,510,RC,23930,HCPCS,Outpatient,,,919.94,459.97,,689.96,75,,,percent of total billed charges,75% of total billed charges,689.96,75,,,percent of total billed charges,75% of total billed charges,2428.67,100,,,Fee Schedule,100% of CMS OPPS Rate,803.83,102,,,Fee Schedule,102% of WV Medicaid Rate,4007.32,165,,,Fee Schedule,165% of CMS OPPS Rate,2517.11,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,6976.06,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,9567.11,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,11983.78,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,788.07,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2428.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2517.11,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,128.79,14,,,percent of total billed charges,14% of total billed charges,128.79,11983.78,
23931- I&D/upper arm/elbow/bursa,3434838,CDM,360,RC,23931,HCPCS,Outpatient,,,757.95,378.98,,568.46,75,,,percent of total billed charges,75% of total billed charges,568.46,75,,,percent of total billed charges,75% of total billed charges,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,479.67,102,,,Fee Schedule,102% of WV Medicaid Rate,2326.19,165,,,Fee Schedule,165% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4049.52,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5553.61,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6956.46,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,470.26,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,106.11,14,,,percent of total billed charges,14% of total billed charges,106.11,6956.46,
23931-PF INCISION&DRAINAGE UPPER ARM/ELBOW BURSA,4321965,CDM,981,RC,23931,HCPCS,Outpatient,,,310.36,155.18,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
23935- Inc/deep/open bone cortex/hum/elbo,3434839,CDM,510,RC,23935,HCPCS,Outpatient,,,1323.49,661.75,,992.62,75,,,percent of total billed charges,75% of total billed charges,992.62,75,,,percent of total billed charges,75% of total billed charges,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,1073.09,102,,,Fee Schedule,102% of WV Medicaid Rate,4617.6,165,,,Fee Schedule,165% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8038.46,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11024.11,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13808.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1052.05,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,185.29,14,,,percent of total billed charges,14% of total billed charges,185.29,13808.81,
24000- Arthrotomy/elbow/exp/drain/rmv FB,3434840,CDM,510,RC,24000,HCPCS,Outpatient,,,1233.02,616.51,,924.77,75,,,percent of total billed charges,75% of total billed charges,924.77,75,,,percent of total billed charges,75% of total billed charges,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,1073.09,102,,,Fee Schedule,102% of WV Medicaid Rate,4617.6,165,,,Fee Schedule,165% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8038.46,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11024.11,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13808.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1052.05,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,172.62,14,,,percent of total billed charges,14% of total billed charges,172.62,13808.81,
24065 Biopsy arm/elbow soft tissue  (the CPT code is built without a description),3428318,CDM,360,RC,24065,HCPCS,Outpatient,,,325.87,162.94,,244.4,75,,,percent of total billed charges,75% of total billed charges,244.4,75,,,percent of total billed charges,75% of total billed charges,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,147.41,102,,,Fee Schedule,102% of WV Medicaid Rate,2326.19,165,,,Fee Schedule,165% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4049.52,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5553.61,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6956.46,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,144.52,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,45.62,14,,,percent of total billed charges,14% of total billed charges,45.62,6956.46,
24071- Exc/tumor/up arm/elbow SQ/>/=3cm,3434843,CDM,510,RC,24071,HCPCS,Outpatient,,,1071.07,535.54,,803.3,75,,,percent of total billed charges,75% of total billed charges,803.3,75,,,percent of total billed charges,75% of total billed charges,2428.67,100,,,Fee Schedule,100% of CMS OPPS Rate,803.83,102,,,Fee Schedule,102% of WV Medicaid Rate,4007.32,165,,,Fee Schedule,165% of CMS OPPS Rate,2517.11,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,6976.06,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,9567.11,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,11983.78,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,788.07,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2428.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2517.11,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,149.95,14,,,percent of total billed charges,14% of total billed charges,149.95,11983.78,
24073 - PF Exc Tumor Sft Tiss Upper Arm/ Elbw Subfasc 5 cm/ >,4311490,CDM,960,RC,24073,HCPCS,Outpatient,,,1626.35,813.18,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
24073- Exc IM tumor/upper arm/elbow 5cm/>,3434844,CDM,510,RC,24073,HCPCS,Outpatient,,,1830.17,915.09,,1372.63,75,,,percent of total billed charges,75% of total billed charges,1372.63,75,,,percent of total billed charges,75% of total billed charges,2428.67,100,,,Fee Schedule,100% of CMS OPPS Rate,803.83,102,,,Fee Schedule,102% of WV Medicaid Rate,4007.32,165,,,Fee Schedule,165% of CMS OPPS Rate,2517.11,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,6976.06,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,9567.11,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,11983.78,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,788.07,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2428.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2517.11,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,256.22,14,,,percent of total billed charges,14% of total billed charges,256.22,11983.78,
24075- Exc/tumor/upper arm/elbow/SQ/<3cm,3434845,CDM,510,RC,24075,HCPCS,Outpatient,,,671.43,335.72,,503.57,75,,,percent of total billed charges,75% of total billed charges,503.57,75,,,percent of total billed charges,75% of total billed charges,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,479.67,102,,,Fee Schedule,102% of WV Medicaid Rate,2326.19,165,,,Fee Schedule,165% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4049.52,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5553.61,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6956.46,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,470.26,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,94,14,,,percent of total billed charges,14% of total billed charges,94,6956.46,
24076- Exc IM tumor/upper arm/elbow < 5 m,3434846,CDM,510,RC,24076,HCPCS,Outpatient,,,1428.47,714.24,,1071.35,75,,,percent of total billed charges,75% of total billed charges,1071.35,75,,,percent of total billed charges,75% of total billed charges,2428.67,100,,,Fee Schedule,100% of CMS OPPS Rate,803.83,102,,,Fee Schedule,102% of WV Medicaid Rate,4007.32,165,,,Fee Schedule,165% of CMS OPPS Rate,2517.11,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,6976.06,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,9567.11,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,11983.78,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,788.07,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2428.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2517.11,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,199.99,14,,,percent of total billed charges,14% of total billed charges,199.99,11983.78,
24105- Excision/olecranon bursa,3434848,CDM,510,RC,24105,HCPCS,Outpatient,,,921.69,460.85,,691.27,75,,,percent of total billed charges,75% of total billed charges,691.27,75,,,percent of total billed charges,75% of total billed charges,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,1073.09,102,,,Fee Schedule,102% of WV Medicaid Rate,4617.6,165,,,Fee Schedule,165% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8038.46,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11024.11,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13808.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1052.05,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,129.04,14,,,percent of total billed charges,14% of total billed charges,129.04,13808.81,
24110- Exc/curet/bone cyst/bgn tum/humeru,3434849,CDM,510,RC,24110,HCPCS,Outpatient,,,1538.84,769.42,,1154.13,75,,,percent of total billed charges,75% of total billed charges,1154.13,75,,,percent of total billed charges,75% of total billed charges,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,1073.09,102,,,Fee Schedule,102% of WV Medicaid Rate,4617.6,165,,,Fee Schedule,165% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8038.46,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11024.11,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13808.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1052.05,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,215.44,14,,,percent of total billed charges,14% of total billed charges,215.44,13808.81,
24120- Exc/curet/bone cyst/bgn tum head/neck/radius/olecranon proc,3434850,CDM,510,RC,24120,HCPCS,Outpatient,,,1387.03,693.52,,1040.27,75,,,percent of total billed charges,75% of total billed charges,1040.27,75,,,percent of total billed charges,75% of total billed charges,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,1073.09,102,,,Fee Schedule,102% of WV Medicaid Rate,4617.6,165,,,Fee Schedule,165% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8038.46,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11024.11,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13808.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1052.05,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,194.18,14,,,percent of total billed charges,14% of total billed charges,194.18,13808.81,
24147- Part exc/bone/olecranon process,3434851,CDM,510,RC,24147,HCPCS,Outpatient,,,1631.94,815.97,,1223.96,75,,,percent of total billed charges,75% of total billed charges,1223.96,75,,,percent of total billed charges,75% of total billed charges,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,1073.09,102,,,Fee Schedule,102% of WV Medicaid Rate,4617.6,165,,,Fee Schedule,165% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8038.46,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11024.11,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13808.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1052.05,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,228.47,14,,,percent of total billed charges,14% of total billed charges,228.47,13808.81,
24200- Rmv foreign body/up arm/elbow/SQ,3434852,CDM,510,RC,24200,HCPCS,Outpatient,,,554.02,277.01,,415.52,75,,,percent of total billed charges,75% of total billed charges,415.52,75,,,percent of total billed charges,75% of total billed charges,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,121.75,102,,,Fee Schedule,102% of WV Medicaid Rate,2326.19,165,,,Fee Schedule,165% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4049.52,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5553.61,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6956.46,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,119.36,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,77.56,14,,,percent of total billed charges,14% of total billed charges,77.56,6956.46,
24200-PF RMVL FOREIGN BODY UPPER ARM/ELBOW SUBCUTANEOUS,4321339,CDM,981,RC,24200,HCPCS,Outpatient,,,269.92,134.96,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
24201- Rmv foreign body/up arm/elbow/deep,3434853,CDM,510,RC,24201,HCPCS,Outpatient,,,1394.6,697.3,,1045.95,75,,,percent of total billed charges,75% of total billed charges,1045.95,75,,,percent of total billed charges,75% of total billed charges,2428.67,100,,,Fee Schedule,100% of CMS OPPS Rate,803.83,102,,,Fee Schedule,102% of WV Medicaid Rate,4007.32,165,,,Fee Schedule,165% of CMS OPPS Rate,2517.11,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,6976.06,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,9567.11,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,11983.78,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,788.07,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2428.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2517.11,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,195.24,14,,,percent of total billed charges,14% of total billed charges,195.24,11983.78,
24201-PF REMOVAL FOREIGN BODY UPPER ARM/ELBOW DEEP,4321340,CDM,981,RC,24201,HCPCS,Outpatient,,,717.68,358.84,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
24341-PF REPAIR TENDON/MUSCLE UPPER ARM/ELBOW EA TDN/MUSC,4321341,CDM,981,RC,24341,HCPCS,Outpatient,,,1455.36,727.68,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
24342-PF RINSJ RPTD BICEPS/TRICEPS TDN DSTL W/WO TDN GRF,4321964,CDM,981,RC,24342,HCPCS,Outpatient,,,1520.1,760.05,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
24500-PF CLSD TX HUMERAL SHAFT FRACTURE W/O MANIPULATION,4321963,CDM,981,RC,24500,HCPCS,Outpatient,,,649.7,324.85,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
24505-PF CLTX HUMERAL SHFT FX W/MANJ W/WO SKELETAL TRACJ,4321962,CDM,981,RC,24505,HCPCS,Outpatient,,,886.4,443.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
24515-PF OPTX HUMERAL SHFT FX W/PLATE/SCREWS W/WOCERCLAGE,4321961,CDM,981,RC,24515,HCPCS,Outpatient,,,1726.78,863.39,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
24516-PF TX HUMRAL SHAFT FX W/INSJ IMED IMPLT W/W CERCLGE,4321960,CDM,981,RC,24516,HCPCS,Outpatient,,,1688.94,844.47,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
24530-PF CLTX SPRCNDYLR/TRANSCNDYLR HUMERAL FX W/WO MANJ,4321959,CDM,981,RC,24530,HCPCS,Outpatient,,,684.9,342.45,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
24535-PF CLTX SPRCNDYLR/TRANSCNDYLR HUMERAL FX W/MANJ,4321958,CDM,981,RC,24535,HCPCS,Outpatient,,,1118.14,559.07,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
24538-PF PRQ SKEL FIXJ SPRCNDYLR/TRANSCNDYLR HUMERAL FX,4321957,CDM,981,RC,24538,HCPCS,Outpatient,,,1539.36,769.68,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
24545-PF OPEN TX HUMERAL SUPRACONDYLAR FRACTURE W/O XTN,4321956,CDM,981,RC,24545,HCPCS,Outpatient,,,1819.06,909.53,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
24546-PF OPEN TX HUMERAL SUPRACONDYLAR FRACTURE W/XT,4321955,CDM,981,RC,24546,HCPCS,Outpatient,,,2035.68,1017.84,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
24560-PF CLTX HUMERAL EPICONDYLAR FX MEDIAL/LAT W/O MANJ,4321950,CDM,981,RC,24560,HCPCS,Outpatient,,,574.64,287.32,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
24565-PF CLTX HUMERAL EPICONDYLAR FX MEDIAL/LAT W/MANJ,4321949,CDM,981,RC,24565,HCPCS,Outpatient,,,968.32,484.16,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
24566-PF PRQ SKEL FIXJ HUMRL EPCNDYLR FX MEDIAL/LAT MANJ,4321948,CDM,981,RC,24566,HCPCS,Outpatient,,,1405.82,702.91,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
24575-PF OPEN TX HUMERAL EPICONDYLAR FRACTURE,4321947,CDM,981,RC,24575,HCPCS,Outpatient,,,1431.98,715.99,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
24576-PF CLTX HUMERAL CONDYLAR FX MEDIAL/LAT W/O MANJ,4321946,CDM,981,RC,24576,HCPCS,Outpatient,,,607.72,303.86,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
24577-PF CLTX HUMERAL CONDYLAR FX MEDIAL/LATERAL W/MANJ,4321945,CDM,981,RC,24577,HCPCS,Outpatient,,,993.48,496.74,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
24579-PF OPEN TREATMENT HUMERAL CONDYLAR FRACTURE,4321944,CDM,981,RC,24579,HCPCS,Outpatient,,,1635.8,817.9,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
24582-PF PRQ SKEL FIXJ HUMRL CNDYLR FX MEDIAL/LAT W/MANJ,4321943,CDM,981,RC,24582,HCPCS,Outpatient,,,1590.26,795.13,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
24586-PF OPTX PERIARTICULAR FRACTURE &/DISLOCATION ELBO,4321942,CDM,981,RC,24586,HCPCS,Outpatient,,,2134.88,1067.44,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
24587-PF OPTX PRIARTICULAR FX&/DISLC ELBW W/IMPLT ARTHR,4321941,CDM,981,RC,24587,HCPCS,Outpatient,,,2140.94,1070.47,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
24600-PF TREATMENT CLOSED ELBOW DISLOCATION W/O ANES,4321940,CDM,981,RC,24600,HCPCS,Outpatient,,,678.54,339.27,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
24605-PF TREATMENT CLOSED ELBOW DISLOCATION REQ ANES,4321939,CDM,981,RC,24605,HCPCS,Outpatient,,,932.98,466.49,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
24615-PF CLTX HUMERAL EPICONDYLAR FX MEDIAL/LAT W/MANJ,4321938,CDM,981,RC,24615,HCPCS,Outpatient,,,1402.16,701.08,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
24620-PF CLOSED TX MONTEGGIA FX DISLOCATION ELBOW W/MANJ,4321937,CDM,981,RC,24620,HCPCS,Outpatient,,,1148.8,574.4,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
24635-PF OPEN TX MONTEGGIA FRACTURE DISLOCATION ELBOW,4321936,CDM,981,RC,24635,HCPCS,Outpatient,,,1322.2,661.1,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
24640-PF CLTX RDL HEAD SUBLXTJ CHLD NURSEMAID ELBW W/MAN,4321935,CDM,981,RC,24640,HCPCS,Outpatient,,,153.92,76.96,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
24650-PF CLOSED TX RADIAL HEAD/NECK FX W/O MANIPULATION,4321934,CDM,981,RC,24650,HCPCS,Outpatient,,,475.84,237.92,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
24655-PF CLOSED TX RADIAL HEAD/NECK FX W/MANIPULATION,4321933,CDM,981,RC,24655,HCPCS,Outpatient,,,791.04,395.52,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
24665-PF OPEN TX RADIAL HEAD/NECK FRACTURE,4321932,CDM,981,RC,24665,HCPCS,Outpatient,,,1281.5,640.75,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
24666-PF OPEN TX RADIAL HEAD/NECK FRACTURE PROSTHETIC,4321931,CDM,981,RC,24666,HCPCS,Outpatient,,,1435.1,717.55,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
24670-PF CLOSED TX ULNAR FRACTURE PROXIMAL END W/O MANJ,4321930,CDM,981,RC,24670,HCPCS,Outpatient,,,521.54,260.77,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
24675-PF CLOSED TX ULNAR FRACTURE PROXIMAL END W/MANJ,4321929,CDM,981,RC,24675,HCPCS,Outpatient,,,817.34,408.67,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
24685-PF OPEN TREATMENT ULNAR FRACTURE PROXIMAL END,4321928,CDM,981,RC,24685,HCPCS,Outpatient,,,1276,638,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
25028- I&D/forearm/wrist/deep absc/hemato,3434886,CDM,510,RC,25028,HCPCS,Outpatient,,,1773.96,886.98,,1330.47,75,,,percent of total billed charges,75% of total billed charges,1330.47,75,,,percent of total billed charges,75% of total billed charges,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,1073.09,102,,,Fee Schedule,102% of WV Medicaid Rate,4617.6,165,,,Fee Schedule,165% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8038.46,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11024.11,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13808.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1052.05,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,248.35,14,,,percent of total billed charges,14% of total billed charges,248.35,13808.81,
25031- I&D/bursa/forearm/wrist,3434887,CDM,510,RC,25031,HCPCS,Outpatient,,,954.47,477.24,,715.85,75,,,percent of total billed charges,75% of total billed charges,715.85,75,,,percent of total billed charges,75% of total billed charges,1348.67,100,,,Fee Schedule,100% of CMS OPPS Rate,584.77,102,,,Fee Schedule,102% of WV Medicaid Rate,2225.32,165,,,Fee Schedule,165% of CMS OPPS Rate,1397.79,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,3873.91,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5312.76,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6654.78,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,573.3,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1348.67,100,,,Fee Schedule,100% of CMS OPPS Rate,1397.79,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,133.63,14,,,percent of total billed charges,14% of total billed charges,133.63,6654.78,
25065- Bx/soft tis/forearm/wrist/superfic,3434888,CDM,510,RC,25065,HCPCS,Outpatient,,,671.43,335.72,,503.57,75,,,percent of total billed charges,75% of total billed charges,503.57,75,,,percent of total billed charges,75% of total billed charges,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,147.41,102,,,Fee Schedule,102% of WV Medicaid Rate,2326.19,165,,,Fee Schedule,165% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4049.52,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5553.61,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6956.46,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,144.52,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,94,14,,,percent of total billed charges,14% of total billed charges,94,6956.46,
25073-MSA EXC FOREARM TUM DEEP 3CM/>,3429072,CDM,360,RC,25073,HCPCS,Outpatient,,,1395.46,697.73,,1046.6,75,,,percent of total billed charges,75% of total billed charges,1046.6,75,,,percent of total billed charges,75% of total billed charges,2428.67,100,,,Fee Schedule,100% of CMS OPPS Rate,803.83,102,,,Fee Schedule,102% of WV Medicaid Rate,4007.32,165,,,Fee Schedule,165% of CMS OPPS Rate,2517.11,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,6976.06,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,9567.11,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,11983.78,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,788.07,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2428.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2517.11,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,195.36,14,,,percent of total billed charges,14% of total billed charges,195.36,11983.78,
25075 - PF Exc Tumor Sft Tiss Forewarm &/ Wrist Subq <3 cm,4305456,CDM,960,RC,25075,HCPCS,Outpatient,,,641.19,320.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
25076 - PF Exc Tumor Soft Tiss Forearm&/Wrist Subfasc <3cm,4301626,CDM,960,RC,25076,HCPCS,Outpatient,,,1075.12,537.56,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
25248-PF EXPL W/REMOVAL DEEP FOREIGN BODY FOREARM/WRIST,4321927,CDM,981,RC,25248,HCPCS,Outpatient,,,813.96,406.98,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
25260-PF RPR TDN/MUSC FLXR F/ARM&/WRST PRIM 1 EA TDN/MU,4321342,CDM,981,RC,25260,HCPCS,Outpatient,,,1239.8,619.9,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
25270 - PF Rpr Tdn/ Musc Xtnsr F/ Arm&/ Wrist Prim 1 Ea Tdn,4311492,CDM,960,RC,25270,HCPCS,Outpatient,,,1144.69,572.35,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
25270-PF RPR TDN/MUSC XTNSR F/ARM&/WRIST PRIM 1 EA TDN,4321344,CDM,981,RC,25270,HCPCS,Outpatient,,,964.2,482.1,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
25500-PF CLOSED TX RADIAL SHAFT FRACTURE W/O MANIPULATION,4321926,CDM,981,RC,25500,HCPCS,Outpatient,,,500.94,250.47,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
25505-PF CLOSED TX RADIAL SHAFT FRACTURE W/MANIPULATION,4321925,CDM,981,RC,25505,HCPCS,Outpatient,,,903.3,451.65,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
25515-PF OPEN TREATMENT RADIAL SHAFT FRACTURE,4321924,CDM,981,RC,25515,HCPCS,Outpatient,,,1310.3,655.15,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
25520-PF CLTX RDL SHFT FX&CLTX DISLC DSTL RAD/ULN JT,4321923,CDM,981,RC,25520,HCPCS,Outpatient,,,1065.58,532.79,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
25525-PF OPEN RDL SHAFT FX CLOSED RAD/ULN JT DISLOCATE,4321922,CDM,981,RC,25525,HCPCS,Outpatient,,,1547.52,773.76,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
25526-PF OPEN RDL SHAFT FX CLOSED RAD/ULN JT DISLOCATE,4321921,CDM,981,RC,25526,HCPCS,Outpatient,,,1875.74,937.87,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
25530-PF CLOSED TX ULNAR SHAFT FRACTURE W/O MANIPULATION,4321920,CDM,981,RC,25530,HCPCS,Outpatient,,,469.64,234.82,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
25535-PF CLOSED TX ULNAR SHAFT FRACTURE W/MANIPULATION,4321919,CDM,981,RC,25535,HCPCS,Outpatient,,,894.34,447.17,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
25545-PF OPEN TREATMENT OF ULNAR SHAFT FRACTURE,4321918,CDM,981,RC,25545,HCPCS,Outpatient,,,1221.06,610.53,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
25560-PF CLOSED TX RADIAL&ULNAR SHAFT FRACTURES W/O MAN,4321917,CDM,981,RC,25560,HCPCS,Outpatient,,,504.04,252.02,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
25565-PF CLOSED TX RADIAL&ULNAR SHAFT FRACTURES W/MANJ,4321916,CDM,981,RC,25565,HCPCS,Outpatient,,,919.72,459.86,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
25574-PF OPEN TX RADIAL&ULNAR SHAFT FX W/FIXJ RADIUS/ULNA,4321915,CDM,981,RC,25574,HCPCS,Outpatient,,,1321.92,660.96,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
25575-PF OPEN TX RADIAL&ULNAR SHAFT FX W/FIXJ RADIUS&ULNA,4321914,CDM,981,RC,25575,HCPCS,Outpatient,,,1770.92,885.46,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
25600-PF CLTX DSTL RADIAL FX/EPIPHYSL SEP W/O MAN,4321913,CDM,981,RC,25600,HCPCS,Outpatient,,,623.52,311.76,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
25605-PF CLTX DSTL RDL FX/EPIPHYSL SEP W/MANJ WHEN PERF,4321912,CDM,981,RC,25605,HCPCS,Outpatient,,,1004.7,502.35,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
25606-PF PRQ SKEL FIXJ DISTAL RADIAL FX/EPIPHYSL SEP,4321911,CDM,981,RC,25606,HCPCS,Outpatient,,,1302.82,651.41,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
25607-PF OPTX DSTL RADL X-ARTIC FX/EPIPHYSL SEP,4321910,CDM,981,RC,25607,HCPCS,Outpatient,,,1445.48,722.74,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
25608-PF OPTX DSTL RADL I-ARTIC FX/EPIPHYSL SEP 2 FRAG,4321909,CDM,981,RC,25608,HCPCS,Outpatient,,,1619.04,809.52,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
25609-PF OPTX DSTL RADL I-ARTIC FX/EPIPHYSL SEP 3 FRAG,4321908,CDM,981,RC,25609,HCPCS,Outpatient,,,2056.9,1028.45,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
25622-PF CLOSED TX CARPAL SCAPHOID FRACTURE W/O MANJ,4321907,CDM,981,RC,25622,HCPCS,Outpatient,,,552.22,276.11,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
25624-PF CLOSED TX CARPAL SCAPHOID FRACTURE W/MANJ,4321906,CDM,981,RC,25624,HCPCS,Outpatient,,,866.7,433.35,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
25628-PF OPEN TX CARPAL SCAPHOID NAVICULAR FRACTURE,4321905,CDM,981,RC,25628,HCPCS,Outpatient,,,1406.7,703.35,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
25630-PF CLTX CARPAL BONE FX W/O MANJ EACH BONE,4321904,CDM,981,RC,25630,HCPCS,Outpatient,,,555.88,277.94,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
25635-PF CLTX CARPAL BONE FX W/MANJ EACH BONE,4321903,CDM,981,RC,25635,HCPCS,Outpatient,,,823.58,411.79,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
25645-PF OPEN TX CARPAL BONE FRACTURE OTH/THN SCAPHOID EA,4321902,CDM,981,RC,25645,HCPCS,Outpatient,,,1121.78,560.89,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
25650-PF CLOSED TREATMENT ULNAR STYLOID FRACTURE,4321901,CDM,981,RC,25650,HCPCS,Outpatient,,,599.64,299.82,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
25660-PF CLTX RDCRPL/INTERCARPL DISLC 1/> BONES W/MANJ,4321900,CDM,981,RC,25660,HCPCS,Outpatient,,,874.46,437.23,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
25670-PF OPEN TX RADIOCARPAL/INTERCARPAL DISLC 1/> BONES,4321899,CDM,981,RC,25670,HCPCS,Outpatient,,,1193,596.5,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
25675-PF CLOSED TX DISTAL RADIOULNAR DISLOCATION W/MANJ,4321898,CDM,981,RC,25675,HCPCS,Outpatient,,,809.52,404.76,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
25676-PF OPEN TX DISTAL RADIOULNAR DISLC ACUTE/CHRONIC,4321897,CDM,981,RC,25676,HCPCS,Outpatient,,,1233.68,616.84,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
25680-PF CLTX TRANS-SCAPHOPRILUNAR TYP FX DISLC W/MANJ,4321896,CDM,981,RC,25680,HCPCS,Outpatient,,,1035.68,517.84,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
25685-PF OPEN TX TRANS-SCAPHOPERILUNAR FRACTURE DISLC,4321895,CDM,981,RC,25685,HCPCS,Outpatient,,,1444.96,722.48,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
25690-PF CLOSED TX LUNATE DISLOCATION W/MANIPULATION,4321894,CDM,981,RC,25690,HCPCS,Outpatient,,,959.34,479.67,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
25695-PF OPEN TREATMENT LUNATE DISLOCATION,4321893,CDM,981,RC,25695,HCPCS,Outpatient,,,1246.3,623.15,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
26010- Drainage/finger abscess/simple,3434901,CDM,510,RC,26010,HCPCS,Outpatient,,,862.27,431.14,,646.7,75,,,percent of total billed charges,75% of total billed charges,646.7,75,,,percent of total billed charges,75% of total billed charges,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,73.31,102,,,Fee Schedule,102% of WV Medicaid Rate,280.12,165,,,Fee Schedule,165% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,487.65,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,668.77,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,837.71,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,71.87,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,120.72,14,,,percent of total billed charges,14% of total billed charges,71.87,837.71,
26010-PF DRAINAGE FINGER ABSCESS SIMPLE,4321892,CDM,981,RC,26010,HCPCS,Outpatient,,,270.24,135.12,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
26011-PF DRAINAGE FINGER ABSCESS COMPLICATED,4321891,CDM,981,RC,26011,HCPCS,Outpatient,,,358.94,179.47,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
26020-PF DRAINAGE TENDON SHEATH DIGIT&/PALM EACH,4321347,CDM,981,RC,26020,HCPCS,Outpatient,,,1082.24,541.12,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
26030-PF DRAINAGE OF PALMAR BURSA MULTIPLE BURSA,4321889,CDM,981,RC,26030,HCPCS,Outpatient,,,958.8,479.4,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
26070-PF ARTHRT EXPL DRG/RMVL LOOSE/FB CARP/MTCRPL JT,4321888,CDM,981,RC,26070,HCPCS,Outpatient,,,626.68,313.34,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
26075-PF ARTHRT EXPL DRG/RMVL LOOSE/FB MTCARPHLNGL JT EA,4321887,CDM,981,RC,26075,HCPCS,Outpatient,,,657.84,328.92,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
26080-PF ARTHRT EXPL DRG/RMVL LOOSE/FB IPHAL JT EA,4321886,CDM,981,RC,26080,HCPCS,Outpatient,,,771.4,385.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
26115-PF EXC TUM/VASC MAL SFT TISS HAND/FNGR SUBQ <1.5CM,4321350,CDM,981,RC,26115,HCPCS,Outpatient,,,672.8,336.4,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
26350-PF RPR/ADVMNT FLXR TDN N/Z/2 W/O FR GRAFT EA TENDON,4321885,CDM,981,RC,26350,HCPCS,Outpatient,,,1416,708,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
26410-PF REPAIR EXTENSOR TENDON HAND W/O GRAFT EACH,4321884,CDM,981,RC,26410,HCPCS,Outpatient,,,1139.88,569.94,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
26418-PF REPAIR EXTENSOR TENDON FINGER W/O GRAFT EACH,4321883,CDM,981,RC,26418,HCPCS,Outpatient,,,1175.32,587.66,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
26420-PF REPAIR EXTENSOR TENDON FINGER W/GRAFT EACH,4321353,CDM,981,RC,26420,HCPCS,Outpatient,,,1419.5,709.75,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
26600-PF CLTX METACARPAL FX W/O MANIPULATION EACH BONE,4321882,CDM,981,RC,26600,HCPCS,Outpatient,,,553.4,276.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
26605-PF CLTX METACARPAL FX W/MANIPULATION EACH BONE,4321881,CDM,981,RC,26605,HCPCS,Outpatient,,,579.2,289.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
26607-PF CLTX METACARPAL FX W/MANJ W/XTRNL FIXJ EA BONE,4321880,CDM,981,RC,26607,HCPCS,Outpatient,,,985.98,492.99,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
26608-PF PRQ SKELETAL FIXJ METACARPAL FX EACH BONE,4321879,CDM,981,RC,26608,HCPCS,Outpatient,,,936.88,468.44,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
26615-PF OPEN TX METACARPAL FRACTURE SINGLE EA BONE,4321878,CDM,981,RC,26615,HCPCS,Outpatient,,,1119.32,559.66,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
26641-PF CLTX CARPO/METACARPAL DISLOCATION THUMB W/MAN,4321877,CDM,981,RC,26641,HCPCS,Outpatient,,,744.28,372.14,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
26645-PF CLTX CARPO/METACARPAL FX DISLC THUMB W/MANJ,4321876,CDM,981,RC,26645,HCPCS,Outpatient,,,773.76,386.88,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
26650-PF PRQ SKELETAL FIX CARPO/METACARPAL FX DISLC THUMB,4321860,CDM,981,RC,26650,HCPCS,Outpatient,,,933.36,466.68,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
26665-PF OPEN TX CARPOMETACARPAL FRACTURE DISLOCATE THUMB,4321859,CDM,981,RC,26665,HCPCS,Outpatient,,,1216.76,608.38,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
26670-PF CLTX CARPO/METACARPL DISLC THMB MANJ EA W/O ANES,4321858,CDM,981,RC,26670,HCPCS,Outpatient,,,615.36,307.68,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
26675-PF CLTX CARPO/MTCRPL DISLC THUMB MANJ EA JT W/ANES,4321857,CDM,981,RC,26675,HCPCS,Outpatient,,,826.16,413.08,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
26685-PF OPEN TX CARPOMETACARPAL DISLOCATE NOT THUMB,4321856,CDM,981,RC,26685,HCPCS,Outpatient,,,1119.06,559.53,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
26686-PF OPTX CARP/MTCRPL DISLC THMB CPLX MLT/DLYD RDCTJ,4321855,CDM,981,RC,26686,HCPCS,Outpatient,,,1221.62,610.81,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
26700-PF CLTX METACARPOPHALANGEAL DISLC W/MANJ W/O ANES,4321854,CDM,981,RC,26700,HCPCS,Outpatient,,,618.86,309.43,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
26705-PF CLTX METACARPOPHALANGEAL DISLC W/MANJ W/ANES,4321853,CDM,981,RC,26705,HCPCS,Outpatient,,,774.8,387.4,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
26720-PF CLTX PHLNGL FX PROX/MIDDLE PX/F/T W/O MANJ EA,4321852,CDM,981,RC,26720,HCPCS,Outpatient,,,365.86,182.93,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
26725-PF CLTX PHLNGL FX PROX/MIDDLE PX/F/T W/MANJ EA,4321851,CDM,981,RC,26725,HCPCS,Outpatient,,,597.6,298.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
26727-PF PRQ SKEL FIXJ PHLNGL SHFT FX PROX/MIDDLE PX/F/T,4321850,CDM,981,RC,26727,HCPCS,Outpatient,,,921.46,460.73,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
26735-PF OPEN TX PHALANGEAL SHAFT FRACTURE PROX/MIDDLE EA,4321849,CDM,981,RC,26735,HCPCS,Outpatient,,,1158.1,579.05,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
26740-PF CLTX ARTCLR FX INVG MTCRPHLNGL/IPHAL JT W/O MANJ,4321848,CDM,981,RC,26740,HCPCS,Outpatient,,,426.16,213.08,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
26742-PF CLTX ARTCLR FX INVG MTCARPHLNGL/IPHAL JT W/MANJ,4321847,CDM,981,RC,26742,HCPCS,Outpatient,,,661.14,330.57,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
26746-PF OPEN TX ARTICULAR FRACTURE MCP/IP JOINT EA,4321846,CDM,981,RC,26746,HCPCS,Outpatient,,,1448.98,724.49,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
26750-PF CLTX DSTL PHLNGL FX FNGR/THMB W/O MANJ EA,4321845,CDM,981,RC,26750,HCPCS,Outpatient,,,368.26,184.13,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
26755-PF CLTX DSTL PHLNGL FX FNGR/THMB W/MANJ EA,4321844,CDM,981,RC,26755,HCPCS,Outpatient,,,541.94,270.97,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
26765-PF OPEN TX DISTAL PHALANGEAL FRACTURE EACH,4321843,CDM,981,RC,26765,HCPCS,Outpatient,,,976.48,488.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
26770-PF CLTX IPHAL JT DISLC W/MANJ W/O ANES,4321839,CDM,981,RC,26770,HCPCS,Outpatient,,,516.76,258.38,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
26775-PF CLTX IPHAL JT DISLC W/MANJ REQ ANES,4321835,CDM,981,RC,26775,HCPCS,Outpatient,,,693,346.5,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
26785-PF OPEN TX INTERPHALANGEAL JOINT DISLOCATION,4321834,CDM,981,RC,26785,HCPCS,Outpatient,,,1066.04,533.02,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
26951-PF AMP F/TH 1/2 JT/PHALANX W/NEURECT W/DIR CLSR,4321833,CDM,981,RC,26951,HCPCS,Outpatient,,,1331.92,665.96,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
"27040 - Biopsy, soft tissue of pelvis and hip area; superficial",4037478,CDM,983,RC,27040,HCPCS,Outpatient,,,855.9,427.95,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
27041- Biopsy/soft tissue/pelvis/hip/deep,3434958,CDM,510,RC,27041,HCPCS,Outpatient,,,1861.37,930.69,,1396.03,75,,,percent of total billed charges,75% of total billed charges,1396.03,75,,,percent of total billed charges,75% of total billed charges,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,479.67,102,,,Fee Schedule,102% of WV Medicaid Rate,2326.19,165,,,Fee Schedule,165% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4049.52,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5553.61,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6956.46,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,470.26,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,260.59,14,,,percent of total billed charges,14% of total billed charges,260.59,6956.46,
27043- Exc subq tum/sft tis/pel/hip 3cm/>,3434959,CDM,510,RC,27043,HCPCS,Outpatient,,,1245.26,622.63,,933.95,75,,,percent of total billed charges,75% of total billed charges,933.95,75,,,percent of total billed charges,75% of total billed charges,2428.67,100,,,Fee Schedule,100% of CMS OPPS Rate,803.83,102,,,Fee Schedule,102% of WV Medicaid Rate,4007.32,165,,,Fee Schedule,165% of CMS OPPS Rate,2517.11,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,6976.06,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,9567.11,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,11983.78,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,788.07,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2428.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2517.11,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,174.34,14,,,percent of total billed charges,14% of total billed charges,174.34,11983.78,
27045 - PF Exc Tumor Soft Tissue Pelvis & Hip Subfasc 5cm/>,4309234,CDM,960,RC,27045,HCPCS,Outpatient,,,1544.95,772.48,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
27047- Exc tumor/pelvis/hip/SQ/<3 cm,3434960,CDM,510,RC,27047,HCPCS,Outpatient,,,1277.72,638.86,,958.29,75,,,percent of total billed charges,75% of total billed charges,958.29,75,,,percent of total billed charges,75% of total billed charges,2428.67,100,,,Fee Schedule,100% of CMS OPPS Rate,803.83,102,,,Fee Schedule,102% of WV Medicaid Rate,4007.32,165,,,Fee Schedule,165% of CMS OPPS Rate,2517.11,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,6976.06,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,9567.11,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,11983.78,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,788.07,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2428.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2517.11,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,178.88,14,,,percent of total billed charges,14% of total billed charges,178.88,11983.78,
27048 - EXC TUMOR SOFT TISSUE PELVIS & HIP SUBFASC <5CM,4037479,CDM,983,RC,27048,HCPCS,Outpatient,,,1610.12,805.06,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
27049 PF - Resect hip/pelv tum <5CM - Assistant,4135109,CDM,960,RC,27049,HCPCS,Outpatient,,,3211.59,1605.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
27059-PF RESECT HIP/PELV TUM 5 CM/>,3429129,CDM,510,RC,27059,HCPCS,Outpatient,,,4810.51,2405.26,,3607.88,75,,,percent of total billed charges,75% of total billed charges,3607.88,75,,,percent of total billed charges,75% of total billed charges,2428.67,100,,,Fee Schedule,100% of CMS OPPS Rate,803.83,102,,,Fee Schedule,102% of WV Medicaid Rate,4007.32,165,,,Fee Schedule,165% of CMS OPPS Rate,2517.11,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,6976.06,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,9567.11,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,11983.78,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,788.07,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2428.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2517.11,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,673.47,14,,,percent of total billed charges,14% of total billed charges,673.47,11983.78,
27200-PF CLOSED TREATMENT COCCYGEAL FRACTURE,4321356,CDM,981,RC,27200,HCPCS,Outpatient,,,364.7,182.35,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
27222-PF CLTX ACETABULM HIP/SOCKT FX MANJ W/WO SKEL TRACJ,4321359,CDM,981,RC,27222,HCPCS,Outpatient,,,1938.42,969.21,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
27227-PF OPTX ACTBLR FX INVG ANT/PST 1 COLUMN/FX W/INT,4321832,CDM,981,RC,27227,HCPCS,Outpatient,,,3252.3,1626.15,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
27228-PF OPTX ACTBLR FX INVG ANT&POST 2 COLUMNS FX W/INT,4321830,CDM,981,RC,27228,HCPCS,Outpatient,,,3705.8,1852.9,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
27250-PF CLTX HIP DISLOCATION TRAUMATIC W/O ANESTHESIA,4321829,CDM,981,RC,27250,HCPCS,Outpatient,,,370.7,185.35,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
27252-PF CLTX HIP DISLOCATION TRAUMATIC REQ ANESTHESIA,4321828,CDM,981,RC,27252,HCPCS,Outpatient,,,1487.36,743.68,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
27253-PF OPTX HIP DISLOCATION TRAUMATIC W/O INTERNAL FIX,4321827,CDM,981,RC,27253,HCPCS,Outpatient,,,1848.26,924.13,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
27254-PF OPTX HIP DISLC TRAUMTC W/ACTBLR WALL&FEM HEAD,4321826,CDM,981,RC,27254,HCPCS,Outpatient,,,2501.78,1250.89,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
27256-PF TX SPONTAN HIP DISLC ABDCT SPLNT/TRCJ W/O ANES,4321825,CDM,981,RC,27256,HCPCS,Outpatient,,,486.2,243.1,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
27257-PF TX SPON HIP DISLC ABDCT SPLNT/TRCJ W/MANJ ANES,4321824,CDM,981,RC,27257,HCPCS,Outpatient,,,711.42,355.71,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
27258-PF OPTX SPON HIP DISLC RPLCMT FEM HEAD ACTBLM,4321823,CDM,981,RC,27258,HCPCS,Outpatient,,,2185.04,1092.52,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
27259-PF OPTX SPON HIP DISLC RPLCMT FEM HEAD ACTBLM SHRT,4321822,CDM,981,RC,27259,HCPCS,Outpatient,,,3036.18,1518.09,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
27265-PF CLTX POST HIP ARTHRP DISLC W/O ANES,4321821,CDM,981,RC,27265,HCPCS,Outpatient,,,817.38,408.69,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
27266-PF CLTX POST HIP ARTHRP DISLC REQ ANES,4321820,CDM,981,RC,27266,HCPCS,Outpatient,,,1146.38,573.19,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
27267-PF CLOSED TX FEMORAL FRACTURE PROX HEAD W/O MANJ,4321362,CDM,981,RC,27267,HCPCS,Outpatient,,,861.22,430.61,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
27268-PF CLOSED TX FEMORAL FRACTURE PROX HEAD W/MANJ,4321365,CDM,981,RC,27268,HCPCS,Outpatient,,,1068.32,534.16,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
27275-PF MANIPULATION HIP JOINT GENERAL ANESTHESIA,4321819,CDM,981,RC,27275,HCPCS,Outpatient,,,357.02,178.51,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
27301- I&D deep absc/bursa/hema/thigh/kne,3434997,CDM,510,RC,27301,HCPCS,Outpatient,,,1727.58,863.79,,1295.69,75,,,percent of total billed charges,75% of total billed charges,1295.69,75,,,percent of total billed charges,75% of total billed charges,2428.67,100,,,Fee Schedule,100% of CMS OPPS Rate,803.83,102,,,Fee Schedule,102% of WV Medicaid Rate,4007.32,165,,,Fee Schedule,165% of CMS OPPS Rate,2517.11,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,6976.06,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,9567.11,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,11983.78,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,788.07,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2428.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2517.11,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,241.86,14,,,percent of total billed charges,14% of total billed charges,241.86,11983.78,
27328 - PF Exc Tumor Soft Tissue Thigh/Knee Subfasc <5cm,4309232,CDM,960,RC,27328,HCPCS,Outpatient,,,1304.97,652.49,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
27337- Exc SQ tumor/thigh/knee area 3cm/>,3435004,CDM,360,RC,27337,HCPCS,Outpatient,,,1108.71,554.36,,831.53,75,,,percent of total billed charges,75% of total billed charges,831.53,75,,,percent of total billed charges,75% of total billed charges,2428.67,100,,,Fee Schedule,100% of CMS OPPS Rate,803.83,102,,,Fee Schedule,102% of WV Medicaid Rate,4007.32,165,,,Fee Schedule,165% of CMS OPPS Rate,2517.11,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,6976.06,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,9567.11,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,11983.78,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,788.07,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2428.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2517.11,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,155.22,14,,,percent of total billed charges,14% of total billed charges,155.22,11983.78,
27339- Exc IM tumor/thigh/knee area 5cm/>,3435005,CDM,510,RC,27339,HCPCS,Outpatient,,,1998.73,999.37,,1499.05,75,,,percent of total billed charges,75% of total billed charges,1499.05,75,,,percent of total billed charges,75% of total billed charges,2428.67,100,,,Fee Schedule,100% of CMS OPPS Rate,803.83,102,,,Fee Schedule,102% of WV Medicaid Rate,4007.32,165,,,Fee Schedule,165% of CMS OPPS Rate,2517.11,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,6976.06,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,9567.11,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,11983.78,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,788.07,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2428.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2517.11,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,279.82,14,,,percent of total billed charges,14% of total billed charges,279.82,11983.78,
27372-PF REMOVAL FOREIGN BODY DEEP THIGH/KNEE,4321818,CDM,981,RC,27372,HCPCS,Outpatient,,,783.28,391.64,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
27385-PF SUTURE QUADRICEPS/HAMSTRING RUPTURE PRIMARY,4321817,CDM,981,RC,27385,HCPCS,Outpatient,,,1174.5,587.25,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
27412 - PF Autologous Chondrocyte Implantation Knee,4313686,CDM,960,RC,27412,HCPCS,Outpatient,,,3436.29,1718.15,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
27470-PF RPR NON/MAL FEMUR DSTL H/N W/O GRF,4321368,CDM,981,RC,27470,HCPCS,Outpatient,,,2319.44,1159.72,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
27500-PF CLOSED TX FEMORAL SHAFT FX W/O MANIPULATION,4321816,CDM,981,RC,27500,HCPCS,Outpatient,,,946.58,473.29,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
27502-PF CLTX FEM SHFT FX W/MANJ W/WO SKIN/SKELETAL TRACJ,4321371,CDM,981,RC,27502,HCPCS,Outpatient,,,1496.8,748.4,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
27510-PF CLTX FEM FX DSTL END MEDIAL/LAT CONDYLE W/MANJ,4321372,CDM,981,RC,27510,HCPCS,Outpatient,,,1346.72,673.36,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
27520-PF CLOSED TX PATELLAR FRACTURE W/O MANIPULATION,4321815,CDM,981,RC,27520,HCPCS,Outpatient,,,585.4,292.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
27524-PF OPTX PATLLR FX W/INT FIXJ/PATLLC&SOFT TISS RPR,4321814,CDM,981,RC,27524,HCPCS,Outpatient,,,1477.9,738.95,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
27530-PF CLTX TIBIAL FX PROXIMAL W/O MANIPULATION,4321813,CDM,981,RC,27530,HCPCS,Outpatient,,,557.92,278.96,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
27532-PF CLTX TIBIAL FX PROXIMAL W/WO MANJ W/SKEL TRACJ,4321812,CDM,981,RC,27532,HCPCS,Outpatient,,,1136.1,568.05,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
27535-PF OPEN TX TIBIAL FRACTURE PROXIMAL UNICONDYLAR,4321811,CDM,981,RC,27535,HCPCS,Outpatient,,,1766.86,883.43,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
27536-PF OPTX TIBIAL FX PROX BICONDYLAR W/WO INT FIX,4321810,CDM,981,RC,27536,HCPCS,Outpatient,,,2332.82,1166.41,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
27538-PF CLTX INTERCONDYLAR SPI&/TUBRST FX KNE W/WO MAN,4321809,CDM,981,RC,27538,HCPCS,Outpatient,,,877.24,438.62,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
27540-PF OPEN TX INTERCONDYLAR SPINE/TUBRST FRACTURE KNEE,4321808,CDM,981,RC,27540,HCPCS,Outpatient,,,1600.02,800.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
27550-PF CLTX TIBIAL SHAFT FX W/O MANIPULATION,4321800,CDM,981,RC,27550,HCPCS,Outpatient,,,929.96,464.98,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
27552-PF CLOSED TX KNEE DISLOCATION W/ANESTHESIA,4321807,CDM,981,RC,27552,HCPCS,Outpatient,,,1238.96,619.48,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
27556-PF OPEN TX KNEE DISLOCATION W/O LIGAMENTOUS REPAIR,4321806,CDM,981,RC,27556,HCPCS,Outpatient,,,1727.48,863.74,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
27557-PF OPEN TX KNEE DISLOCATION W/LIGAMENTOUS REPAIR,4321805,CDM,981,RC,27557,HCPCS,Outpatient,,,2060.08,1030.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
27558-PF OPEN TX KNEE DISLOCATION W/REPAIR/RECONSTRUCTION,4321804,CDM,981,RC,27558,HCPCS,Outpatient,,,2347.78,1173.89,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
27560-PF CLOSED TX PATELLAR DISLOCATION W/O ANESTHESIA,4321803,CDM,981,RC,27560,HCPCS,Outpatient,,,672.18,336.09,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
27562-PF CLOSED TX PATELLAR DISLOCATION W/ANESTHESIA,4321802,CDM,981,RC,27562,HCPCS,Outpatient,,,958.8,479.4,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
27566-PF OPTX PATELLAR DISLC W/WO PRTL/TOT PATELLECTOMY,4321801,CDM,981,RC,27566,HCPCS,Outpatient,,,1754,877,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
27590- Amputate thigh/through femur,3435060,CDM,510,RC,27590,HCPCS,Outpatient,,,2124.13,1062.07,,1593.1,75,,,percent of total billed charges,75% of total billed charges,1593.1,75,,,percent of total billed charges,75% of total billed charges,2124.13,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,2124.13,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2124.13,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2124.13,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2124.13,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2124.13,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,2124.13,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2124.13,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,297.38,14,,,percent of total billed charges,14% of total billed charges,297.38,2124.13,
27592 - Amputate Leg at Thigh thru Femur Open Circular,3898995,CDM,983,RC,27592,HCPCS,Outpatient,,,1797.58,898.79,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
"27596 - (PF) Amputation, thigh, through femur, any level; re-amputation",3634896,CDM,510,RC,27596,HCPCS,Outpatient,,,1907.11,953.56,,1430.33,75,,,percent of total billed charges,75% of total billed charges,1430.33,75,,,percent of total billed charges,75% of total billed charges,1907.11,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,1907.11,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1907.11,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1907.11,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1907.11,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1907.11,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,1907.11,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1907.11,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,267,14,,,percent of total billed charges,14% of total billed charges,267,1907.11,
27600- Decompress fasciotomy/leg/ant/lat,3435063,CDM,510,RC,27600,HCPCS,Outpatient,,,1067.03,533.52,,800.27,75,,,percent of total billed charges,75% of total billed charges,800.27,75,,,percent of total billed charges,75% of total billed charges,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,1073.09,102,,,Fee Schedule,102% of WV Medicaid Rate,4617.6,165,,,Fee Schedule,165% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8038.46,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11024.11,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13808.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1052.05,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,149.38,14,,,percent of total billed charges,14% of total billed charges,149.38,13808.81,
"27602 Decompression fasciotomy, leg; anterior and/or lateral, and posterior compartment(s)",3621977,CDM,510,RC,27602,HCPCS,Outpatient,,,1285.76,642.88,,964.32,75,,,percent of total billed charges,75% of total billed charges,964.32,75,,,percent of total billed charges,75% of total billed charges,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,1073.09,102,,,Fee Schedule,102% of WV Medicaid Rate,4617.6,165,,,Fee Schedule,165% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8038.46,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11024.11,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13808.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1052.05,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,180.01,14,,,percent of total billed charges,14% of total billed charges,180.01,13808.81,
27632- Exc SQ tumor/leg/ankle 3cm/>,3435075,CDM,510,RC,27632,HCPCS,Outpatient,,,1087.24,543.62,,815.43,75,,,percent of total billed charges,75% of total billed charges,815.43,75,,,percent of total billed charges,75% of total billed charges,2428.67,100,,,Fee Schedule,100% of CMS OPPS Rate,803.83,102,,,Fee Schedule,102% of WV Medicaid Rate,4007.32,165,,,Fee Schedule,165% of CMS OPPS Rate,2517.11,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,6976.06,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,9567.11,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,11983.78,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,788.07,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2428.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2517.11,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,152.21,14,,,percent of total billed charges,14% of total billed charges,152.21,11983.78,
27687- Gastrocnemius recession,3435090,CDM,510,RC,27687,HCPCS,Outpatient,,,1175.53,587.77,,881.65,75,,,percent of total billed charges,75% of total billed charges,881.65,75,,,percent of total billed charges,75% of total billed charges,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,1073.09,102,,,Fee Schedule,102% of WV Medicaid Rate,4617.6,165,,,Fee Schedule,165% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8038.46,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11024.11,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13808.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1052.05,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,164.57,14,,,percent of total billed charges,14% of total billed charges,164.57,13808.81,
27752-PF CLTX TIBIAL SHAFT FX W/MANJ W/WO SKEL TRACJ,4321799,CDM,981,RC,27752,HCPCS,Outpatient,,,965.54,482.77,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
27756-PF PRQ SKELETAL FIXATION TIBIAL SHAFT FRACTURE,4321798,CDM,981,RC,27756,HCPCS,Outpatient,,,1128.26,564.13,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
27758-PF OPTX TIBIAL SHFT FX W/PLATE/SCREWS W/WO CERCLAG,4321797,CDM,981,RC,27758,HCPCS,Outpatient,,,1757.44,878.72,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
27759-PF TX TIBL SHFT FX IMED IMPLT W/WO SCREWS&/CERCLA,4321796,CDM,981,RC,27759,HCPCS,Outpatient,,,1959.42,979.71,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
27760-PF CLTX MEDIAL MALLEOLUS FX W/O MANIPULATION,4321795,CDM,981,RC,27760,HCPCS,Outpatient,,,594.06,297.03,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
27762-PF CLTX MEDIAL MALLS FX W/MANJ W/WO SKN/SKEL TRACJ,4321794,CDM,981,RC,27762,HCPCS,Outpatient,,,859.18,429.59,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
27766-PF OPEN TREATMENT MEDIAL MALLEOLUS FRACTURE,4321793,CDM,981,RC,27766,HCPCS,Outpatient,,,1183.38,591.69,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
27780-PF CLTX PROX FIBULA/SHFT FX W/O MANJ,4321792,CDM,981,RC,27780,HCPCS,Outpatient,,,552.88,276.44,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
27781-PF CLTX PROX FIBULA/SHFT FX W/MANJ,4321791,CDM,981,RC,27781,HCPCS,Outpatient,,,788.42,394.21,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
27784-PF OPEN TREATMENT PROXIMAL FIBULA/SHAFT FRACTURE,4321790,CDM,981,RC,27784,HCPCS,Outpatient,,,1390.84,695.42,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
27786-PF CLTX DSTL FIBULAR FX LAT MALLS W/O MANJ,4321789,CDM,981,RC,27786,HCPCS,Outpatient,,,558.18,279.09,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
27788-PF CLTX DSTL FIBULAR FX LAT MALLS W/MANJ,4321788,CDM,981,RC,27788,HCPCS,Outpatient,,,755.7,377.85,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
27792-PF OPEN TX DISTAL FIBULAR FRACTURE LAT MALLEOLUS,4321787,CDM,981,RC,27792,HCPCS,Outpatient,,,1260.72,630.36,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
27808-PF CLOSED TX BIMALLEOLAR ANKLE FRACTURE W/O MANJ,4321786,CDM,981,RC,27808,HCPCS,Outpatient,,,592.04,296.02,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
27810-PF CLOSED TX BIMALLEOLAR ANKLE FRACTURE W/MANJ,4321785,CDM,981,RC,27810,HCPCS,Outpatient,,,841.44,420.72,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
27814-PF OPEN TREATMENT BIMALLEOLAR ANKLE FRACTURE,4321784,CDM,981,RC,27814,HCPCS,Outpatient,,,1497.82,748.91,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
27816-PF CLTX TRIMALLEOLAR ANKLE FX W/O MANIPULATION,4321783,CDM,981,RC,27816,HCPCS,Outpatient,,,570.82,285.41,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
27818-PF CLTX TRIMALLEOLAR ANKLE FX W/MANIPULATION,4321782,CDM,981,RC,27818,HCPCS,Outpatient,,,867.86,433.93,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
27822-PF OPEN TX TRIMALLEOLAR ANKLE FX W/O FIXJ PST LIP,4321781,CDM,981,RC,27822,HCPCS,Outpatient,,,1698.86,849.43,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
27823-PF OPEN TX TRIMALLEOLAR ANKLE FX W/FIXJ PST LIP,4321780,CDM,981,RC,27823,HCPCS,Outpatient,,,1920.12,960.06,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
27824-PF CLTX FX W8 BRG ARTCLR PRTN DSTL TIBIA W/O MANJ,4321779,CDM,981,RC,27824,HCPCS,Outpatient,,,594.64,297.32,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
27825-PF CLTX FX W8 BRG ARTCLR PRTN DSTL TIB W/SKEL TRACJ,4321778,CDM,981,RC,27825,HCPCS,Outpatient,,,971.8,485.9,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
27826-PF OPEN TREATMENT FRACTURE DISTAL TIBIA FIBUL,4321777,CDM,981,RC,27826,HCPCS,Outpatient,,,1660.92,830.46,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
27827-PF OPEN TREATMENT FRACTURE DISTAL TIBIA ONLY,4321776,CDM,981,RC,27827,HCPCS,Outpatient,,,2184.44,1092.22,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
27828-PF OPEN TREATMENT FRACTURE DISTAL TIBIA & FIBULA,4321775,CDM,981,RC,27828,HCPCS,Outpatient,,,2596.96,1298.48,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
27829-PF OPEN TX DISTAL TIBIOFIBULAR JOINT DISRUPTION,4321774,CDM,981,RC,27829,HCPCS,Outpatient,,,1371.34,685.67,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
27830-PF CLTX PROX TIBFIB JT DISLC W/O ANES,4321773,CDM,981,RC,27830,HCPCS,Outpatient,,,702.78,351.39,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
27831-PF CLTX PROX TIBFIB JT DISLC REQ ANES,4321772,CDM,981,RC,27831,HCPCS,Outpatient,,,797.84,398.92,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
27832-PF OPEN TX PROX TIBFIB JOINT DISLOCATE EXC PROX FIB,4321771,CDM,981,RC,27832,HCPCS,Outpatient,,,1483.88,741.94,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
27840-PF SED TX ANKLE DISLOCATION W/O ANESTHESIA,4321770,CDM,981,RC,27840,HCPCS,Outpatient,,,760.34,380.17,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
27842-PF CLTX ANKLE DISLC REQ ANES W/WO PRQ SKEL FIX,4321769,CDM,981,RC,27842,HCPCS,Outpatient,,,962.2,481.1,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
27846-PF OPTX ANKLE DISLOCATION W/O REPAIR/INTERNAL FIXJ,4321768,CDM,981,RC,27846,HCPCS,Outpatient,,,1407.48,703.74,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
27848-PF OPTX ANKLE DISLOCATION W/REPAIR/INT/XTRNL FIXJ,4321767,CDM,981,RC,27848,HCPCS,Outpatient,,,1541.06,770.53,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
27880- Amputate leg/through tib/fib,3435129,CDM,510,RC,27880,HCPCS,Outpatient,,,2425.23,1212.62,,1818.92,75,,,percent of total billed charges,75% of total billed charges,1818.92,75,,,percent of total billed charges,75% of total billed charges,2425.23,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,2425.23,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2425.23,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2425.23,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2425.23,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2425.23,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,2425.23,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2425.23,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,339.53,14,,,percent of total billed charges,14% of total billed charges,339.53,2425.23,
27882 - Amputate Lower Leg thru Tibia&Fibula Open Circular,3899012,CDM,983,RC,27882,HCPCS,Outpatient,,,1591.03,795.52,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
27886- Re-amputate/leg/tibia/fibula,3435130,CDM,510,RC,27886,HCPCS,Outpatient,,,1729.38,864.69,,1297.04,75,,,percent of total billed charges,75% of total billed charges,1297.04,75,,,percent of total billed charges,75% of total billed charges,1729.38,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,1729.38,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1729.38,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1729.38,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1729.38,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1729.38,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,1729.38,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1729.38,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,242.11,14,,,percent of total billed charges,14% of total billed charges,242.11,1729.38,
27899 - PF Unlisted Procedure Leg or Ankle,4315548,CDM,960,RC,27899,HCPCS,Outpatient,,,1802,901,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
28001- I&D/bursa/foot,3435133,CDM,510,RC,28001,HCPCS,Outpatient,,,440.31,220.16,,330.23,75,,,percent of total billed charges,75% of total billed charges,330.23,75,,,percent of total billed charges,75% of total billed charges,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,2326.19,165,,,Fee Schedule,165% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4049.52,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5553.61,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6956.46,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,61.64,14,,,percent of total billed charges,14% of total billed charges,61.64,6956.46,
28002- I&D below fascia/foot/single bursa,3435134,CDM,510,RC,28002,HCPCS,Outpatient,,,631.59,315.8,,473.69,75,,,percent of total billed charges,75% of total billed charges,473.69,75,,,percent of total billed charges,75% of total billed charges,1348.67,100,,,Fee Schedule,100% of CMS OPPS Rate,584.77,102,,,Fee Schedule,102% of WV Medicaid Rate,2225.32,165,,,Fee Schedule,165% of CMS OPPS Rate,1397.79,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,3873.91,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5312.76,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6654.78,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,573.3,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1348.67,100,,,Fee Schedule,100% of CMS OPPS Rate,1397.79,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,88.42,14,,,percent of total billed charges,14% of total billed charges,88.42,6654.78,
28003- I&D below fascia/foot/mult area,3435135,CDM,510,RC,28003,HCPCS,Outpatient,,,987.59,493.8,,740.69,75,,,percent of total billed charges,75% of total billed charges,740.69,75,,,percent of total billed charges,75% of total billed charges,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,1073.09,102,,,Fee Schedule,102% of WV Medicaid Rate,4617.6,165,,,Fee Schedule,165% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8038.46,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11024.11,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13808.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1052.05,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,138.26,14,,,percent of total billed charges,14% of total billed charges,138.26,13808.81,
28122- Part exc/tarsal/metatarsal,3435162,CDM,510,RC,28122,HCPCS,Outpatient,,,1489.07,744.54,,1116.8,75,,,percent of total billed charges,75% of total billed charges,1116.8,75,,,percent of total billed charges,75% of total billed charges,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,1073.09,102,,,Fee Schedule,102% of WV Medicaid Rate,4617.6,165,,,Fee Schedule,165% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8038.46,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11024.11,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13808.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1052.05,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,208.47,14,,,percent of total billed charges,14% of total billed charges,208.47,13808.81,
28190- Remove foreign body/foot/subq,3435165,CDM,360,RC,28190,HCPCS,Outpatient,,,603.43,301.72,,452.57,75,,,percent of total billed charges,75% of total billed charges,452.57,75,,,percent of total billed charges,75% of total billed charges,610.13,100,,,Fee Schedule,100% of CMS OPPS Rate,137.04,102,,,Fee Schedule,102% of WV Medicaid Rate,1006.72,165,,,Fee Schedule,165% of CMS OPPS Rate,632.35,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1752.53,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2403.46,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,3010.58,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,134.35,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,610.13,100,,,Fee Schedule,100% of CMS OPPS Rate,632.35,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,84.48,14,,,percent of total billed charges,14% of total billed charges,84.48,3010.58,
28190-PF REMOVAL FOREIGN BODY FOOT SUBCUTANEOUS,4321766,CDM,981,RC,28190,HCPCS,Outpatient,,,253.36,126.68,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
28192- Remove foreign body/foot/deep,3435166,CDM,510,RC,28192,HCPCS,Outpatient,,,1150.91,575.46,,863.18,75,,,percent of total billed charges,75% of total billed charges,863.18,75,,,percent of total billed charges,75% of total billed charges,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,479.67,102,,,Fee Schedule,102% of WV Medicaid Rate,2326.19,165,,,Fee Schedule,165% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4049.52,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5553.61,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6956.46,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,470.26,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,161.13,14,,,percent of total billed charges,14% of total billed charges,161.13,6956.46,
28193- Rmv foreign body/foot/complicated,3435167,CDM,510,RC,28193,HCPCS,Outpatient,,,1310.94,655.47,,983.21,75,,,percent of total billed charges,75% of total billed charges,983.21,75,,,percent of total billed charges,75% of total billed charges,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,479.67,102,,,Fee Schedule,102% of WV Medicaid Rate,2326.19,165,,,Fee Schedule,165% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4049.52,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5553.61,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6956.46,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,470.26,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,183.53,14,,,percent of total billed charges,14% of total billed charges,183.53,6956.46,
28208-PF REPAIR TENDON EXTENSOR FOOT 1/2 EACH TENDON,4321765,CDM,981,RC,28208,HCPCS,Outpatient,,,619.8,309.9,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
28400-PF CLOSED TX CALCANEAL FRACTURE W/O MANIPULATION,4321764,CDM,981,RC,28400,HCPCS,Outpatient,,,440.4,220.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
28405-PF CLOSED TX CALCANEAL FRACTURE W/MANIPULATION,4321763,CDM,981,RC,28405,HCPCS,Outpatient,,,792.12,396.06,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
28406-PF PRQ SKELETAL FIXJ CALCANEAL FRACTURE W/MANJ,4321762,CDM,981,RC,28406,HCPCS,Outpatient,,,1089.34,544.67,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
28415-PF OPEN TREATMENT CALCANEAL FRACTURE,4321761,CDM,981,RC,28415,HCPCS,Outpatient,,,2193.1,1096.55,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
28430-PF CLOSED TX TALUS FRACTURE W/O MANIPULATION,4321760,CDM,981,RC,28430,HCPCS,Outpatient,,,405.48,202.74,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
28435-PF CLOSED TX TALUS FRACTURE W/MANIPULATION,4321759,CDM,981,RC,28435,HCPCS,Outpatient,,,638,319,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
28436-PF PRQ SKELETAL FIXATION TALUS FRACTURE W/MAN,4321758,CDM,981,RC,28436,HCPCS,Outpatient,,,952.42,476.21,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
28445-PF OPEN TREATMENT TALUS FRACTURE,4321757,CDM,981,RC,28445,HCPCS,Outpatient,,,2036.34,1018.17,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
28450-PF TX TARSAL BONE FX XCP TALUS&CALCN W/O MANJ,4321756,CDM,981,RC,28450,HCPCS,Outpatient,,,364.74,182.37,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
28455-PF TX TARSAL BONE FX XCP TALUS&CALCN W/MANJ,4321755,CDM,981,RC,28455,HCPCS,Outpatient,,,502.54,251.27,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
28456-PF PRQ SKEL FIXJ TARSL FX XCP TALUS&CALCNS W/MANJ,4321754,CDM,981,RC,28456,HCPCS,Outpatient,,,701.72,350.86,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
28465-PF OPEN TX TARSAL FRACTURE XCP TALUS & CALCANEUS EA,4321753,CDM,981,RC,28465,HCPCS,Outpatient,,,1227.44,613.72,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
28470-PF CLOSED TX METATARSAL FRACTURE W/O MANIPULATION,4321752,CDM,981,RC,28470,HCPCS,Outpatient,,,389.82,194.91,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
28475-PF CLTX METAR FX W/MANJ,4321751,CDM,981,RC,28475,HCPCS,Outpatient,,,439.2,219.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
28476-PF PRQ SKEL FIXJ METAR FX W/MAN,4321750,CDM,981,RC,28476,HCPCS,Outpatient,,,735.9,367.95,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
28485-PF OPEN TREATMENT METATARSAL FRACTURE EACH,4321749,CDM,981,RC,28485,HCPCS,Outpatient,,,1080.6,540.3,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
28490-PF CLTX FX GRT TOE PHLX/PHLG W/O MANJ,4321748,CDM,981,RC,28490,HCPCS,Outpatient,,,237.26,118.63,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
28495-PF CLTX FX GRT TOE PHLX/PHLG W/MANJ,4321747,CDM,981,RC,28495,HCPCS,Outpatient,,,283.46,141.73,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
28496-PF PRQ SKEL FIXJ FX GRT TOE PHLX/PHLG W/MANJ,4321746,CDM,981,RC,28496,HCPCS,Outpatient,,,471.1,235.55,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
28505-PF OPEN TX FRACTURE GREAT TOE/PHALANX/PHALANGES,4321745,CDM,981,RC,28505,HCPCS,Outpatient,,,958.58,479.29,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
28510-PF CLTX FX PHLX/PHLG OTH/THN GRT TOE W/O MANJ,4321744,CDM,981,RC,28510,HCPCS,Outpatient,,,227.7,113.85,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
28515-PF CLTX FX PHLX/PHLG OTH/THN GRT TOE W/MANJ,4321743,CDM,981,RC,28515,HCPCS,Outpatient,,,272.72,136.36,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
28525-PF OPEN TX FRACTURE PHALANX/PHALANGES NOT GREAT TOE,4321742,CDM,981,RC,28525,HCPCS,Outpatient,,,779.36,389.68,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
28540-PF CLTX TARSAL DISLC OTH/THN TALOTARSAL W/O ANES,4321741,CDM,981,RC,28540,HCPCS,Outpatient,,,334.06,167.03,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
28545-PF CLTX TARSAL DISLC OTH/THN TALOTARSAL W/ANES,4321740,CDM,981,RC,28545,HCPCS,Outpatient,,,522.44,261.22,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
28546-PF PRQ SKEL FIXJ TARSL DISLC XCP TALOTARSAL W/MANJ,4321739,CDM,981,RC,28546,HCPCS,Outpatient,,,672.6,336.3,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
28570-PF CLOSED TX TALOTARSAL JOINT DISLC W/O ANES,4321738,CDM,981,RC,28570,HCPCS,Outpatient,,,377.22,188.61,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
28575-PF CLOSED TX TALOTARSAL JOINT DISLOCATION W/ANES,4321737,CDM,981,RC,28575,HCPCS,Outpatient,,,657.08,328.54,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
28576-PF PRQ SKEL FIXJ TALOTARSAL JT DISLC W/MANJ,4321736,CDM,981,RC,28576,HCPCS,Outpatient,,,751.8,375.9,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
28600-PF CLOSED TX TARSOMETATARSAL DISLOCATION W/O ANES,4321735,CDM,981,RC,28600,HCPCS,Outpatient,,,355.64,177.82,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
28605-PF CLOSED TX TARSOMETATARSAL DISLOCATION W/ANES,4321734,CDM,981,RC,28605,HCPCS,Outpatient,,,586.6,293.3,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
28606-PF PRQ SKEL FIXJ TARS JT DISLC W/MANJ,4321733,CDM,981,RC,28606,HCPCS,Outpatient,,,748.42,374.21,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
28630-PF CLTX METATARSOPHLNGL JT DISLC W/O ANES,4321732,CDM,981,RC,28630,HCPCS,Outpatient,,,217.26,108.63,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
28635-PF CLTX METATARSOPHLNGL JT DISLC REQ ANES,4321731,CDM,981,RC,28635,HCPCS,Outpatient,,,259.24,129.62,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
28636-PF PRQ SKEL FIXJ METATARSOPHLNGL JT DISLC W/MANJ,4321730,CDM,981,RC,28636,HCPCS,Outpatient,,,384.1,192.05,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
28660-PF CLTX INTERPHALANGEAL JOINT DISLOCATION W/O ANES,4321729,CDM,981,RC,28660,HCPCS,Outpatient,,,181.4,90.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
28665-PF CLTX INTERPHALANGEAL JOINT DISLOCATION REQ ANES,4321728,CDM,981,RC,28665,HCPCS,Outpatient,,,240.46,120.23,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
28666-PF PRQ SKEL FIXJ INTERPHALANGEAL JOINT DISLC W/MANJ,4321727,CDM,981,RC,28666,HCPCS,Outpatient,,,337.9,168.95,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
28805- Amputate foot/transmetatarsal,3435231,CDM,510,RC,28805,HCPCS,Outpatient,,,1872.91,936.46,,1404.68,75,,,percent of total billed charges,75% of total billed charges,1404.68,75,,,percent of total billed charges,75% of total billed charges,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,4617.6,165,,,Fee Schedule,165% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8038.46,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11024.11,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13808.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,262.21,14,,,percent of total billed charges,14% of total billed charges,262.21,13808.81,
"28810 Amputation, metatarsal, with toe, single",3621667,CDM,510,RC,28810,HCPCS,Outpatient,,,1109.8,554.9,,832.35,75,,,percent of total billed charges,75% of total billed charges,832.35,75,,,percent of total billed charges,75% of total billed charges,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,1073.09,102,,,Fee Schedule,102% of WV Medicaid Rate,4617.6,165,,,Fee Schedule,165% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8038.46,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11024.11,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13808.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1052.05,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,155.37,14,,,percent of total billed charges,14% of total billed charges,155.37,13808.81,
28820- Amputate toe/metatarsophalang jnt,3435232,CDM,510,RC,28820,HCPCS,Outpatient,,,763.34,381.67,,572.51,75,,,percent of total billed charges,75% of total billed charges,572.51,75,,,percent of total billed charges,75% of total billed charges,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,1073.09,102,,,Fee Schedule,102% of WV Medicaid Rate,4617.6,165,,,Fee Schedule,165% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8038.46,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11024.11,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13808.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1052.05,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,106.87,14,,,percent of total billed charges,14% of total billed charges,106.87,13808.81,
28825-PF AMPUTATION TOE INTERPHALANGEAL JOINT,4321726,CDM,981,RC,28825,HCPCS,Outpatient,,,340.66,170.33,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
29046-PF APPLICATION BODY CAST SHOULDER HIPS BOTH THIGHS,4321725,CDM,981,RC,29046,HCPCS,Outpatient,,,362.76,181.38,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
29049-PF APPLICATION CAST FIGURE-OF-8,4321724,CDM,981,RC,29049,HCPCS,Outpatient,,,134.04,67.02,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
29065-PF APPLICATION CAST SHOULDER HAND LONG ARM,4321723,CDM,981,RC,29065,HCPCS,Outpatient,,,132.12,66.06,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
29075-PF APPLICATION CAST ELBOW FINGER SHORT ARM,4321722,CDM,981,RC,29075,HCPCS,Outpatient,,,121.56,60.78,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
29085-PF APPLICATION CAST HAND & LOWER FOREARM GAUNTLET,4321721,CDM,981,RC,29085,HCPCS,Outpatient,,,130.08,65.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
29105-PF APPLICATION LONG ARM SPLINT SHOULDER HAND,4321720,CDM,981,RC,29105,HCPCS,Outpatient,,,85.7,42.85,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
29125-PF APPLICATION SHORT ARM SPLINT FOREARM-HAND STATIC,4321719,CDM,981,RC,29125,HCPCS,Outpatient,,,78.02,39.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
29126-PF APPLICATION SHORT ARM SPLINT DYNAMIC,4321718,CDM,981,RC,29126,HCPCS,Outpatient,,,94.88,47.44,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
29130-PF APPLICATION FINGER SPLINT STATIC,4321717,CDM,981,RC,29130,HCPCS,Outpatient,,,58.78,29.39,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
29131-PF APPLICATION FINGER SPLINT DYNAMIC,4321716,CDM,981,RC,29131,HCPCS,Outpatient,,,68.58,34.29,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
29240-PF STRAPPING SHOULDER,4321715,CDM,981,RC,29240,HCPCS,Outpatient,,,35.72,17.86,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
29260-PF STRAPPING ELBOW/WRIST,4321714,CDM,981,RC,29260,HCPCS,Outpatient,,,38.22,19.11,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
29280-PF STRAPPING HAND/FINGER,4321713,CDM,981,RC,29280,HCPCS,Outpatient,,,41.28,20.64,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
29345-PF APPLICATION LONG LEG CAST THIGH-TOE,4321712,CDM,981,RC,29345,HCPCS,Outpatient,,,193.82,96.91,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
29355-PF APPLICATION LONG LEG CAST WALKER/AMBULATORY TYPE,4321711,CDM,981,RC,29355,HCPCS,Outpatient,,,207.26,103.63,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
29358-PF APPLICATION LONG LEG CAST BRACE,4321710,CDM,981,RC,29358,HCPCS,Outpatient,,,200.48,100.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
29365-PF APPLICATION CYLINDER CAST THIGH ANKLE,4321709,CDM,981,RC,29365,HCPCS,Outpatient,,,169.06,84.53,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
29405-PF APPLICATION SHORT LEG CAST BELOW KNEE-TOE,4321708,CDM,981,RC,29405,HCPCS,Outpatient,,,117.83,58.92,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
29435-PF APPLICATION PATELLAR TENDON BEARING CAST,4321707,CDM,981,RC,29435,HCPCS,Outpatient,,,157.16,78.58,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
29440-PF ADDING WALKER PREVIOUSLY APPLIED CAST,4321706,CDM,981,RC,29440,HCPCS,Outpatient,,,54.3,27.15,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
29445-PF APPLICATION RIGID TOTAL CONTACT LEG CAST,4321705,CDM,981,RC,29445,HCPCS,Outpatient,,,200.11,100.06,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
29450-PF APPL CLUBFOOT CAST MOLDING/MANJ LONG/SHORT LEG,4321704,CDM,981,RC,29450,HCPCS,Outpatient,,,221.88,110.94,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
29505-PF APPLICATION LONG LEG SPLINT THIGH ANKLE/TOES,4321703,CDM,981,RC,29505,HCPCS,Outpatient,,,100.2,50.1,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
29515-PF APPLICATION SHORT LEG SPLINT CALF FOOT,4321702,CDM,981,RC,29515,HCPCS,Outpatient,,,95.64,47.82,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
29530-PF STRAPPING KNEE,4321701,CDM,981,RC,29530,HCPCS,Outpatient,,,35.72,17.86,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
29540-PF STRAPPING ANKLE &/FOOT,4321700,CDM,981,RC,29540,HCPCS,Outpatient,,,35.23,17.62,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
29550-PF STRAPPING TOES,4321699,CDM,981,RC,29550,HCPCS,Outpatient,,,22.16,11.08,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
29580 Application of Unna Boot,4135334,CDM,510,RC,29580,HCPCS,Outpatient,,,54.23,27.12,,40.67,75,,,percent of total billed charges,75% of total billed charges,40.67,75,,,percent of total billed charges,75% of total billed charges,137.03,100,,,Fee Schedule,100% of CMS OPPS Rate,34.67,102,,,Fee Schedule,102% of WV Medicaid Rate,226.1,165,,,Fee Schedule,165% of CMS OPPS Rate,142.02,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,393.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,539.8,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,676.18,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,33.99,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,137.03,100,,,Fee Schedule,100% of CMS OPPS Rate,142.02,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,7.59,14,,,percent of total billed charges,14% of total billed charges,7.59,676.18,
29580-PF STRAPPING UNNA BOOT,4321373,CDM,981,RC,29580,HCPCS,Outpatient,,,54.23,27.12,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
29700-PF REMOVAL/BIVALVING GAUNTLET BOOT/BODY CAST,4321698,CDM,981,RC,29700,HCPCS,Outpatient,,,65.28,32.64,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
29705-PF REMOVAL/BIVALVING FULL ARM/FULL LEG CAST,4321697,CDM,981,RC,29705,HCPCS,Outpatient,,,88.04,44.02,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
29710-PF RMVL/BIVALV SHO/HIP SPICA MINERVA/RISSER JACKET,4321696,CDM,981,RC,29710,HCPCS,Outpatient,,,162.94,81.47,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
29730-PF WINDOWING CAST,4321374,CDM,981,RC,29730,HCPCS,Outpatient,,,87.36,43.68,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
30000-PF DRAINAGE ABSCESS/HEMATOMA NASAL INT APPROACH,4321694,CDM,981,RC,30000,HCPCS,Outpatient,,,232.84,116.42,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
30020-PF DRAINAGE ABSCESS/HEMATOMA NASAL SEPTUM,4321693,CDM,981,RC,30020,HCPCS,Outpatient,,,234.58,117.29,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
30300-PF REMOVAL FOREIGN BODY INTRANASAL OFFICE PROCEDURE,4321692,CDM,981,RC,30300,HCPCS,Outpatient,,,233.6,116.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
30310-PF REMOVAL FOREIGN BODY INTRANASAL GENERAL ANES,4321691,CDM,981,RC,30310,HCPCS,Outpatient,,,393.7,196.85,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
30801-PF ABLTJ SOFT TIS INFERIOR TURBINATES UNI/BI SUPFC,4321690,CDM,981,RC,30801,HCPCS,Outpatient,,,284.78,142.39,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
30802-PF ABLTJ SOF TISS INF TURBS UNI/BI SUPFC INTRAMURAL,4321689,CDM,981,RC,30802,HCPCS,Outpatient,,,385.6,192.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
30901-PF CONTROL NASAL HEMORRHAGE ANTERIOR SIMPLE,4321688,CDM,981,RC,30901,HCPCS,Outpatient,,,114.16,57.08,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
30903-PF CONTROL NASAL HEMORRHAGE ANTERIOR COMPLEX,4321687,CDM,981,RC,30903,HCPCS,Outpatient,,,156.4,78.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
30905-PF CTRL NSL HEMRRG PST NASAL PACKS&/CAUTERY 1ST,4321686,CDM,981,RC,30905,HCPCS,Outpatient,,,212.5,106.25,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
30906-PF CTRL NSL HEMRRG PST NASAL PACKS&/CAUTERY SUBSQ,4321685,CDM,981,RC,30906,HCPCS,Outpatient,,,265.1,132.55,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
Endoscopy,3428425,CDM,490,RC,31231,HCPCS,Outpatient,,,131.25,65.63,,98.44,75,,,percent of total billed charges,75% of total billed charges,98.44,75,,,percent of total billed charges,75% of total billed charges,168.05,100,,,Fee Schedule,100% of CMS OPPS Rate,67.2,102,,,Fee Schedule,102% of WV Medicaid Rate,277.27,165,,,Fee Schedule,165% of CMS OPPS Rate,174.17,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,482.7,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,661.99,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,829.22,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,65.88,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,168.05,100,,,Fee Schedule,100% of CMS OPPS Rate,174.17,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,18.38,14,,,percent of total billed charges,14% of total billed charges,18.38,829.22,
31254 - NASAL/SINUS NDSC W/PARTIAL ETHMOIDECTOMY,4037482,CDM,983,RC,31254,HCPCS,Outpatient,,,1115.29,557.65,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
31255 - NASAL/SINUS NDSC W/TOTAL ETHOIDECTOMY,4037483,CDM,983,RC,31255,HCPCS,Outpatient,,,853.62,426.81,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
"31256 - Nasal/sinus endoscopy, surgical, with maxillary antrostomy",4037484,CDM,983,RC,31256,HCPCS,Outpatient,,,469.91,234.96,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
31500-PF INTUBATION ENDOTRACHEAL EMERGENCY PROCEDURE,4321683,CDM,981,RC,31500,HCPCS,Outpatient,,,283.34,141.67,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
TRACH TUBE INSERT,3428532,CDM,981,RC,31500,HCPCS,Outpatient,,,380.04,190.02,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
31502-PF TRACHEOTOMY TUBE CHANGE PRIOR TO FISTULA TRACT,4321375,CDM,981,RC,31502,HCPCS,Outpatient,,,69.54,34.77,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
31505 Diagnostic Laryncoscopy,3584869,CDM,960,RC,31505,HCPCS,Outpatient,,,226.36,113.18,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
31505-PF LARYNGOSCOPY INDIRECT DIAGNOSTIC SPX,4321682,CDM,981,RC,31505,HCPCS,Outpatient,,,93.66,46.83,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
31511-PF LARYNGOSCOPY INDIRECT W/REMOVAL FOREIGN BOD,4321681,CDM,981,RC,31511,HCPCS,Outpatient,,,261.32,130.66,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
31515 - Laryngoscopy for Aspiration,4189305,CDM,960,RC,31515,HCPCS,Outpatient,,,479.89,239.95,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
31525- Laryngoscopy/diag/except newborn,3435866,CDM,510,RC,31525,HCPCS,Outpatient,,,636.4,318.2,,477.3,75,,,percent of total billed charges,75% of total billed charges,477.3,75,,,percent of total billed charges,75% of total billed charges,1502.91,100,,,Fee Schedule,100% of CMS OPPS Rate,518.37,102,,,Fee Schedule,102% of WV Medicaid Rate,2479.79,165,,,Fee Schedule,165% of CMS OPPS Rate,1557.63,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4316.89,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5920.29,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,7415.77,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,508.21,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1502.91,100,,,Fee Schedule,100% of CMS OPPS Rate,1557.63,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,89.1,14,,,percent of total billed charges,14% of total billed charges,89.1,7415.77,
31526- Laryngoscopy/diag/micro/telescope,3435867,CDM,510,RC,31526,HCPCS,Outpatient,,,407.59,203.8,,305.69,75,,,percent of total billed charges,75% of total billed charges,305.69,75,,,percent of total billed charges,75% of total billed charges,1502.91,100,,,Fee Schedule,100% of CMS OPPS Rate,518.37,102,,,Fee Schedule,102% of WV Medicaid Rate,2479.79,165,,,Fee Schedule,165% of CMS OPPS Rate,1557.63,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4316.89,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5920.29,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,7415.77,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,508.21,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1502.91,100,,,Fee Schedule,100% of CMS OPPS Rate,1557.63,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,57.06,14,,,percent of total billed charges,14% of total billed charges,57.06,7415.77,
31535- Laryngoscopy/operative/w biopsy,3435868,CDM,510,RC,31535,HCPCS,Outpatient,,,490.94,245.47,,368.21,75,,,percent of total billed charges,75% of total billed charges,368.21,75,,,percent of total billed charges,75% of total billed charges,3134.18,100,,,Fee Schedule,100% of CMS OPPS Rate,1047.42,102,,,Fee Schedule,102% of WV Medicaid Rate,5171.39,165,,,Fee Schedule,165% of CMS OPPS Rate,3248.31,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,9002.51,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,12346.23,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,15464.9,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1026.88,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,3134.18,100,,,Fee Schedule,100% of CMS OPPS Rate,3248.31,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,68.73,14,,,percent of total billed charges,14% of total billed charges,68.73,15464.9,
31536- Laryngoscopy/w bx/micro/telescope,3435869,CDM,510,RC,31536,HCPCS,Outpatient,,,548.75,274.38,,411.56,75,,,percent of total billed charges,75% of total billed charges,411.56,75,,,percent of total billed charges,75% of total billed charges,3134.18,100,,,Fee Schedule,100% of CMS OPPS Rate,1047.42,102,,,Fee Schedule,102% of WV Medicaid Rate,5171.39,165,,,Fee Schedule,165% of CMS OPPS Rate,3248.31,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,9002.51,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,12346.23,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,15464.9,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1026.88,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,3134.18,100,,,Fee Schedule,100% of CMS OPPS Rate,3248.31,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,76.83,14,,,percent of total billed charges,14% of total billed charges,76.83,15464.9,
31541- Laryngoscopy/exc tum/micro/telesco,3435870,CDM,510,RC,31541,HCPCS,Outpatient,,,687.09,343.55,,515.32,75,,,percent of total billed charges,75% of total billed charges,515.32,75,,,percent of total billed charges,75% of total billed charges,3134.18,100,,,Fee Schedule,100% of CMS OPPS Rate,1047.42,102,,,Fee Schedule,102% of WV Medicaid Rate,5171.39,165,,,Fee Schedule,165% of CMS OPPS Rate,3248.31,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,9002.51,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,12346.23,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,15464.9,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1026.88,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,3134.18,100,,,Fee Schedule,100% of CMS OPPS Rate,3248.31,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,96.19,14,,,percent of total billed charges,14% of total billed charges,96.19,15464.9,
31570- Laryngoscopy/direct w/injection,3435871,CDM,510,RC,31570,HCPCS,Outpatient,,,875.43,437.72,,656.57,75,,,percent of total billed charges,75% of total billed charges,656.57,75,,,percent of total billed charges,75% of total billed charges,3134.18,100,,,Fee Schedule,100% of CMS OPPS Rate,1047.42,102,,,Fee Schedule,102% of WV Medicaid Rate,5171.39,165,,,Fee Schedule,165% of CMS OPPS Rate,3248.31,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,9002.51,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,12346.23,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,15464.9,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1026.88,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,3134.18,100,,,Fee Schedule,100% of CMS OPPS Rate,3248.31,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,122.56,14,,,percent of total billed charges,14% of total billed charges,122.56,15464.9,
31575 - DIAGNOSTIC LARYNGOSCOPY,3908940,CDM,761,RC,31575,HCPCS,Outpatient,,,318.11,159.06,,238.58,75,,,percent of total billed charges,75% of total billed charges,238.58,75,,,percent of total billed charges,75% of total billed charges,168.05,100,,,Fee Schedule,100% of CMS OPPS Rate,67.2,102,,,Fee Schedule,102% of WV Medicaid Rate,277.27,165,,,Fee Schedule,165% of CMS OPPS Rate,174.17,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,482.7,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,661.99,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,829.22,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,65.88,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,168.05,100,,,Fee Schedule,100% of CMS OPPS Rate,174.17,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,44.54,14,,,percent of total billed charges,14% of total billed charges,44.54,829.22,
"31575 Laryngoscopy, flexible; diagnostic",3584895,CDM,510,RC,31575,HCPCS,Outpatient,,,320.05,160.03,,240.04,75,,,percent of total billed charges,75% of total billed charges,240.04,75,,,percent of total billed charges,75% of total billed charges,168.05,100,,,Fee Schedule,100% of CMS OPPS Rate,67.2,102,,,Fee Schedule,102% of WV Medicaid Rate,277.27,165,,,Fee Schedule,165% of CMS OPPS Rate,174.17,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,482.7,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,661.99,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,829.22,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,65.88,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,168.05,100,,,Fee Schedule,100% of CMS OPPS Rate,174.17,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,44.81,14,,,percent of total billed charges,14% of total billed charges,44.81,829.22,
31575-PF LARYNGOSCOPY FLEXIBLE DIAGNOSTIC,4321680,CDM,981,RC,31575,HCPCS,Outpatient,,,131.1,65.55,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
31577-PF LARYNGOSCOPY FLX RMVL FOREIGN BODY(S,4321679,CDM,981,RC,31577,HCPCS,Outpatient,,,262.7,131.35,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
31599-PF UNLISTED PROCEDURE LARYNX,4321376,CDM,981,RC,31599,HCPCS,Outpatient,,,587,293.5,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
"31600 - (PF) Tracheostomy, planned (separate procedure);",3634897,CDM,510,RC,31600,HCPCS,Outpatient,,,817.75,408.88,,613.31,75,,,percent of total billed charges,75% of total billed charges,613.31,75,,,percent of total billed charges,75% of total billed charges,2674.8,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,4413.39,165,,,Fee Schedule,165% of CMS OPPS Rate,2772.2,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,7682.99,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,10536.61,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13198.18,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,2674.8,100,,,Fee Schedule,100% of CMS OPPS Rate,2772.2,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,114.49,14,,,percent of total billed charges,14% of total billed charges,114.49,13198.18,
"31600-PF Tracheostomy, planned sep px",4322033,CDM,960,RC,31600,HCPCS,Outpatient,,,595.58,297.79,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
31603- Tracheostomy/emergent/transtrach,3435872,CDM,510,RC,31603,HCPCS,Outpatient,,,859.5,429.75,,644.63,75,,,percent of total billed charges,75% of total billed charges,644.63,75,,,percent of total billed charges,75% of total billed charges,1305.07,100,,,Fee Schedule,100% of CMS OPPS Rate,414.77,102,,,Fee Schedule,102% of WV Medicaid Rate,2153.38,165,,,Fee Schedule,165% of CMS OPPS Rate,1352.6,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,3748.66,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5141,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6439.62,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,406.64,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1305.07,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,120.33,14,,,percent of total billed charges,14% of total billed charges,120.33,6439.62,
31603-PF TRACHEOSTOMY EMERGENCY PROCEDURE TRANSTRACHEAL,4321377,CDM,981,RC,31603,HCPCS,Outpatient,,,641.5,320.75,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
31605-PF TRACHEOSTOMY EMERGENCY CRICOTHYROID MEMBRANE,4321678,CDM,981,RC,31605,HCPCS,Outpatient,,,670.54,335.27,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
31622-PF BRNCHSC INCL FLUOR GDNCE DX W/CELL WASHG SPX,4321379,CDM,981,RC,31622,HCPCS,Outpatient,,,256.38,128.19,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
31622-PF Dx Bronch Incl Fluor Gdnc/Wash,4322037,CDM,960,RC,31622,HCPCS,Outpatient,,,252.58,126.29,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
Bronchoscopy ED,3428396,CDM,981,RC,31622,HCPCS,Outpatient,,,626.94,313.47,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
31623-DX BRONCHOSCOPE/BRUSH,3430809,CDM,510,RC,31623,HCPCS,Outpatient,,,699,349.5,,524.25,75,,,percent of total billed charges,75% of total billed charges,524.25,75,,,percent of total billed charges,75% of total billed charges,1502.91,100,,,Fee Schedule,100% of CMS OPPS Rate,518.37,102,,,Fee Schedule,102% of WV Medicaid Rate,2479.79,165,,,Fee Schedule,165% of CMS OPPS Rate,1557.63,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4316.89,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5920.29,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,7415.77,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,508.21,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1502.91,100,,,Fee Schedule,100% of CMS OPPS Rate,1557.63,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,97.86,14,,,percent of total billed charges,14% of total billed charges,97.86,7415.77,
31623-PF Dx Bronch Incl Fluor Gdnc/Brush,4322038,CDM,960,RC,31623,HCPCS,Outpatient,,,249.32,124.66,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
31624-DX BRONCHOSCOPY/LAVAGE,3430810,CDM,510,RC,31624,HCPCS,Outpatient,,,648,324,,486,75,,,percent of total billed charges,75% of total billed charges,486,75,,,percent of total billed charges,75% of total billed charges,1502.91,100,,,Fee Schedule,100% of CMS OPPS Rate,518.37,102,,,Fee Schedule,102% of WV Medicaid Rate,2479.79,165,,,Fee Schedule,165% of CMS OPPS Rate,1557.63,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4316.89,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5920.29,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,7415.77,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,508.21,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1502.91,100,,,Fee Schedule,100% of CMS OPPS Rate,1557.63,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,90.72,14,,,percent of total billed charges,14% of total billed charges,90.72,7415.77,
31624-PF Dx Bronch Incl Fluor Gdnc/Lavage,4322039,CDM,960,RC,31624,HCPCS,Outpatient,,,252.46,126.23,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
31625-BRONCHOSCOPY W BIOPSY,3430811,CDM,510,RC,31625,HCPCS,Outpatient,,,890.34,445.17,,667.76,75,,,percent of total billed charges,75% of total billed charges,667.76,75,,,percent of total billed charges,75% of total billed charges,1502.91,100,,,Fee Schedule,100% of CMS OPPS Rate,518.37,102,,,Fee Schedule,102% of WV Medicaid Rate,2479.79,165,,,Fee Schedule,165% of CMS OPPS Rate,1557.63,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4316.89,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5920.29,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,7415.77,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,508.21,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1502.91,100,,,Fee Schedule,100% of CMS OPPS Rate,1557.63,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,124.65,14,,,percent of total billed charges,14% of total billed charges,124.65,7415.77,
31625-PF Bronch w/Bx,4322040,CDM,960,RC,31625,HCPCS,Outpatient,,,295.9,147.95,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
"31626 - PF Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with pl",3712915,CDM,510,RC,31626,HCPCS,Outpatient,,,1999.57,999.79,,1499.68,75,,,percent of total billed charges,75% of total billed charges,1499.68,75,,,percent of total billed charges,75% of total billed charges,5816.87,100,,,Fee Schedule,100% of CMS OPPS Rate,1607.38,102,,,Fee Schedule,102% of WV Medicaid Rate,9597.85,165,,,Fee Schedule,165% of CMS OPPS Rate,6028.69,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,16708.2,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,22913.96,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,28702.06,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1575.86,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,5816.87,100,,,Fee Schedule,100% of CMS OPPS Rate,6028.69,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,279.94,14,,,percent of total billed charges,14% of total billed charges,279.94,28702.06,
31626-PF Bronch w/Markers,4322041,CDM,960,RC,31626,HCPCS,Outpatient,,,375.82,187.91,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
"31627 - PF Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with co",3712966,CDM,510,RC,31627,HCPCS,Outpatient,,,2744.72,1372.36,,2058.54,75,,,percent of total billed charges,75% of total billed charges,2058.54,75,,,percent of total billed charges,75% of total billed charges,878.31,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,384.26,14,,,percent of total billed charges,14% of total billed charges,384.26,2058.54,
31627-PF Bronch w/CPTR Image-Guid Navigation,4322042,CDM,960,RC,31627,HCPCS,Outpatient,,,183.74,91.87,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
"31628 - Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with trans",3572799,CDM,960,RC,31628,HCPCS,Outpatient,,,948.2,474.1,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
31629-BRONCH W/TRANSBRONCHIAL NEEDLE ASP,3430812,CDM,510,RC,31629,HCPCS,Outpatient,,,1155.33,577.67,,866.5,75,,,percent of total billed charges,75% of total billed charges,866.5,75,,,percent of total billed charges,75% of total billed charges,3134.18,100,,,Fee Schedule,100% of CMS OPPS Rate,1047.42,102,,,Fee Schedule,102% of WV Medicaid Rate,5171.39,165,,,Fee Schedule,165% of CMS OPPS Rate,3248.31,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,9002.51,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,12346.23,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,15464.9,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1026.88,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,3134.18,100,,,Fee Schedule,100% of CMS OPPS Rate,3248.31,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,161.75,14,,,percent of total billed charges,14% of total billed charges,161.75,15464.9,
"31632 - Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with trans",3572792,CDM,976,RC,31632,HCPCS,Outpatient,,,167.88,83.94,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
"31633 - Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with trans",3572793,CDM,976,RC,31633,HCPCS,Outpatient,,,208.63,104.32,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
31635-PF BRONCHOSCOPY W/REMOVAL FOREIGN BODY,4321677,CDM,981,RC,31635,HCPCS,Outpatient,,,339.62,169.81,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
31640-PF Bronch w/Tumor Excise,4322043,CDM,960,RC,31640,HCPCS,Outpatient,,,468.68,234.34,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
31641-PF Bronch Treat Blockage,4322044,CDM,960,RC,31641,HCPCS,Outpatient,,,481.72,240.86,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
31645-BRONCHOSCOPY CLEAR AIRWAYS,3430813,CDM,510,RC,31645,HCPCS,Outpatient,,,692.94,346.47,,519.71,75,,,percent of total billed charges,75% of total billed charges,519.71,75,,,percent of total billed charges,75% of total billed charges,1502.91,100,,,Fee Schedule,100% of CMS OPPS Rate,518.37,102,,,Fee Schedule,102% of WV Medicaid Rate,2479.79,165,,,Fee Schedule,165% of CMS OPPS Rate,1557.63,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4316.89,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5920.29,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,7415.77,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,508.21,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1502.91,100,,,Fee Schedule,100% of CMS OPPS Rate,1557.63,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,97.01,14,,,percent of total billed charges,14% of total billed charges,97.01,7415.77,
31646- Bronch/asp/tracheobronch tree/subs,3435873,CDM,510,RC,31646,HCPCS,Outpatient,,,371.06,185.53,,278.3,75,,,percent of total billed charges,75% of total billed charges,278.3,75,,,percent of total billed charges,75% of total billed charges,354.56,100,,,Fee Schedule,100% of CMS OPPS Rate,153.43,102,,,Fee Schedule,102% of WV Medicaid Rate,585.04,165,,,Fee Schedule,165% of CMS OPPS Rate,367.48,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1018.46,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1396.74,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1749.56,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,150.42,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,354.56,100,,,Fee Schedule,100% of CMS OPPS Rate,367.48,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,51.95,14,,,percent of total billed charges,14% of total billed charges,51.95,1749.56,
31647-PF Bronchial Valve Init Insert,4322045,CDM,960,RC,31647,HCPCS,Outpatient,,,388.5,194.25,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
31648-PF Bronchial Valve Init Remov,4322046,CDM,960,RC,31648,HCPCS,Outpatient,,,374.84,187.42,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
31652-BRONCH EBUS SAMPLNG 1/2 NODE,3430814,CDM,510,RC,31652,HCPCS,Outpatient,,,3190.08,1595.04,,2392.56,75,,,percent of total billed charges,75% of total billed charges,2392.56,75,,,percent of total billed charges,75% of total billed charges,3134.18,100,,,Fee Schedule,100% of CMS OPPS Rate,1047.42,102,,,Fee Schedule,102% of WV Medicaid Rate,5171.39,165,,,Fee Schedule,165% of CMS OPPS Rate,3248.31,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,9002.51,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,12346.23,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,15464.9,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1026.88,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,3134.18,100,,,Fee Schedule,100% of CMS OPPS Rate,3248.31,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,446.61,14,,,percent of total billed charges,14% of total billed charges,446.61,15464.9,
31652-PF Bronch Ebus Sampling 1/2 Node,4322034,CDM,960,RC,31652,HCPCS,Outpatient,,,417.38,208.69,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
"31653 - Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with endob",3572800,CDM,960,RC,31653,HCPCS,Outpatient,,,3316.32,1658.16,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
31653-PF Bronch Ebus Samploing 3/> Node,4322035,CDM,960,RC,31653,HCPCS,Outpatient,,,463.26,231.63,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
"31654 - PF Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with tr",3712969,CDM,510,RC,31654,HCPCS,Outpatient,,,308.38,154.19,,231.29,75,,,percent of total billed charges,75% of total billed charges,231.29,75,,,percent of total billed charges,75% of total billed charges,98.68,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.17,14,,,percent of total billed charges,14% of total billed charges,43.17,231.29,
31654-PF Bronch Ebus Ivn Perph Les,4322036,CDM,960,RC,31654,HCPCS,Outpatient,,,127.3,63.65,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
31720-PF CATHETER ASPIRATION NASOTRACHEAL SPX,4321676,CDM,981,RC,31720,HCPCS,Outpatient,,,95.6,47.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
Nasotracheal Suction,1879111,CDM,410,RC,31720,HCPCS,Outpatient,,,154.37,77.19,,115.78,75,,,percent of total billed charges,75% of total billed charges,115.78,75,,,percent of total billed charges,75% of total billed charges,180.04,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,297.06,165,,,Fee Schedule,165% of CMS OPPS Rate,186.59,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,517.14,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,709.22,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,888.37,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,180.04,100,,,Fee Schedule,100% of CMS OPPS Rate,186.59,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,21.61,14,,,percent of total billed charges,14% of total billed charges,21.61,888.37,
Bedside Bronchoscopy,1151013,CDM,410,RC,31725,HCPCS,Outpatient,,,209.29,104.65,,156.97,75,,,percent of total billed charges,75% of total billed charges,156.97,75,,,percent of total billed charges,75% of total billed charges,209.29,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,209.29,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,209.29,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,209.29,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,209.29,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,209.29,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,209.29,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,209.29,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,29.3,14,,,percent of total billed charges,14% of total billed charges,29.3,209.29,
32097- Thoracotomy w/bx/nod/mass/unilat,3435875,CDM,510,RC,32097,HCPCS,Outpatient,,,2142.18,1071.09,,1606.64,75,,,percent of total billed charges,75% of total billed charges,1606.64,75,,,percent of total billed charges,75% of total billed charges,2142.18,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,2142.18,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2142.18,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2142.18,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2142.18,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2142.18,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,2142.18,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2142.18,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,299.91,14,,,percent of total billed charges,14% of total billed charges,299.91,2142.18,
32098 - PF Thoracotomy w/Biopsy of Pleura,4309275,CDM,960,RC,32098,HCPCS,Outpatient,,,1604.27,802.14,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
32100- Thoracotomy w/exploration,3435876,CDM,510,RC,32100,HCPCS,Outpatient,,,2163.49,1081.75,,1622.62,75,,,percent of total billed charges,75% of total billed charges,1622.62,75,,,percent of total billed charges,75% of total billed charges,2163.49,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,2163.49,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2163.49,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2163.49,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2163.49,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2163.49,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,2163.49,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2163.49,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,302.89,14,,,percent of total billed charges,14% of total billed charges,302.89,2163.49,
32100-PF Thoracotomy w/ Exploration,4322047,CDM,960,RC,32100,HCPCS,Outpatient,,,1583.9,791.95,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
32110- Thoracot/control trauma hemorrhag,3435877,CDM,510,RC,32110,HCPCS,Outpatient,,,3941.71,1970.86,,2956.28,75,,,percent of total billed charges,75% of total billed charges,2956.28,75,,,percent of total billed charges,75% of total billed charges,3941.71,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,3941.71,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3941.71,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3941.71,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3941.71,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3941.71,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,3941.71,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3941.71,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,551.84,14,,,percent of total billed charges,14% of total billed charges,551.84,3941.71,
32140 - THRMBC DIR/W/CATH V/C ILIAC FEMPOP VEIN LEG INC,4037485,CDM,983,RC,32140,HCPCS,Outpatient,,,2642.23,1321.12,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
32160-PF THORACOTOMY W/CARDIAC MASSAGE,4321383,CDM,981,RC,32160,HCPCS,Outpatient,,,1582.64,791.32,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
32220- Pulmonary decortication/total,3435878,CDM,510,RC,32220,HCPCS,Outpatient,,,4256.41,2128.21,,3192.31,75,,,percent of total billed charges,75% of total billed charges,3192.31,75,,,percent of total billed charges,75% of total billed charges,4256.41,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,4256.41,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4256.41,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4256.41,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4256.41,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4256.41,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,4256.41,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4256.41,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,595.9,14,,,percent of total billed charges,14% of total billed charges,595.9,4256.41,
32225- Pulmonary decortication/partial,3435879,CDM,510,RC,32225,HCPCS,Outpatient,,,2664.41,1332.21,,1998.31,75,,,percent of total billed charges,75% of total billed charges,1998.31,75,,,percent of total billed charges,75% of total billed charges,2664.41,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,2664.41,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2664.41,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2664.41,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2664.41,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2664.41,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,2664.41,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2664.41,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,373.02,14,,,percent of total billed charges,14% of total billed charges,373.02,2664.41,
32310-PF Pleurectomy Parietal Sep Px,4322048,CDM,960,RC,32310,HCPCS,Outpatient,,,1794.92,897.46,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
32320-PF Decort & Parietal Pleurectomy,4322049,CDM,960,RC,32320,HCPCS,Outpatient,,,3134.96,1567.48,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
CT add Needle Bx Chest Lining,645122,CDM,360,RC,32400,HCPCS,Outpatient,,,417.16,208.58,,312.87,75,,,percent of total billed charges,75% of total billed charges,312.87,75,,,percent of total billed charges,75% of total billed charges,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,479.67,102,,,Fee Schedule,102% of WV Medicaid Rate,2326.19,165,,,Fee Schedule,165% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4049.52,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5553.61,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6956.46,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,470.26,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,58.4,14,,,percent of total billed charges,14% of total billed charges,58.4,6956.46,
Read,4181196,CDM,972,RC,32400,HCPCS,Outpatient,,,166.87,83.44,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
32408-PF CORE NDL BX LNG/MED PERQ,4321675,CDM,981,RC,32408,HCPCS,Outpatient,,,298.96,149.48,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
CT add Needle Bx Lung or Mediastinum,645124,CDM,360,RC,32408,HCPCS,Outpatient,,,2053.46,1026.73,,1540.1,75,,,percent of total billed charges,75% of total billed charges,1540.1,75,,,percent of total billed charges,75% of total billed charges,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,479.67,102,,,Fee Schedule,102% of WV Medicaid Rate,2326.19,165,,,Fee Schedule,165% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4049.52,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5553.61,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6956.46,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,470.26,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,287.48,14,,,percent of total billed charges,14% of total billed charges,287.48,6956.46,
Read,4181200,CDM,972,RC,32408,HCPCS,Outpatient,,,821.38,410.69,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
32440-PF Rmv Lung Pneumonectomy,4322050,CDM,960,RC,32440,HCPCS,Outpatient,,,3072.52,1536.26,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
32480- Lung removal/single lobe/lobectomy,3435881,CDM,510,RC,32480,HCPCS,Outpatient,,,3967.66,1983.83,,2975.75,75,,,percent of total billed charges,75% of total billed charges,2975.75,75,,,percent of total billed charges,75% of total billed charges,3967.66,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,3967.66,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3967.66,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3967.66,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3967.66,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3967.66,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,3967.66,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3967.66,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,555.47,14,,,percent of total billed charges,14% of total billed charges,555.47,3967.66,
32480-PF Rmvl Lung oth thn Pneumonect 1 Lobe,4322051,CDM,960,RC,32480,HCPCS,Outpatient,,,2895.92,1447.96,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
32482-PF Bilobectomy,4322052,CDM,960,RC,32482,HCPCS,Outpatient,,,3093.42,1546.71,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
32484- Lung removal/sng seg/segmentectomy,3435882,CDM,510,RC,32484,HCPCS,Outpatient,,,3850.92,1925.46,,2888.19,75,,,percent of total billed charges,75% of total billed charges,2888.19,75,,,percent of total billed charges,75% of total billed charges,3850.92,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,3850.92,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3850.92,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3850.92,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3850.92,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3850.92,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,3850.92,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3850.92,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,539.13,14,,,percent of total billed charges,14% of total billed charges,539.13,3850.92,
32484-PF Rmvl lung oth thn pneumonect 1 segemntect,4322072,CDM,960,RC,32484,HCPCS,Outpatient,,,2810.12,1405.06,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
32486-PF Sleeve Lobectomy,4322053,CDM,960,RC,32486,HCPCS,Outpatient,,,4607.44,2303.72,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
32501-PF Repair Bronchus Add-On,4322054,CDM,960,RC,32501,HCPCS,Outpatient,,,481.44,240.72,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
32505- Thorocotomy/wedge resect/initial,3435883,CDM,510,RC,32505,HCPCS,Outpatient,,,2486.88,1243.44,,1865.16,75,,,percent of total billed charges,75% of total billed charges,1865.16,75,,,percent of total billed charges,75% of total billed charges,2486.88,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,2486.88,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2486.88,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2486.88,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2486.88,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2486.88,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,2486.88,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2486.88,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,348.16,14,,,percent of total billed charges,14% of total billed charges,348.16,2486.88,
32550- Pleural cath insert/cuff/tunneled,3435884,CDM,510,RC,32550,HCPCS,Outpatient,,,2013.72,1006.86,,1510.29,75,,,percent of total billed charges,75% of total billed charges,1510.29,75,,,percent of total billed charges,75% of total billed charges,3329.99,100,,,Fee Schedule,100% of CMS OPPS Rate,1529.86,102,,,Fee Schedule,102% of WV Medicaid Rate,5494.49,165,,,Fee Schedule,165% of CMS OPPS Rate,3451.26,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,9564.96,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,13117.59,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,16431.12,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1499.86,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,3329.99,100,,,Fee Schedule,100% of CMS OPPS Rate,3451.26,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,281.92,14,,,percent of total billed charges,14% of total billed charges,281.92,16431.12,
32550-PF Insert Indwel Tunn Pleural Cath,4322073,CDM,960,RC,32550,HCPCS,Outpatient,,,390.78,195.39,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
32551 - PF Tube Thoracostomy Incl Water Seal,4311493,CDM,960,RC,32551,HCPCS,Outpatient,,,368.49,184.25,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
32551- Chest tube instert/open w/drainage,3435885,CDM,510,RC,32551,HCPCS,Outpatient,,,420.95,210.48,,315.71,75,,,percent of total billed charges,75% of total billed charges,315.71,75,,,percent of total billed charges,75% of total billed charges,1398.82,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,2308.05,165,,,Fee Schedule,165% of CMS OPPS Rate,1449.76,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4017.93,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5510.28,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6902.18,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,1398.82,100,,,Fee Schedule,100% of CMS OPPS Rate,1449.76,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,58.93,14,,,percent of total billed charges,14% of total billed charges,58.93,6902.18,
32551-PF TUBE THORACOSTOMY INCLUDES WATER SEA,4321674,CDM,981,RC,32551,HCPCS,Outpatient,,,310.38,155.19,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
32552- Rmv tunneled pleural cath w/cuff,3435886,CDM,510,RC,32552,HCPCS,Outpatient,,,471.99,236,,353.99,75,,,percent of total billed charges,75% of total billed charges,353.99,75,,,percent of total billed charges,75% of total billed charges,543.88,100,,,Fee Schedule,100% of CMS OPPS Rate,220.64,102,,,Fee Schedule,102% of WV Medicaid Rate,897.41,165,,,Fee Schedule,165% of CMS OPPS Rate,563.69,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1562.23,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2142.48,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,2683.68,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,216.31,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,543.88,100,,,Fee Schedule,100% of CMS OPPS Rate,563.69,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,66.08,14,,,percent of total billed charges,14% of total billed charges,66.08,2683.68,
32552-PF Rmv Indwel Tunn Pleural Cath w/cuff,4322074,CDM,960,RC,32552,HCPCS,Outpatient,,,297.34,148.67,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
32554- Thoracentesis w/o image guide,3435887,CDM,510,RC,32554,HCPCS,Outpatient,,,599.36,299.68,,449.52,75,,,percent of total billed charges,75% of total billed charges,449.52,75,,,percent of total billed charges,75% of total billed charges,543.88,100,,,Fee Schedule,100% of CMS OPPS Rate,220.64,102,,,Fee Schedule,102% of WV Medicaid Rate,897.4,165,,,Fee Schedule,165% of CMS OPPS Rate,563.67,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1562.23,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2142.48,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,2683.68,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,216.31,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,543.88,100,,,Fee Schedule,100% of CMS OPPS Rate,563.67,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,83.91,14,,,percent of total billed charges,14% of total billed charges,83.91,2683.68,
32554-PF THORACENTESIS NEEDLE/CATH PLEURA W/O IMAGING,4321402,CDM,981,RC,32554,HCPCS,Outpatient,,,174.32,87.16,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
32555- Thoracentesis/image guide,3435888,CDM,360,RC,32555,HCPCS,Outpatient,,,798.68,399.34,,599.01,75,,,percent of total billed charges,75% of total billed charges,599.01,75,,,percent of total billed charges,75% of total billed charges,543.88,100,,,Fee Schedule,100% of CMS OPPS Rate,220.64,102,,,Fee Schedule,102% of WV Medicaid Rate,897.4,165,,,Fee Schedule,165% of CMS OPPS Rate,563.67,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1562.23,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2142.48,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,2683.68,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,216.31,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,543.88,100,,,Fee Schedule,100% of CMS OPPS Rate,563.67,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,111.82,14,,,percent of total billed charges,14% of total billed charges,111.82,2683.68,
32555-PF THORACENTESIS NEEDLE/CATH PLEURA W/IMAGING,4321673,CDM,981,RC,32555,HCPCS,Outpatient,,,214.14,107.07,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
CT add Thoracentesis,645110,CDM,360,RC,32555,HCPCS,Outpatient,,,768.74,384.37,,576.56,75,,,percent of total billed charges,75% of total billed charges,576.56,75,,,percent of total billed charges,75% of total billed charges,543.88,100,,,Fee Schedule,100% of CMS OPPS Rate,220.64,102,,,Fee Schedule,102% of WV Medicaid Rate,897.4,165,,,Fee Schedule,165% of CMS OPPS Rate,563.67,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1562.23,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2142.48,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,2683.68,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,216.31,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,543.88,100,,,Fee Schedule,100% of CMS OPPS Rate,563.67,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,107.62,14,,,percent of total billed charges,14% of total billed charges,107.62,2683.68,
Read,2964113,CDM,972,RC,32555,HCPCS,Outpatient,,,307.5,153.75,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
Read,3351393,CDM,972,RC,32555,HCPCS,Outpatient,,,307.5,153.75,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
Read,3351395,CDM,972,RC,32555,HCPCS,Outpatient,,,307.5,153.75,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
Read,3351914,CDM,972,RC,32555,HCPCS,Outpatient,,,307.5,153.75,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
Read,3351916,CDM,972,RC,32555,HCPCS,Outpatient,,,307.5,153.75,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
Read,3351989,CDM,972,RC,32555,HCPCS,Outpatient,,,307.5,153.75,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
Read,3351991,CDM,972,RC,32555,HCPCS,Outpatient,,,307.5,153.75,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
US add Thoracentesis,645146,CDM,360,RC,32555,HCPCS,Outpatient,,,768.74,384.37,,576.56,75,,,percent of total billed charges,75% of total billed charges,576.56,75,,,percent of total billed charges,75% of total billed charges,543.88,100,,,Fee Schedule,100% of CMS OPPS Rate,220.64,102,,,Fee Schedule,102% of WV Medicaid Rate,897.4,165,,,Fee Schedule,165% of CMS OPPS Rate,563.67,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1562.23,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2142.48,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,2683.68,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,216.31,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,543.88,100,,,Fee Schedule,100% of CMS OPPS Rate,563.67,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,107.62,14,,,percent of total billed charges,14% of total billed charges,107.62,2683.68,
32556- Pleural drain/cath/perc w/o image,3435889,CDM,510,RC,32556,HCPCS,Outpatient,,,1859.58,929.79,,1394.69,75,,,percent of total billed charges,75% of total billed charges,1394.69,75,,,percent of total billed charges,75% of total billed charges,1637.37,100,,,Fee Schedule,100% of CMS OPPS Rate,557.09,102,,,Fee Schedule,102% of WV Medicaid Rate,2701.67,165,,,Fee Schedule,165% of CMS OPPS Rate,1697,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4703.14,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,6450,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,8079.28,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,546.17,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1637.37,100,,,Fee Schedule,100% of CMS OPPS Rate,1697,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,260.34,14,,,percent of total billed charges,14% of total billed charges,260.34,8079.28,
"32557 - Pleural drainage, percutaneous, with insertion of indwelling catheter; with imaging guidance",3760897,CDM,983,RC,32557,HCPCS,Outpatient,,,1667.93,833.97,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
32560- Instill agent/chest tube/pleurodesis,3435890,CDM,510,RC,32560,HCPCS,Outpatient,,,652.99,326.5,,489.74,75,,,percent of total billed charges,75% of total billed charges,489.74,75,,,percent of total billed charges,75% of total billed charges,543.88,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,897.4,165,,,Fee Schedule,165% of CMS OPPS Rate,563.67,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1562.23,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2142.48,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,2683.68,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,543.88,100,,,Fee Schedule,100% of CMS OPPS Rate,563.67,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,91.42,14,,,percent of total billed charges,14% of total billed charges,91.42,2683.68,
32560-PF Instl via Chst Tub/Cath Agnt for Pleurodesis,4322075,CDM,960,RC,32560,HCPCS,Outpatient,,,147.78,73.89,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
32561-PF Lyse Chest Fibrin Init Day,4322076,CDM,960,RC,32561,HCPCS,Outpatient,,,129.28,64.64,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
32562-PF Lyse Chest Fibrin Subq Day,4322077,CDM,960,RC,32562,HCPCS,Outpatient,,,115.44,57.72,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
32606-PF Thoracoscopy w/Bx Mediastinal Spc,4322078,CDM,960,RC,32606,HCPCS,Outpatient,,,906.54,453.27,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
32607- Thoracoscopy/bx infiltrate/unilat,3435891,CDM,510,RC,32607,HCPCS,Outpatient,,,824.48,412.24,,618.36,75,,,percent of total billed charges,75% of total billed charges,618.36,75,,,percent of total billed charges,75% of total billed charges,4900.27,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,8085.46,165,,,Fee Schedule,165% of CMS OPPS Rate,5078.72,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,14075.4,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,19303.29,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,24179.33,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,4900.27,100,,,Fee Schedule,100% of CMS OPPS Rate,5078.72,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,115.43,14,,,percent of total billed charges,14% of total billed charges,115.43,24179.33,
32607-PF Thoracoscopy w/Dx Bx of Lung Infiltrate Uni,4322079,CDM,960,RC,32607,HCPCS,Outpatient,,,602.44,301.22,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
32608- Thoracoscopy/bx nodule/mass/unilat,3435892,CDM,510,RC,32608,HCPCS,Outpatient,,,1016.85,508.43,,762.64,75,,,percent of total billed charges,75% of total billed charges,762.64,75,,,percent of total billed charges,75% of total billed charges,4900.27,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,8085.46,165,,,Fee Schedule,165% of CMS OPPS Rate,5078.72,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,14075.4,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,19303.29,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,24179.33,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,4900.27,100,,,Fee Schedule,100% of CMS OPPS Rate,5078.72,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,142.36,14,,,percent of total billed charges,14% of total billed charges,142.36,24179.33,
32609- Thoracoscopy/bx pleura,3435893,CDM,510,RC,32609,HCPCS,Outpatient,,,682.09,341.05,,511.57,75,,,percent of total billed charges,75% of total billed charges,511.57,75,,,percent of total billed charges,75% of total billed charges,4900.27,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,8085.46,165,,,Fee Schedule,165% of CMS OPPS Rate,5078.72,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,14075.4,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,19303.29,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,24179.33,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,4900.27,100,,,Fee Schedule,100% of CMS OPPS Rate,5078.72,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,95.49,14,,,percent of total billed charges,14% of total billed charges,95.49,24179.33,
32609-PF Thoracoscopy w/ Bx of Pluera,4322080,CDM,960,RC,32609,HCPCS,Outpatient,,,498.14,249.07,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
32650- Thoracoscopy/surg/pleurodesis,3435894,CDM,510,RC,32650,HCPCS,Outpatient,,,1772.12,886.06,,1329.09,75,,,percent of total billed charges,75% of total billed charges,1329.09,75,,,percent of total billed charges,75% of total billed charges,1772.12,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,1772.12,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1772.12,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1772.12,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1772.12,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1772.12,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,1772.12,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1772.12,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,248.1,14,,,percent of total billed charges,14% of total billed charges,248.1,1772.12,
32650-PF Thoracoscopy w/ Pluerodesis,4322081,CDM,960,RC,32650,HCPCS,Outpatient,,,1300.26,650.13,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
32651- Thoracoscopy/surg/part pulm decort,3435895,CDM,510,RC,32651,HCPCS,Outpatient,,,2928.01,1464.01,,2196.01,75,,,percent of total billed charges,75% of total billed charges,2196.01,75,,,percent of total billed charges,75% of total billed charges,2928.01,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,2928.01,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2928.01,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2928.01,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2928.01,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2928.01,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,2928.01,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2928.01,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,409.92,14,,,percent of total billed charges,14% of total billed charges,409.92,2928.01,
32651-PF Thoracoscopy w/prtl Pulm Decortication,4322082,CDM,960,RC,32651,HCPCS,Outpatient,,,2141.4,1070.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
32652- Thoracoscopy/tot pulm decorticatio,3435896,CDM,510,RC,32652,HCPCS,Outpatient,,,4451.93,2225.97,,3338.95,75,,,percent of total billed charges,75% of total billed charges,3338.95,75,,,percent of total billed charges,75% of total billed charges,4451.93,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,4451.93,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4451.93,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4451.93,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4451.93,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4451.93,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,4451.93,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4451.93,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,623.27,14,,,percent of total billed charges,14% of total billed charges,623.27,4451.93,
"32655- Thoracoscopy, surgical; with resection-plication of bullae, includes any pleural procedure wh",3566781,CDM,510,RC,32655,HCPCS,Outpatient,,,2552.64,1276.32,,1914.48,75,,,percent of total billed charges,75% of total billed charges,1914.48,75,,,percent of total billed charges,75% of total billed charges,2552.64,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,2552.64,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2552.64,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2552.64,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2552.64,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2552.64,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,2552.64,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2552.64,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,357.37,14,,,percent of total billed charges,14% of total billed charges,357.37,2552.64,
32655-PF Thorcoscopy w/Resect Bullae w/wo Plueral Px,4322083,CDM,960,RC,32655,HCPCS,Outpatient,,,1869.48,934.74,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
32656- Thoracoscopy/parietal pleurectomy,3435897,CDM,510,RC,32656,HCPCS,Outpatient,,,2141.96,1070.98,,1606.47,75,,,percent of total billed charges,75% of total billed charges,1606.47,75,,,percent of total billed charges,75% of total billed charges,2141.96,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,2141.96,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2141.96,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2141.96,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2141.96,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2141.96,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,2141.96,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2141.96,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,299.87,14,,,percent of total billed charges,14% of total billed charges,299.87,2141.96,
32656-PF Thorcoscopy w/Parietal Pleurectomy,4322084,CDM,960,RC,32656,HCPCS,Outpatient,,,1566.38,783.19,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
32658- Thoracoscopy/rmv clot/pericard sac,3435898,CDM,510,RC,32658,HCPCS,Outpatient,,,1901.38,950.69,,1426.04,75,,,percent of total billed charges,75% of total billed charges,1426.04,75,,,percent of total billed charges,75% of total billed charges,1901.38,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,1901.38,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1901.38,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1901.38,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1901.38,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1901.38,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,1901.38,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1901.38,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,266.19,14,,,percent of total billed charges,14% of total billed charges,266.19,1901.38,
32658-PF Thoracoscopy w/Rmvl Clot/FB frm Pericard Sac,4322085,CDM,960,RC,32658,HCPCS,Outpatient,,,1394.24,697.12,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
"32659- Thoracoscopy, surgical; with creation of pericardial window or partial resection of pericardi",3569383,CDM,510,RC,32659,HCPCS,Outpatient,,,1946.52,973.26,,1459.89,75,,,percent of total billed charges,75% of total billed charges,1459.89,75,,,percent of total billed charges,75% of total billed charges,1946.52,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,1946.52,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1946.52,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1946.52,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1946.52,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1946.52,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,1946.52,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1946.52,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,272.51,14,,,percent of total billed charges,14% of total billed charges,272.51,1946.52,
32659-PF Thoracoscopy w/Sac Drainage,4322087,CDM,960,RC,32659,HCPCS,Outpatient,,,1430.24,715.12,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
32662- Thoracoscopy/exc med cyst/tum/mass,3435899,CDM,510,RC,32662,HCPCS,Outpatient,,,2382.39,1191.2,,1786.79,75,,,percent of total billed charges,75% of total billed charges,1786.79,75,,,percent of total billed charges,75% of total billed charges,2382.39,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,2382.39,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2382.39,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2382.39,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2382.39,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2382.39,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,2382.39,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2382.39,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,333.53,14,,,percent of total billed charges,14% of total billed charges,333.53,2382.39,
32663-PF Thoracoscopy w/Lobectomy,4322088,CDM,960,RC,32663,HCPCS,Outpatient,,,2740.16,1370.08,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
32664- Thoracoscopy/thoracic sympathectom,3435900,CDM,510,RC,32664,HCPCS,Outpatient,,,2262.77,1131.39,,1697.08,75,,,percent of total billed charges,75% of total billed charges,1697.08,75,,,percent of total billed charges,75% of total billed charges,2262.77,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,2262.77,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2262.77,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2262.77,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2262.77,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2262.77,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,2262.77,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2262.77,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,316.79,14,,,percent of total billed charges,14% of total billed charges,316.79,2262.77,
32665- Thoracoscopy/surg/esophagomyotomy,3435901,CDM,510,RC,32665,HCPCS,Outpatient,,,3296.95,1648.48,,2472.71,75,,,percent of total billed charges,75% of total billed charges,2472.71,75,,,percent of total billed charges,75% of total billed charges,3296.95,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,3296.95,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3296.95,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3296.95,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3296.95,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3296.95,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,3296.95,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3296.95,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,461.57,14,,,percent of total billed charges,14% of total billed charges,461.57,3296.95,
32666- Thoracoscopy/surg/wedg resect/init,3435902,CDM,510,RC,32666,HCPCS,Outpatient,,,2319.15,1159.58,,1739.36,75,,,percent of total billed charges,75% of total billed charges,1739.36,75,,,percent of total billed charges,75% of total billed charges,2319.15,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,2319.15,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2319.15,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2319.15,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2319.15,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2319.15,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,2319.15,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2319.15,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,324.68,14,,,percent of total billed charges,14% of total billed charges,324.68,2319.15,
32666-PF Thoracoscopy w/Wedge Resect Init Uni,4322089,CDM,960,RC,32666,HCPCS,Outpatient,,,1698.42,849.21,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
32667- Thoracoscopy/surg/wedge resect,3435903,CDM,510,RC,32667,HCPCS,Outpatient,,,424.95,212.48,,318.71,75,,,percent of total billed charges,75% of total billed charges,318.71,75,,,percent of total billed charges,75% of total billed charges,424.95,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,424.95,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,424.95,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,424.95,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,424.95,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,424.95,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,424.95,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,424.95,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,59.49,14,,,percent of total billed charges,14% of total billed charges,59.49,424.95,
32667-PF Thoracoscopy w/Wedge Resect Addl,4322090,CDM,960,RC,32667,HCPCS,Outpatient,,,309.04,154.52,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
32668- Thoracoscopy/surg/wedg/lung resect,3435904,CDM,510,RC,32668,HCPCS,Outpatient,,,426.05,213.03,,319.54,75,,,percent of total billed charges,75% of total billed charges,319.54,75,,,percent of total billed charges,75% of total billed charges,426.05,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,426.05,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,426.05,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,426.05,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,426.05,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,426.05,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,426.05,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,426.05,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,59.65,14,,,percent of total billed charges,14% of total billed charges,59.65,426.05,
32668-PF Thoracoscopy w/Dx Wedge Resect Diag,4322091,CDM,960,RC,32668,HCPCS,Outpatient,,,309.04,154.52,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
32669-PF Thoracoscopy w/Segmentectomy,4322092,CDM,960,RC,32669,HCPCS,Outpatient,,,2629.52,1314.76,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
32670-PF Thoracoscopy w/Bilobectomy,4322093,CDM,960,RC,32670,HCPCS,Outpatient,,,3136.24,1568.12,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
32671-PF Thoracoscopy w/Pneumonectomy,4322094,CDM,960,RC,32671,HCPCS,Outpatient,,,3481.4,1740.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
32673 - PF Thoracoscopy Resect w/Thymus Uni/Bilat,4301613,CDM,960,RC,32673,HCPCS,Outpatient,,,2569.14,1284.57,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
32674 - Thoracoscopy Lymph Node Exc PF,4231109,CDM,960,RC,32674,HCPCS,Outpatient,,,457.41,228.71,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
32674-PF Thoracoscopy Lymph Node Exc,4322095,CDM,960,RC,32674,HCPCS,Outpatient,,,425.22,212.61,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
32701-PF Thorax Stereotactic Rad Target w/Tx,4322096,CDM,960,RC,32701,HCPCS,Outpatient,,,409.88,204.94,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
32998-PF Ablate Pulm Tumor Perq RF,4322097,CDM,960,RC,32998,HCPCS,Outpatient,,,833.54,416.77,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
"33010- Pericardiocentesis, initial",3430823,CDM,481,RC,33016,HCPCS,Outpatient,,,632.36,316.18,,474.27,75,,,percent of total billed charges,75% of total billed charges,474.27,75,,,percent of total billed charges,75% of total billed charges,1398.82,100,,,Fee Schedule,100% of CMS OPPS Rate,440.05,102,,,Fee Schedule,102% of WV Medicaid Rate,2308.05,165,,,Fee Schedule,165% of CMS OPPS Rate,1449.76,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4017.93,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5510.28,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6902.18,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,431.42,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1398.82,100,,,Fee Schedule,100% of CMS OPPS Rate,1449.76,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,88.53,14,,,percent of total billed charges,14% of total billed charges,88.53,6902.18,
33010-PERICARDIOCENTESIS,3431747,CDM,481,RC,33016,HCPCS,Outpatient,,,632.36,316.18,,474.27,75,,,percent of total billed charges,75% of total billed charges,474.27,75,,,percent of total billed charges,75% of total billed charges,1398.82,100,,,Fee Schedule,100% of CMS OPPS Rate,440.05,102,,,Fee Schedule,102% of WV Medicaid Rate,2308.05,165,,,Fee Schedule,165% of CMS OPPS Rate,1449.76,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4017.93,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5510.28,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6902.18,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,431.42,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1398.82,100,,,Fee Schedule,100% of CMS OPPS Rate,1449.76,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,88.53,14,,,percent of total billed charges,14% of total billed charges,88.53,6902.18,
33016-Pericardiocentesis,3586871,CDM,481,RC,33016,HCPCS,Outpatient,,,632.36,316.18,,474.27,75,,,percent of total billed charges,75% of total billed charges,474.27,75,,,percent of total billed charges,75% of total billed charges,1398.82,100,,,Fee Schedule,100% of CMS OPPS Rate,440.05,102,,,Fee Schedule,102% of WV Medicaid Rate,2308.05,165,,,Fee Schedule,165% of CMS OPPS Rate,1449.76,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4017.93,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5510.28,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6902.18,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,431.42,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1398.82,100,,,Fee Schedule,100% of CMS OPPS Rate,1449.76,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,88.53,14,,,percent of total billed charges,14% of total billed charges,88.53,6902.18,
"33016-PERICARDIOCENTSIS, W/IMAGING",3430627,CDM,481,RC,33016,HCPCS,Outpatient,,,619.39,309.7,,464.54,75,,,percent of total billed charges,75% of total billed charges,464.54,75,,,percent of total billed charges,75% of total billed charges,1398.82,100,,,Fee Schedule,100% of CMS OPPS Rate,440.05,102,,,Fee Schedule,102% of WV Medicaid Rate,2308.05,165,,,Fee Schedule,165% of CMS OPPS Rate,1449.76,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4017.93,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5510.28,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6902.18,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,431.42,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1398.82,100,,,Fee Schedule,100% of CMS OPPS Rate,1449.76,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,86.71,14,,,percent of total billed charges,14% of total billed charges,86.71,6902.18,
33016-PF Pericardiocentesis,3586870,CDM,960,RC,33016,HCPCS,Outpatient,,,632.36,316.18,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
33016-PF PERICARDIOCENTESIS W/IMG GUIDANCE WHEN PERFORMED,4321403,CDM,981,RC,33016,HCPCS,Outpatient,,,467.46,233.73,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
Pericardiocentesis,604580,CDM,481,RC,33016,HCPCS,Outpatient,,,619.39,309.7,,464.54,75,,,percent of total billed charges,75% of total billed charges,464.54,75,,,percent of total billed charges,75% of total billed charges,1398.82,100,,,Fee Schedule,100% of CMS OPPS Rate,440.05,102,,,Fee Schedule,102% of WV Medicaid Rate,2308.05,165,,,Fee Schedule,165% of CMS OPPS Rate,1449.76,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4017.93,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5510.28,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6902.18,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,431.42,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1398.82,100,,,Fee Schedule,100% of CMS OPPS Rate,1449.76,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,86.71,14,,,percent of total billed charges,14% of total billed charges,86.71,6902.18,
"33017 - Pericardial drainage with insertion of indwelling catheter, percutaneous, including fluorosc",3572784,CDM,960,RC,33017,HCPCS,Outpatient,,,661.46,330.73,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
33017 - PerQ Prcrd DRG 6yr+ w/o Congenital Car Anomoly,3899022,CDM,983,RC,33017,HCPCS,Outpatient,,,661.46,330.73,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
33017-Pericardiocentesis with indwelling catheter,4271112,CDM,481,RC,33017,HCPCS,Outpatient,,,519.89,259.95,,389.92,75,,,percent of total billed charges,75% of total billed charges,389.92,75,,,percent of total billed charges,75% of total billed charges,519.89,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,519.89,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,519.89,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,519.89,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,519.89,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,519.89,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,519.89,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,519.89,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,72.78,14,,,percent of total billed charges,14% of total billed charges,72.78,519.89,
33017-PF Pericardiocentesis with indwelling catheter,4271113,CDM,960,RC,33017,HCPCS,Outpatient,,,519.89,259.95,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
33017-PF PERQ PRCRD DRG 6YR+ W/O CONGENITAL CAR ANOMALY,4321405,CDM,981,RC,33017,HCPCS,Outpatient,,,490.46,245.23,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
Pericardiocentesis with indwelling catheter,,,761,RC,33017,HCPCS,Outpatient,,,519.89,259.95,,389.92,75,,,percent of total billed charges,75% of total billed charges,389.92,75,,,percent of total billed charges,75% of total billed charges,519.89,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,519.89,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,519.89,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,519.89,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,519.89,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,519.89,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,519.89,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,519.89,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,72.78,14,,,percent of total billed charges,14% of total billed charges,72.78,519.89,
33018-PF PERQ PRCRD DRG 0-5YR/ANY AGE W/CGEN CAR ANOMALY,4321408,CDM,981,RC,33018,HCPCS,Outpatient,,,577.04,288.52,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
"33019 - Pericardial drainage with insertion of indwelling catheter, percutaneous, including CT guida",3572785,CDM,960,RC,33019,HCPCS,Outpatient,,,573.09,286.55,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
33019-PF PERQ PERICARDIAL DRG W/INSJ NDWELLG CATH W/CT,4321413,CDM,981,RC,33019,HCPCS,Outpatient,,,417.24,208.62,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
33020- Pericardiotomy/clot/for bod remove,3430824,CDM,510,RC,33020,HCPCS,Outpatient,,,2217.83,1108.92,,1663.37,75,,,percent of total billed charges,75% of total billed charges,1663.37,75,,,percent of total billed charges,75% of total billed charges,2217.83,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,2217.83,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2217.83,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2217.83,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2217.83,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2217.83,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,2217.83,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2217.83,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,310.5,14,,,percent of total billed charges,14% of total billed charges,310.5,2217.83,
33025- Pericard window/part resect/drain,3430825,CDM,510,RC,33025,HCPCS,Outpatient,,,2055.3,1027.65,,1541.48,75,,,percent of total billed charges,75% of total billed charges,1541.48,75,,,percent of total billed charges,75% of total billed charges,2055.3,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,2055.3,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2055.3,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2055.3,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2055.3,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2055.3,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,2055.3,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2055.3,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,287.74,14,,,percent of total billed charges,14% of total billed charges,287.74,2055.3,
33025- Pericardial Window (Cath Lab),4233154,CDM,481,RC,33025,HCPCS,Outpatient,,,1624.13,812.07,,1218.1,75,,,percent of total billed charges,75% of total billed charges,1218.1,75,,,percent of total billed charges,75% of total billed charges,1624.13,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,1624.13,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1624.13,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1624.13,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1624.13,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1624.13,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,1624.13,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1624.13,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,227.38,14,,,percent of total billed charges,14% of total billed charges,227.38,1624.13,
33025-PF Incicision of Heart Sac,4322098,CDM,960,RC,33025,HCPCS,Outpatient,,,1504.72,752.36,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
33025-PF Pericardial Window (Cath Lab),4233155,CDM,960,RC,33025,HCPCS,Outpatient,,,1624.13,812.07,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
Pericardial Window (Cath Lab),,,960,RC,33025,HCPCS,Outpatient,,,1624.13,812.07,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
33031- Pericardiectomy/sub or com/w bypas,3430828,CDM,510,RC,33031,HCPCS,Outpatient,,,6654.35,3327.18,,4990.76,75,,,percent of total billed charges,75% of total billed charges,4990.76,75,,,percent of total billed charges,75% of total billed charges,6654.35,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,6654.35,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6654.35,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6654.35,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6654.35,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6654.35,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,6654.35,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6654.35,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,931.61,14,,,percent of total billed charges,14% of total billed charges,931.61,6654.35,
33120- Exc intracard tumor/resect/bypass,3430829,CDM,510,RC,33120,HCPCS,Outpatient,,,5632.27,2816.14,,4224.2,75,,,percent of total billed charges,75% of total billed charges,4224.2,75,,,percent of total billed charges,75% of total billed charges,5632.27,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,5632.27,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5632.27,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5632.27,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5632.27,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5632.27,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,5632.27,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5632.27,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,788.52,14,,,percent of total billed charges,14% of total billed charges,788.52,5632.27,
33202- Insert epicardial lead/open,3430830,CDM,510,RC,33202,HCPCS,Outpatient,,,2060.96,1030.48,,1545.72,75,,,percent of total billed charges,75% of total billed charges,1545.72,75,,,percent of total billed charges,75% of total billed charges,2060.96,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,2060.96,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2060.96,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2060.96,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2060.96,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2060.96,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,2060.96,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2060.96,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,288.53,14,,,percent of total billed charges,14% of total billed charges,288.53,2060.96,
33206- Insertion/replace PPM/atrial lead,3430628,CDM,481,RC,33206,HCPCS,Outpatient,,,1210.62,605.31,,907.97,75,,,percent of total billed charges,75% of total billed charges,907.97,75,,,percent of total billed charges,75% of total billed charges,9710.75,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,16022.75,165,,,Fee Schedule,165% of CMS OPPS Rate,10064.37,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,27892.83,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,38252.79,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,47915.5,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,9710.75,100,,,Fee Schedule,100% of CMS OPPS Rate,10064.37,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,169.49,14,,,percent of total billed charges,14% of total billed charges,169.49,47915.5,
33206-INSERT PM W/LEADS SGL CHBR ATRIAL,3431748,CDM,481,RC,33206,HCPCS,Outpatient,,,1210.62,605.31,,907.97,75,,,percent of total billed charges,75% of total billed charges,907.97,75,,,percent of total billed charges,75% of total billed charges,9710.75,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,16022.75,165,,,Fee Schedule,165% of CMS OPPS Rate,10064.37,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,27892.83,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,38252.79,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,47915.5,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,9710.75,100,,,Fee Schedule,100% of CMS OPPS Rate,10064.37,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,169.49,14,,,percent of total billed charges,14% of total billed charges,169.49,47915.5,
33206-Pacemaker Insertion Single,3431749,CDM,481,RC,33206,HCPCS,Outpatient,,,1210.62,605.31,,907.97,75,,,percent of total billed charges,75% of total billed charges,907.97,75,,,percent of total billed charges,75% of total billed charges,9710.75,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,16022.75,165,,,Fee Schedule,165% of CMS OPPS Rate,10064.37,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,27892.83,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,38252.79,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,47915.5,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,9710.75,100,,,Fee Schedule,100% of CMS OPPS Rate,10064.37,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,169.49,14,,,percent of total billed charges,14% of total billed charges,169.49,47915.5,
Pacemaker Insertion Single,,,761,RC,33206,HCPCS,Outpatient,,,1187.28,593.64,,890.46,75,,,percent of total billed charges,75% of total billed charges,890.46,75,,,percent of total billed charges,75% of total billed charges,9710.75,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,16022.75,165,,,Fee Schedule,165% of CMS OPPS Rate,10064.37,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,27892.83,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,38252.79,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,47915.5,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,9710.75,100,,,Fee Schedule,100% of CMS OPPS Rate,10064.37,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,166.22,14,,,percent of total billed charges,14% of total billed charges,166.22,47915.5,
33207- Insert new or repl PPM w/vent lead,3430629,CDM,481,RC,33207,HCPCS,Outpatient,,,1277.14,638.57,,957.86,75,,,percent of total billed charges,75% of total billed charges,957.86,75,,,percent of total billed charges,75% of total billed charges,9710.75,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,16022.75,165,,,Fee Schedule,165% of CMS OPPS Rate,10064.37,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,27892.83,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,38252.79,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,47915.5,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,9710.75,100,,,Fee Schedule,100% of CMS OPPS Rate,10064.37,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,178.8,14,,,percent of total billed charges,14% of total billed charges,178.8,47915.5,
33207-INSERT PM W/LEADS SGL CHBR VENTRICL,3431750,CDM,481,RC,33207,HCPCS,Outpatient,,,1277.14,638.57,,957.86,75,,,percent of total billed charges,75% of total billed charges,957.86,75,,,percent of total billed charges,75% of total billed charges,9710.75,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,16022.75,165,,,Fee Schedule,165% of CMS OPPS Rate,10064.37,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,27892.83,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,38252.79,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,47915.5,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,9710.75,100,,,Fee Schedule,100% of CMS OPPS Rate,10064.37,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,178.8,14,,,percent of total billed charges,14% of total billed charges,178.8,47915.5,
33207-Pacemaker Insertion Single,3431751,CDM,481,RC,33207,HCPCS,Outpatient,,,1277.14,638.57,,957.86,75,,,percent of total billed charges,75% of total billed charges,957.86,75,,,percent of total billed charges,75% of total billed charges,9710.75,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,16022.75,165,,,Fee Schedule,165% of CMS OPPS Rate,10064.37,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,27892.83,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,38252.79,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,47915.5,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,9710.75,100,,,Fee Schedule,100% of CMS OPPS Rate,10064.37,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,178.8,14,,,percent of total billed charges,14% of total billed charges,178.8,47915.5,
33207-PF INSERT PM W/LEADS SGL CHBR VENTRICL,3580862,CDM,960,RC,33207,HCPCS,Outpatient,,,1277.14,638.57,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
33208- Insert new or repl PPM w/A&V leads,3430630,CDM,481,RC,33208,HCPCS,Outpatient,,,1386.31,693.16,,1039.73,75,,,percent of total billed charges,75% of total billed charges,1039.73,75,,,percent of total billed charges,75% of total billed charges,9710.75,100,,,Fee Schedule,100% of CMS OPPS Rate,6360.89,102,,,Fee Schedule,102% of WV Medicaid Rate,16022.75,165,,,Fee Schedule,165% of CMS OPPS Rate,10064.37,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,27892.83,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,38252.79,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,47915.5,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,6236.17,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,9710.75,100,,,Fee Schedule,100% of CMS OPPS Rate,10064.37,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,194.08,14,,,percent of total billed charges,14% of total billed charges,194.08,47915.5,
33208- PF HIS Bundle Pacemaker Insertion,3690972,CDM,960,RC,33208,HCPCS,Outpatient,,,1386.31,693.16,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
33208-HIS Bundle Pacemaker Insertion,3690971,CDM,481,RC,33208,HCPCS,Outpatient,,,1386.31,693.16,,1039.73,75,,,percent of total billed charges,75% of total billed charges,1039.73,75,,,percent of total billed charges,75% of total billed charges,9710.75,100,,,Fee Schedule,100% of CMS OPPS Rate,6360.89,102,,,Fee Schedule,102% of WV Medicaid Rate,16022.75,165,,,Fee Schedule,165% of CMS OPPS Rate,10064.37,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,27892.83,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,38252.79,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,47915.5,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,6236.17,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,9710.75,100,,,Fee Schedule,100% of CMS OPPS Rate,10064.37,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,194.08,14,,,percent of total billed charges,14% of total billed charges,194.08,47915.5,
33208-INSERT PM W/LEADS DUAL CHAMBER,3431752,CDM,481,RC,33208,HCPCS,Outpatient,,,1386.31,693.16,,1039.73,75,,,percent of total billed charges,75% of total billed charges,1039.73,75,,,percent of total billed charges,75% of total billed charges,9710.75,100,,,Fee Schedule,100% of CMS OPPS Rate,6360.89,102,,,Fee Schedule,102% of WV Medicaid Rate,16022.75,165,,,Fee Schedule,165% of CMS OPPS Rate,10064.37,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,27892.83,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,38252.79,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,47915.5,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,6236.17,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,9710.75,100,,,Fee Schedule,100% of CMS OPPS Rate,10064.37,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,194.08,14,,,percent of total billed charges,14% of total billed charges,194.08,47915.5,
33208-Pacemaker Insertion Biv,3431753,CDM,481,RC,33208,HCPCS,Outpatient,,,1386.31,693.16,,1039.73,75,,,percent of total billed charges,75% of total billed charges,1039.73,75,,,percent of total billed charges,75% of total billed charges,9710.75,100,,,Fee Schedule,100% of CMS OPPS Rate,6360.89,102,,,Fee Schedule,102% of WV Medicaid Rate,16022.75,165,,,Fee Schedule,165% of CMS OPPS Rate,10064.37,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,27892.83,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,38252.79,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,47915.5,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,6236.17,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,9710.75,100,,,Fee Schedule,100% of CMS OPPS Rate,10064.37,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,194.08,14,,,percent of total billed charges,14% of total billed charges,194.08,47915.5,
33208-Pacemaker Insertion Dual,3431754,CDM,481,RC,33208,HCPCS,Outpatient,,,1386.31,693.16,,1039.73,75,,,percent of total billed charges,75% of total billed charges,1039.73,75,,,percent of total billed charges,75% of total billed charges,9710.75,100,,,Fee Schedule,100% of CMS OPPS Rate,6360.89,102,,,Fee Schedule,102% of WV Medicaid Rate,16022.75,165,,,Fee Schedule,165% of CMS OPPS Rate,10064.37,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,27892.83,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,38252.79,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,47915.5,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,6236.17,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,9710.75,100,,,Fee Schedule,100% of CMS OPPS Rate,10064.37,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,194.08,14,,,percent of total billed charges,14% of total billed charges,194.08,47915.5,
HIS Bundle Pacemaker Insertion,,,761,RC,33208,HCPCS,Outpatient,,,1359.53,679.77,,1019.65,75,,,percent of total billed charges,75% of total billed charges,1019.65,75,,,percent of total billed charges,75% of total billed charges,9710.75,100,,,Fee Schedule,100% of CMS OPPS Rate,6360.89,102,,,Fee Schedule,102% of WV Medicaid Rate,16022.75,165,,,Fee Schedule,165% of CMS OPPS Rate,10064.37,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,27892.83,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,38252.79,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,47915.5,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,6236.17,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,9710.75,100,,,Fee Schedule,100% of CMS OPPS Rate,10064.37,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,190.33,14,,,percent of total billed charges,14% of total billed charges,190.33,47915.5,
Pacemaker Insertion Biv,,,761,RC,33208,HCPCS,Outpatient,,,1359.53,679.77,,1019.65,75,,,percent of total billed charges,75% of total billed charges,1019.65,75,,,percent of total billed charges,75% of total billed charges,9710.75,100,,,Fee Schedule,100% of CMS OPPS Rate,6360.89,102,,,Fee Schedule,102% of WV Medicaid Rate,16022.75,165,,,Fee Schedule,165% of CMS OPPS Rate,10064.37,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,27892.83,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,38252.79,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,47915.5,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,6236.17,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,9710.75,100,,,Fee Schedule,100% of CMS OPPS Rate,10064.37,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,190.33,14,,,percent of total billed charges,14% of total billed charges,190.33,47915.5,
Pacemaker Insertion Dual,,,761,RC,33208,HCPCS,Outpatient,,,1359.53,679.77,,1019.65,75,,,percent of total billed charges,75% of total billed charges,1019.65,75,,,percent of total billed charges,75% of total billed charges,9710.75,100,,,Fee Schedule,100% of CMS OPPS Rate,6360.89,102,,,Fee Schedule,102% of WV Medicaid Rate,16022.75,165,,,Fee Schedule,165% of CMS OPPS Rate,10064.37,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,27892.83,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,38252.79,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,47915.5,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,6236.17,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,9710.75,100,,,Fee Schedule,100% of CMS OPPS Rate,10064.37,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,190.33,14,,,percent of total billed charges,14% of total billed charges,190.33,47915.5,
33210- Insert/repla temp pace or sgn lead,3430631,CDM,481,RC,33210,HCPCS,Outpatient,,,435.72,217.86,,326.79,75,,,percent of total billed charges,75% of total billed charges,326.79,75,,,percent of total billed charges,75% of total billed charges,7674.35,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,12662.69,165,,,Fee Schedule,165% of CMS OPPS Rate,7953.81,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,22043.54,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,30230.97,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,37867.35,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,7674.35,100,,,Fee Schedule,100% of CMS OPPS Rate,7953.81,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,61,14,,,percent of total billed charges,14% of total billed charges,61,37867.35,
33210-INSERTION TEMPORARY PACEMAKER,3431755,CDM,481,RC,33210,HCPCS,Outpatient,,,435.72,217.86,,326.79,75,,,percent of total billed charges,75% of total billed charges,326.79,75,,,percent of total billed charges,75% of total billed charges,7674.35,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,12662.69,165,,,Fee Schedule,165% of CMS OPPS Rate,7953.81,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,22043.54,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,30230.97,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,37867.35,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,7674.35,100,,,Fee Schedule,100% of CMS OPPS Rate,7953.81,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,61,14,,,percent of total billed charges,14% of total billed charges,61,37867.35,
33210-PF INSERTION TEMPORARY PACEMAKER,3580863,CDM,960,RC,33210,HCPCS,Outpatient,,,435.72,217.86,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
33210-PF INSJ/RPLCMT TEMP TRANSVNS 1CHMBR ELTRD/PM CATH,4321416,CDM,981,RC,33210,HCPCS,Outpatient,,,322.82,161.41,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
Temporary Pacemaker Insertion,604627,CDM,481,RC,33210,HCPCS,Outpatient,,,427.74,213.87,,320.81,75,,,percent of total billed charges,75% of total billed charges,320.81,75,,,percent of total billed charges,75% of total billed charges,7674.35,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,12662.69,165,,,Fee Schedule,165% of CMS OPPS Rate,7953.81,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,22043.54,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,30230.97,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,37867.35,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,7674.35,100,,,Fee Schedule,100% of CMS OPPS Rate,7953.81,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,59.88,14,,,percent of total billed charges,14% of total billed charges,59.88,37867.35,
33211- Insert/replace temp dual electrode,3430831,CDM,510,RC,33211,HCPCS,Outpatient,,,455.22,227.61,,341.42,75,,,percent of total billed charges,75% of total billed charges,341.42,75,,,percent of total billed charges,75% of total billed charges,7674.35,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,12662.69,165,,,Fee Schedule,165% of CMS OPPS Rate,7953.81,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,22043.54,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,30230.97,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,37867.35,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,7674.35,100,,,Fee Schedule,100% of CMS OPPS Rate,7953.81,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,63.73,14,,,percent of total billed charges,14% of total billed charges,63.73,37867.35,
33212- Ins pace gen only/exist singl lead,3430832,CDM,481,RC,33212,HCPCS,Outpatient,,,856.65,428.33,,642.49,75,,,percent of total billed charges,75% of total billed charges,642.49,75,,,percent of total billed charges,75% of total billed charges,7674.35,100,,,Fee Schedule,100% of CMS OPPS Rate,5423.18,102,,,Fee Schedule,102% of WV Medicaid Rate,12662.69,165,,,Fee Schedule,165% of CMS OPPS Rate,7953.81,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,22043.54,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,30230.97,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,37867.35,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,5316.84,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,7674.35,100,,,Fee Schedule,100% of CMS OPPS Rate,7953.81,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,119.93,14,,,percent of total billed charges,14% of total billed charges,119.93,37867.35,
33212-Pacemaker Change Single,3431756,CDM,481,RC,33212,HCPCS,Outpatient,,,856.65,428.33,,642.49,75,,,percent of total billed charges,75% of total billed charges,642.49,75,,,percent of total billed charges,75% of total billed charges,7674.35,100,,,Fee Schedule,100% of CMS OPPS Rate,5423.18,102,,,Fee Schedule,102% of WV Medicaid Rate,12662.69,165,,,Fee Schedule,165% of CMS OPPS Rate,7953.81,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,22043.54,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,30230.97,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,37867.35,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,5316.84,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,7674.35,100,,,Fee Schedule,100% of CMS OPPS Rate,7953.81,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,119.93,14,,,percent of total billed charges,14% of total billed charges,119.93,37867.35,
Pacemaker Change Single,,,761,RC,33212,HCPCS,Outpatient,,,838.65,419.33,,628.99,75,,,percent of total billed charges,75% of total billed charges,628.99,75,,,percent of total billed charges,75% of total billed charges,7674.35,100,,,Fee Schedule,100% of CMS OPPS Rate,5423.18,102,,,Fee Schedule,102% of WV Medicaid Rate,12662.69,165,,,Fee Schedule,165% of CMS OPPS Rate,7953.81,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,22043.54,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,30230.97,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,37867.35,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,5316.84,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,7674.35,100,,,Fee Schedule,100% of CMS OPPS Rate,7953.81,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,117.41,14,,,percent of total billed charges,14% of total billed charges,117.41,37867.35,
Replacement of Pacemaker Single,604665,CDM,481,RC,33212,HCPCS,Outpatient,,,838.65,419.33,,628.99,75,,,percent of total billed charges,75% of total billed charges,628.99,75,,,percent of total billed charges,75% of total billed charges,7674.35,100,,,Fee Schedule,100% of CMS OPPS Rate,5423.18,102,,,Fee Schedule,102% of WV Medicaid Rate,12662.69,165,,,Fee Schedule,165% of CMS OPPS Rate,7953.81,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,22043.54,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,30230.97,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,37867.35,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,5316.84,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,7674.35,100,,,Fee Schedule,100% of CMS OPPS Rate,7953.81,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,117.41,14,,,percent of total billed charges,14% of total billed charges,117.41,37867.35,
33213- Ins pace gen only/exist dual leads,3430833,CDM,481,RC,33213,HCPCS,Outpatient,,,893.79,446.9,,670.34,75,,,percent of total billed charges,75% of total billed charges,670.34,75,,,percent of total billed charges,75% of total billed charges,9710.75,100,,,Fee Schedule,100% of CMS OPPS Rate,6347.67,102,,,Fee Schedule,102% of WV Medicaid Rate,16022.75,165,,,Fee Schedule,165% of CMS OPPS Rate,10064.37,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,27892.83,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,38252.79,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,47915.5,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,6223.21,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,9710.75,100,,,Fee Schedule,100% of CMS OPPS Rate,10064.37,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,125.13,14,,,percent of total billed charges,14% of total billed charges,125.13,47915.5,
33228-Insert Generator Dual,3431757,CDM,481,RC,33213,HCPCS,Outpatient,,,893.79,446.9,,670.34,75,,,percent of total billed charges,75% of total billed charges,670.34,75,,,percent of total billed charges,75% of total billed charges,9710.75,100,,,Fee Schedule,100% of CMS OPPS Rate,6347.67,102,,,Fee Schedule,102% of WV Medicaid Rate,16022.75,165,,,Fee Schedule,165% of CMS OPPS Rate,10064.37,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,27892.83,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,38252.79,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,47915.5,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,6223.21,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,9710.75,100,,,Fee Schedule,100% of CMS OPPS Rate,10064.37,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,125.13,14,,,percent of total billed charges,14% of total billed charges,125.13,47915.5,
Insert Generator Dual,,,761,RC,33213,HCPCS,Outpatient,,,877.84,438.92,,658.38,75,,,percent of total billed charges,75% of total billed charges,658.38,75,,,percent of total billed charges,75% of total billed charges,9710.75,100,,,Fee Schedule,100% of CMS OPPS Rate,6347.67,102,,,Fee Schedule,102% of WV Medicaid Rate,16022.75,165,,,Fee Schedule,165% of CMS OPPS Rate,10064.37,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,27892.83,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,38252.79,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,47915.5,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,6223.21,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,9710.75,100,,,Fee Schedule,100% of CMS OPPS Rate,10064.37,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,122.9,14,,,percent of total billed charges,14% of total billed charges,122.9,47915.5,
Pacemaker Change Dual,,,761,RC,33213,HCPCS,Outpatient,,,877.84,438.92,,658.38,75,,,percent of total billed charges,75% of total billed charges,658.38,75,,,percent of total billed charges,75% of total billed charges,9710.75,100,,,Fee Schedule,100% of CMS OPPS Rate,6347.67,102,,,Fee Schedule,102% of WV Medicaid Rate,16022.75,165,,,Fee Schedule,165% of CMS OPPS Rate,10064.37,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,27892.83,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,38252.79,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,47915.5,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,6223.21,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,9710.75,100,,,Fee Schedule,100% of CMS OPPS Rate,10064.37,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,122.9,14,,,percent of total billed charges,14% of total billed charges,122.9,47915.5,
Replacement of Pacemaker Dual,604667,CDM,481,RC,33213,HCPCS,Outpatient,,,877.84,438.92,,658.38,75,,,percent of total billed charges,75% of total billed charges,658.38,75,,,percent of total billed charges,75% of total billed charges,9710.75,100,,,Fee Schedule,100% of CMS OPPS Rate,6347.67,102,,,Fee Schedule,102% of WV Medicaid Rate,16022.75,165,,,Fee Schedule,165% of CMS OPPS Rate,10064.37,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,27892.83,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,38252.79,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,47915.5,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,6223.21,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,9710.75,100,,,Fee Schedule,100% of CMS OPPS Rate,10064.37,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,122.9,14,,,percent of total billed charges,14% of total billed charges,122.9,47915.5,
33214- PPM upgrade single to dual chamber,3430834,CDM,510,RC,33214,HCPCS,Outpatient,,,1273.47,636.74,,955.1,75,,,percent of total billed charges,75% of total billed charges,955.1,75,,,percent of total billed charges,75% of total billed charges,9710.75,100,,,Fee Schedule,100% of CMS OPPS Rate,6258.17,102,,,Fee Schedule,102% of WV Medicaid Rate,16022.75,165,,,Fee Schedule,165% of CMS OPPS Rate,10064.37,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,27892.83,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,38252.79,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,47915.5,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,6135.46,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,9710.75,100,,,Fee Schedule,100% of CMS OPPS Rate,10064.37,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,178.29,14,,,percent of total billed charges,14% of total billed charges,178.29,47915.5,
"33214-PF Upgrade PM system single to dual chamber. Incl. removal, testing, insertion of new lead and",4271116,CDM,960,RC,33214,HCPCS,Outpatient,,,1001.47,500.74,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
"33214-Upgrade PM system single to dual chamber. Incl. removal, testing, insertion of new lead and/or",4271115,CDM,481,RC,33214,HCPCS,Outpatient,,,1001.47,500.74,,751.1,75,,,percent of total billed charges,75% of total billed charges,751.1,75,,,percent of total billed charges,75% of total billed charges,9710.75,100,,,Fee Schedule,100% of CMS OPPS Rate,6258.17,102,,,Fee Schedule,102% of WV Medicaid Rate,16022.75,165,,,Fee Schedule,165% of CMS OPPS Rate,10064.37,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,27892.83,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,38252.79,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,47915.5,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,6135.46,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,9710.75,100,,,Fee Schedule,100% of CMS OPPS Rate,10064.37,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,140.21,14,,,percent of total billed charges,14% of total billed charges,140.21,47915.5,
"Upgrade PM system single to dual chamber. Incl. removal, testing, insertion of new lead and/or Gen.",,,761,RC,33214,HCPCS,Outpatient,,,1001.47,500.74,,751.1,75,,,percent of total billed charges,75% of total billed charges,751.1,75,,,percent of total billed charges,75% of total billed charges,9710.75,100,,,Fee Schedule,100% of CMS OPPS Rate,6258.17,102,,,Fee Schedule,102% of WV Medicaid Rate,16022.75,165,,,Fee Schedule,165% of CMS OPPS Rate,10064.37,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,27892.83,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,38252.79,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,47915.5,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,6135.46,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,9710.75,100,,,Fee Schedule,100% of CMS OPPS Rate,10064.37,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,140.21,14,,,percent of total billed charges,14% of total billed charges,140.21,47915.5,
33215- Reposition RA or RV lead/PM/ICD,3430632,CDM,481,RC,33215,HCPCS,Outpatient,,,823.41,411.71,,617.56,75,,,percent of total billed charges,75% of total billed charges,617.56,75,,,percent of total billed charges,75% of total billed charges,2800.71,100,,,Fee Schedule,100% of CMS OPPS Rate,1102.62,102,,,Fee Schedule,102% of WV Medicaid Rate,4621.18,165,,,Fee Schedule,165% of CMS OPPS Rate,2902.7,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8044.7,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11032.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13819.53,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1081,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2800.71,100,,,Fee Schedule,100% of CMS OPPS Rate,2902.7,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,115.28,14,,,percent of total billed charges,14% of total billed charges,115.28,13819.53,
33215-LEAD REPOSITION PACING LEAD ICD/PM,3431759,CDM,481,RC,33215,HCPCS,Outpatient,,,823.41,411.71,,617.56,75,,,percent of total billed charges,75% of total billed charges,617.56,75,,,percent of total billed charges,75% of total billed charges,2800.71,100,,,Fee Schedule,100% of CMS OPPS Rate,1102.62,102,,,Fee Schedule,102% of WV Medicaid Rate,4621.18,165,,,Fee Schedule,165% of CMS OPPS Rate,2902.7,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8044.7,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11032.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13819.53,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1081,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2800.71,100,,,Fee Schedule,100% of CMS OPPS Rate,2902.7,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,115.28,14,,,percent of total billed charges,14% of total billed charges,115.28,13819.53,
33215-PF LEAD REPOSITION PACING LEAD ICD/PM,3580864,CDM,960,RC,33215,HCPCS,Outpatient,,,823.41,411.71,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
Repositioning of Pacemaker Leads,604649,CDM,481,RC,33215,HCPCS,Outpatient,,,811.3,405.65,,608.48,75,,,percent of total billed charges,75% of total billed charges,608.48,75,,,percent of total billed charges,75% of total billed charges,2800.71,100,,,Fee Schedule,100% of CMS OPPS Rate,1102.62,102,,,Fee Schedule,102% of WV Medicaid Rate,4621.18,165,,,Fee Schedule,165% of CMS OPPS Rate,2902.7,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8044.7,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11032.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13819.53,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1081,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2800.71,100,,,Fee Schedule,100% of CMS OPPS Rate,2902.7,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,113.58,14,,,percent of total billed charges,14% of total billed charges,113.58,13819.53,
33216- Insert single lead PPM or ICD,3430633,CDM,481,RC,33216,HCPCS,Outpatient,,,984.75,492.38,,738.56,75,,,percent of total billed charges,75% of total billed charges,738.56,75,,,percent of total billed charges,75% of total billed charges,7674.35,100,,,Fee Schedule,100% of CMS OPPS Rate,4474.97,102,,,Fee Schedule,102% of WV Medicaid Rate,12662.69,165,,,Fee Schedule,165% of CMS OPPS Rate,7953.81,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,22043.54,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,30230.97,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,37867.35,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,4387.23,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,7674.35,100,,,Fee Schedule,100% of CMS OPPS Rate,7953.81,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,137.87,14,,,percent of total billed charges,14% of total billed charges,137.87,37867.35,
33216-LEAD INSERT SINGLE TRANSV ICD/PM,3431760,CDM,481,RC,33216,HCPCS,Outpatient,,,984.75,492.38,,738.56,75,,,percent of total billed charges,75% of total billed charges,738.56,75,,,percent of total billed charges,75% of total billed charges,7674.35,100,,,Fee Schedule,100% of CMS OPPS Rate,4474.97,102,,,Fee Schedule,102% of WV Medicaid Rate,12662.69,165,,,Fee Schedule,165% of CMS OPPS Rate,7953.81,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,22043.54,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,30230.97,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,37867.35,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,4387.23,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,7674.35,100,,,Fee Schedule,100% of CMS OPPS Rate,7953.81,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,137.87,14,,,percent of total billed charges,14% of total billed charges,137.87,37867.35,
33216-Lead Insertion RA no generator,3431761,CDM,481,RC,33216,HCPCS,Outpatient,,,984.75,492.38,,738.56,75,,,percent of total billed charges,75% of total billed charges,738.56,75,,,percent of total billed charges,75% of total billed charges,7674.35,100,,,Fee Schedule,100% of CMS OPPS Rate,4474.97,102,,,Fee Schedule,102% of WV Medicaid Rate,12662.69,165,,,Fee Schedule,165% of CMS OPPS Rate,7953.81,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,22043.54,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,30230.97,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,37867.35,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,4387.23,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,7674.35,100,,,Fee Schedule,100% of CMS OPPS Rate,7953.81,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,137.87,14,,,percent of total billed charges,14% of total billed charges,137.87,37867.35,
33216-Lead Insertion RV no generator,3431762,CDM,481,RC,33216,HCPCS,Outpatient,,,984.75,492.38,,738.56,75,,,percent of total billed charges,75% of total billed charges,738.56,75,,,percent of total billed charges,75% of total billed charges,7674.35,100,,,Fee Schedule,100% of CMS OPPS Rate,4474.97,102,,,Fee Schedule,102% of WV Medicaid Rate,12662.69,165,,,Fee Schedule,165% of CMS OPPS Rate,7953.81,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,22043.54,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,30230.97,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,37867.35,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,4387.23,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,7674.35,100,,,Fee Schedule,100% of CMS OPPS Rate,7953.81,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,137.87,14,,,percent of total billed charges,14% of total billed charges,137.87,37867.35,
33216-Lead Revision LV or Multiples,3431763,CDM,481,RC,33216,HCPCS,Outpatient,,,984.75,492.38,,738.56,75,,,percent of total billed charges,75% of total billed charges,738.56,75,,,percent of total billed charges,75% of total billed charges,7674.35,100,,,Fee Schedule,100% of CMS OPPS Rate,4474.97,102,,,Fee Schedule,102% of WV Medicaid Rate,12662.69,165,,,Fee Schedule,165% of CMS OPPS Rate,7953.81,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,22043.54,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,30230.97,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,37867.35,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,4387.23,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,7674.35,100,,,Fee Schedule,100% of CMS OPPS Rate,7953.81,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,137.87,14,,,percent of total billed charges,14% of total billed charges,137.87,37867.35,
33216-Lead Revision RA or Multiples,3431764,CDM,481,RC,33216,HCPCS,Outpatient,,,984.75,492.38,,738.56,75,,,percent of total billed charges,75% of total billed charges,738.56,75,,,percent of total billed charges,75% of total billed charges,7674.35,100,,,Fee Schedule,100% of CMS OPPS Rate,4474.97,102,,,Fee Schedule,102% of WV Medicaid Rate,12662.69,165,,,Fee Schedule,165% of CMS OPPS Rate,7953.81,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,22043.54,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,30230.97,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,37867.35,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,4387.23,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,7674.35,100,,,Fee Schedule,100% of CMS OPPS Rate,7953.81,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,137.87,14,,,percent of total billed charges,14% of total billed charges,137.87,37867.35,
33216-Lead Revision RV or Multiples,3431765,CDM,481,RC,33216,HCPCS,Outpatient,,,984.75,492.38,,738.56,75,,,percent of total billed charges,75% of total billed charges,738.56,75,,,percent of total billed charges,75% of total billed charges,7674.35,100,,,Fee Schedule,100% of CMS OPPS Rate,4474.97,102,,,Fee Schedule,102% of WV Medicaid Rate,12662.69,165,,,Fee Schedule,165% of CMS OPPS Rate,7953.81,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,22043.54,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,30230.97,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,37867.35,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,4387.23,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,7674.35,100,,,Fee Schedule,100% of CMS OPPS Rate,7953.81,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,137.87,14,,,percent of total billed charges,14% of total billed charges,137.87,37867.35,
Lead Insertion RA no generator,,,761,RC,33216,HCPCS,Outpatient,,,968.08,484.04,,726.06,75,,,percent of total billed charges,75% of total billed charges,726.06,75,,,percent of total billed charges,75% of total billed charges,7674.35,100,,,Fee Schedule,100% of CMS OPPS Rate,4474.97,102,,,Fee Schedule,102% of WV Medicaid Rate,12662.69,165,,,Fee Schedule,165% of CMS OPPS Rate,7953.81,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,22043.54,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,30230.97,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,37867.35,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,4387.23,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,7674.35,100,,,Fee Schedule,100% of CMS OPPS Rate,7953.81,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,135.53,14,,,percent of total billed charges,14% of total billed charges,135.53,37867.35,
Lead Insertion RV no generator,,,761,RC,33216,HCPCS,Outpatient,,,968.08,484.04,,726.06,75,,,percent of total billed charges,75% of total billed charges,726.06,75,,,percent of total billed charges,75% of total billed charges,7674.35,100,,,Fee Schedule,100% of CMS OPPS Rate,4474.97,102,,,Fee Schedule,102% of WV Medicaid Rate,12662.69,165,,,Fee Schedule,165% of CMS OPPS Rate,7953.81,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,22043.54,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,30230.97,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,37867.35,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,4387.23,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,7674.35,100,,,Fee Schedule,100% of CMS OPPS Rate,7953.81,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,135.53,14,,,percent of total billed charges,14% of total billed charges,135.53,37867.35,
Repositioning of Single AICD Lead,604651,CDM,481,RC,33216,HCPCS,Outpatient,,,968.08,484.04,,726.06,75,,,percent of total billed charges,75% of total billed charges,726.06,75,,,percent of total billed charges,75% of total billed charges,7674.35,100,,,Fee Schedule,100% of CMS OPPS Rate,4474.97,102,,,Fee Schedule,102% of WV Medicaid Rate,12662.69,165,,,Fee Schedule,165% of CMS OPPS Rate,7953.81,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,22043.54,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,30230.97,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,37867.35,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,4387.23,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,7674.35,100,,,Fee Schedule,100% of CMS OPPS Rate,7953.81,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,135.53,14,,,percent of total billed charges,14% of total billed charges,135.53,37867.35,
33217- Ins 2 trans ven electrodes PPM/ICD,3430634,CDM,481,RC,33217,HCPCS,Outpatient,,,976.16,488.08,,732.12,75,,,percent of total billed charges,75% of total billed charges,732.12,75,,,percent of total billed charges,75% of total billed charges,7674.35,100,,,Fee Schedule,100% of CMS OPPS Rate,5764.01,102,,,Fee Schedule,102% of WV Medicaid Rate,12662.69,165,,,Fee Schedule,165% of CMS OPPS Rate,7953.81,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,22043.54,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,30230.97,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,37867.35,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,5650.99,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,7674.35,100,,,Fee Schedule,100% of CMS OPPS Rate,7953.81,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,136.66,14,,,percent of total billed charges,14% of total billed charges,136.66,37867.35,
33217-Lead Insertion dual no generator,3431766,CDM,481,RC,33217,HCPCS,Outpatient,,,976.16,488.08,,732.12,75,,,percent of total billed charges,75% of total billed charges,732.12,75,,,percent of total billed charges,75% of total billed charges,7674.35,100,,,Fee Schedule,100% of CMS OPPS Rate,5764.01,102,,,Fee Schedule,102% of WV Medicaid Rate,12662.69,165,,,Fee Schedule,165% of CMS OPPS Rate,7953.81,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,22043.54,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,30230.97,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,37867.35,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,5650.99,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,7674.35,100,,,Fee Schedule,100% of CMS OPPS Rate,7953.81,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,136.66,14,,,percent of total billed charges,14% of total billed charges,136.66,37867.35,
33217-Lead Insertion multiple no generator,3431767,CDM,481,RC,33217,HCPCS,Outpatient,,,976.16,488.08,,732.12,75,,,percent of total billed charges,75% of total billed charges,732.12,75,,,percent of total billed charges,75% of total billed charges,7674.35,100,,,Fee Schedule,100% of CMS OPPS Rate,5764.01,102,,,Fee Schedule,102% of WV Medicaid Rate,12662.69,165,,,Fee Schedule,165% of CMS OPPS Rate,7953.81,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,22043.54,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,30230.97,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,37867.35,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,5650.99,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,7674.35,100,,,Fee Schedule,100% of CMS OPPS Rate,7953.81,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,136.66,14,,,percent of total billed charges,14% of total billed charges,136.66,37867.35,
Lead Insertion dual no generator,,,761,RC,33217,HCPCS,Outpatient,,,958.82,479.41,,719.12,75,,,percent of total billed charges,75% of total billed charges,719.12,75,,,percent of total billed charges,75% of total billed charges,7674.35,100,,,Fee Schedule,100% of CMS OPPS Rate,5764.01,102,,,Fee Schedule,102% of WV Medicaid Rate,12662.69,165,,,Fee Schedule,165% of CMS OPPS Rate,7953.81,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,22043.54,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,30230.97,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,37867.35,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,5650.99,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,7674.35,100,,,Fee Schedule,100% of CMS OPPS Rate,7953.81,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,134.23,14,,,percent of total billed charges,14% of total billed charges,134.23,37867.35,
33218- Repair single lead PPM/ICD,3430835,CDM,510,RC,33218,HCPCS,Outpatient,,,1028.9,514.45,,771.68,75,,,percent of total billed charges,75% of total billed charges,771.68,75,,,percent of total billed charges,75% of total billed charges,3150.43,100,,,Fee Schedule,100% of CMS OPPS Rate,1405.55,102,,,Fee Schedule,102% of WV Medicaid Rate,5198.2,165,,,Fee Schedule,165% of CMS OPPS Rate,3265.15,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,9049.17,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,12410.22,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,15545.07,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1377.99,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,3150.43,100,,,Fee Schedule,100% of CMS OPPS Rate,3265.15,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,144.05,14,,,percent of total billed charges,14% of total billed charges,144.05,15545.07,
"33218-PF Repair of single transvenous electrode, pacemaker or ICD",4271244,CDM,960,RC,33218,HCPCS,Outpatient,,,810.71,405.36,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
"33218-Repair of single transvenous electrode, pacemaker or ICD",4271243,CDM,481,RC,33218,HCPCS,Outpatient,,,810.71,405.36,,608.03,75,,,percent of total billed charges,75% of total billed charges,608.03,75,,,percent of total billed charges,75% of total billed charges,3150.43,100,,,Fee Schedule,100% of CMS OPPS Rate,1405.55,102,,,Fee Schedule,102% of WV Medicaid Rate,5198.2,165,,,Fee Schedule,165% of CMS OPPS Rate,3265.15,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,9049.17,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,12410.22,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,15545.07,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1377.99,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,3150.43,100,,,Fee Schedule,100% of CMS OPPS Rate,3265.15,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,113.5,14,,,percent of total billed charges,14% of total billed charges,113.5,15545.07,
"Repair of single transvenous electrode, pacemaker or ICD",4271245,CDM,761,RC,33218,HCPCS,Outpatient,,,810.71,405.36,,608.03,75,,,percent of total billed charges,75% of total billed charges,608.03,75,,,percent of total billed charges,75% of total billed charges,3150.43,100,,,Fee Schedule,100% of CMS OPPS Rate,1405.55,102,,,Fee Schedule,102% of WV Medicaid Rate,5198.2,165,,,Fee Schedule,165% of CMS OPPS Rate,3265.15,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,9049.17,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,12410.22,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,15545.07,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1377.99,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,3150.43,100,,,Fee Schedule,100% of CMS OPPS Rate,3265.15,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,113.5,14,,,percent of total billed charges,14% of total billed charges,113.5,15545.07,
33220- Repair 2 leads PPM/ICD,3430836,CDM,510,RC,33220,HCPCS,Outpatient,,,1003.08,501.54,,752.31,75,,,percent of total billed charges,75% of total billed charges,752.31,75,,,percent of total billed charges,75% of total billed charges,3150.43,100,,,Fee Schedule,100% of CMS OPPS Rate,1878,102,,,Fee Schedule,102% of WV Medicaid Rate,5198.2,165,,,Fee Schedule,165% of CMS OPPS Rate,3265.15,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,9049.17,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,12410.22,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,15545.07,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1841.18,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,3150.43,100,,,Fee Schedule,100% of CMS OPPS Rate,3265.15,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,140.43,14,,,percent of total billed charges,14% of total billed charges,140.43,15545.07,
"33220-PF Repair of 2 transvenous electrodes, pacemaker or ICD",4271247,CDM,960,RC,33220,HCPCS,Outpatient,,,786.1,393.05,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
"33220-Repair of 2 transvenous electrodes, pacemaker or ICD",4271246,CDM,481,RC,33220,HCPCS,Outpatient,,,786.1,393.05,,589.58,75,,,percent of total billed charges,75% of total billed charges,589.58,75,,,percent of total billed charges,75% of total billed charges,3150.43,100,,,Fee Schedule,100% of CMS OPPS Rate,1878,102,,,Fee Schedule,102% of WV Medicaid Rate,5198.2,165,,,Fee Schedule,165% of CMS OPPS Rate,3265.15,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,9049.17,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,12410.22,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,15545.07,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1841.18,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,3150.43,100,,,Fee Schedule,100% of CMS OPPS Rate,3265.15,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,110.05,14,,,percent of total billed charges,14% of total billed charges,110.05,15545.07,
"Repair of 2 transvenous electrodes, pacemaker or ICD",4271248,CDM,761,RC,33220,HCPCS,Outpatient,,,786.1,393.05,,589.58,75,,,percent of total billed charges,75% of total billed charges,589.58,75,,,percent of total billed charges,75% of total billed charges,3150.43,100,,,Fee Schedule,100% of CMS OPPS Rate,1878,102,,,Fee Schedule,102% of WV Medicaid Rate,5198.2,165,,,Fee Schedule,165% of CMS OPPS Rate,3265.15,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,9049.17,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,12410.22,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,15545.07,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1841.18,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,3150.43,100,,,Fee Schedule,100% of CMS OPPS Rate,3265.15,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,110.05,14,,,percent of total billed charges,14% of total billed charges,110.05,15545.07,
33221-Insert Generator  Biventricular,3431768,CDM,481,RC,33221,HCPCS,Outpatient,,,957.15,478.58,,717.86,75,,,percent of total billed charges,75% of total billed charges,717.86,75,,,percent of total billed charges,75% of total billed charges,17554.78,100,,,Fee Schedule,100% of CMS OPPS Rate,9730.78,102,,,Fee Schedule,102% of WV Medicaid Rate,28965.4,165,,,Fee Schedule,165% of CMS OPPS Rate,18194.05,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,50423.74,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,69152.14,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,86620.07,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,9539.98,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,17554.78,100,,,Fee Schedule,100% of CMS OPPS Rate,18194.05,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,134,14,,,percent of total billed charges,14% of total billed charges,134,86620.07,
33221-Pacemaker Change Biventricular,3431769,CDM,481,RC,33221,HCPCS,Outpatient,,,957.15,478.58,,717.86,75,,,percent of total billed charges,75% of total billed charges,717.86,75,,,percent of total billed charges,75% of total billed charges,17554.78,100,,,Fee Schedule,100% of CMS OPPS Rate,9730.78,102,,,Fee Schedule,102% of WV Medicaid Rate,28965.4,165,,,Fee Schedule,165% of CMS OPPS Rate,18194.05,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,50423.74,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,69152.14,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,86620.07,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,9539.98,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,17554.78,100,,,Fee Schedule,100% of CMS OPPS Rate,18194.05,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,134,14,,,percent of total billed charges,14% of total billed charges,134,86620.07,
Insert Generator Biventricular,3427150,CDM,960,RC,33221,HCPCS,Outpatient,,,935.61,467.81,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
Pacemaker Change Biventricular,3427130,CDM,960,RC,33221,HCPCS,Outpatient,,,935.61,467.81,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
33222- Relocate skin pocket/PPM,3430635,CDM,481,RC,33222,HCPCS,Outpatient,,,900.06,450.03,,675.05,75,,,percent of total billed charges,75% of total billed charges,675.05,75,,,percent of total billed charges,75% of total billed charges,1622.59,100,,,Fee Schedule,100% of CMS OPPS Rate,699.11,102,,,Fee Schedule,102% of WV Medicaid Rate,2677.27,165,,,Fee Schedule,165% of CMS OPPS Rate,1681.67,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4660.68,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,6391.75,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,8006.31,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,685.4,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1622.59,100,,,Fee Schedule,100% of CMS OPPS Rate,1681.67,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,126.01,14,,,percent of total billed charges,14% of total billed charges,126.01,8006.31,
33222-PF Pocket Relocation- Pacemaker,3882894,CDM,960,RC,33222,HCPCS,Outpatient,,,900.06,450.03,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
33222-Pocket Relocation- Pacemaker,3882893,CDM,481,RC,33222,HCPCS,Outpatient,,,900.06,450.03,,675.05,75,,,percent of total billed charges,75% of total billed charges,675.05,75,,,percent of total billed charges,75% of total billed charges,1622.59,100,,,Fee Schedule,100% of CMS OPPS Rate,699.11,102,,,Fee Schedule,102% of WV Medicaid Rate,2677.27,165,,,Fee Schedule,165% of CMS OPPS Rate,1681.67,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4660.68,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,6391.75,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,8006.31,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,685.4,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1622.59,100,,,Fee Schedule,100% of CMS OPPS Rate,1681.67,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,126.01,14,,,percent of total billed charges,14% of total billed charges,126.01,8006.31,
Pocket Relocation- Pacemaker,,,761,RC,33222,HCPCS,Outpatient,,,886.53,443.27,,664.9,75,,,percent of total billed charges,75% of total billed charges,664.9,75,,,percent of total billed charges,75% of total billed charges,1622.59,100,,,Fee Schedule,100% of CMS OPPS Rate,699.11,102,,,Fee Schedule,102% of WV Medicaid Rate,2677.27,165,,,Fee Schedule,165% of CMS OPPS Rate,1681.67,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4660.68,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,6391.75,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,8006.31,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,685.4,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1622.59,100,,,Fee Schedule,100% of CMS OPPS Rate,1681.67,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,124.11,14,,,percent of total billed charges,14% of total billed charges,124.11,8006.31,
33223- Relocate skin pocket/ICD,3430636,CDM,510,RC,33223,HCPCS,Outpatient,,,1086.77,543.39,,815.08,75,,,percent of total billed charges,75% of total billed charges,815.08,75,,,percent of total billed charges,75% of total billed charges,1622.59,100,,,Fee Schedule,100% of CMS OPPS Rate,699.11,102,,,Fee Schedule,102% of WV Medicaid Rate,2677.27,165,,,Fee Schedule,165% of CMS OPPS Rate,1681.67,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4660.68,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,6391.75,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,8006.31,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,685.4,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1622.59,100,,,Fee Schedule,100% of CMS OPPS Rate,1681.67,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,152.15,14,,,percent of total billed charges,14% of total billed charges,152.15,8006.31,
33223-PF Relocation/revision of ICD pocket,3872930,CDM,960,RC,33223,HCPCS,Outpatient,,,1086.77,543.39,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
33223-Relocation/revision of ICD pocket,3872928,CDM,481,RC,33223,HCPCS,Outpatient,,,1086.77,543.39,,815.08,75,,,percent of total billed charges,75% of total billed charges,815.08,75,,,percent of total billed charges,75% of total billed charges,1622.59,100,,,Fee Schedule,100% of CMS OPPS Rate,699.11,102,,,Fee Schedule,102% of WV Medicaid Rate,2677.27,165,,,Fee Schedule,165% of CMS OPPS Rate,1681.67,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4660.68,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,6391.75,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,8006.31,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,685.4,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1622.59,100,,,Fee Schedule,100% of CMS OPPS Rate,1681.67,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,152.15,14,,,percent of total billed charges,14% of total billed charges,152.15,8006.31,
Pocket Relocation - ICD,,,761,RC,33223,HCPCS,Outpatient,,,1066.68,533.34,,800.01,75,,,percent of total billed charges,75% of total billed charges,800.01,75,,,percent of total billed charges,75% of total billed charges,1622.59,100,,,Fee Schedule,100% of CMS OPPS Rate,699.11,102,,,Fee Schedule,102% of WV Medicaid Rate,2677.27,165,,,Fee Schedule,165% of CMS OPPS Rate,1681.67,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4660.68,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,6391.75,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,8006.31,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,685.4,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1622.59,100,,,Fee Schedule,100% of CMS OPPS Rate,1681.67,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,149.34,14,,,percent of total billed charges,14% of total billed charges,149.34,8006.31,
33224- Insert LV lead to existing PPM/ICD,3430637,CDM,481,RC,33224,HCPCS,Outpatient,,,1380.75,690.38,,1035.56,75,,,percent of total billed charges,75% of total billed charges,1035.56,75,,,percent of total billed charges,75% of total billed charges,9710.75,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,16022.75,165,,,Fee Schedule,165% of CMS OPPS Rate,10064.37,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,27892.83,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,38252.79,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,47915.5,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,9710.75,100,,,Fee Schedule,100% of CMS OPPS Rate,10064.37,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,193.31,14,,,percent of total billed charges,14% of total billed charges,193.31,47915.5,
33224-BIV LEAD INSERT W OR W/O GEN CHANGE,3431770,CDM,481,RC,33224,HCPCS,Outpatient,,,1380.75,690.38,,1035.56,75,,,percent of total billed charges,75% of total billed charges,1035.56,75,,,percent of total billed charges,75% of total billed charges,9710.75,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,16022.75,165,,,Fee Schedule,165% of CMS OPPS Rate,10064.37,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,27892.83,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,38252.79,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,47915.5,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,9710.75,100,,,Fee Schedule,100% of CMS OPPS Rate,10064.37,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,193.31,14,,,percent of total billed charges,14% of total billed charges,193.31,47915.5,
33224-Lead Insertion LV no generator,3431771,CDM,481,RC,33224,HCPCS,Outpatient,,,1380.75,690.38,,1035.56,75,,,percent of total billed charges,75% of total billed charges,1035.56,75,,,percent of total billed charges,75% of total billed charges,9710.75,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,16022.75,165,,,Fee Schedule,165% of CMS OPPS Rate,10064.37,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,27892.83,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,38252.79,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,47915.5,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,9710.75,100,,,Fee Schedule,100% of CMS OPPS Rate,10064.37,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,193.31,14,,,percent of total billed charges,14% of total billed charges,193.31,47915.5,
33224-Lead Insertion multiple no generator,3431772,CDM,481,RC,33224,HCPCS,Outpatient,,,1380.75,690.38,,1035.56,75,,,percent of total billed charges,75% of total billed charges,1035.56,75,,,percent of total billed charges,75% of total billed charges,9710.75,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,16022.75,165,,,Fee Schedule,165% of CMS OPPS Rate,10064.37,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,27892.83,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,38252.79,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,47915.5,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,9710.75,100,,,Fee Schedule,100% of CMS OPPS Rate,10064.37,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,193.31,14,,,percent of total billed charges,14% of total billed charges,193.31,47915.5,
33224-Pocket Revision,3431773,CDM,481,RC,33224,HCPCS,Outpatient,,,1380.75,690.38,,1035.56,75,,,percent of total billed charges,75% of total billed charges,1035.56,75,,,percent of total billed charges,75% of total billed charges,9710.75,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,16022.75,165,,,Fee Schedule,165% of CMS OPPS Rate,10064.37,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,27892.83,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,38252.79,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,47915.5,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,9710.75,100,,,Fee Schedule,100% of CMS OPPS Rate,10064.37,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,193.31,14,,,percent of total billed charges,14% of total billed charges,193.31,47915.5,
Insertion of LV Lead (Upgrade),604663,CDM,481,RC,33224,HCPCS,Outpatient,,,1353.86,676.93,,1015.4,75,,,percent of total billed charges,75% of total billed charges,1015.4,75,,,percent of total billed charges,75% of total billed charges,9710.75,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,16022.75,165,,,Fee Schedule,165% of CMS OPPS Rate,10064.37,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,27892.83,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,38252.79,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,47915.5,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,9710.75,100,,,Fee Schedule,100% of CMS OPPS Rate,10064.37,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,189.54,14,,,percent of total billed charges,14% of total billed charges,189.54,47915.5,
Lead Insertion LV no generator,,,761,RC,33224,HCPCS,Outpatient,,,1353.86,676.93,,1015.4,75,,,percent of total billed charges,75% of total billed charges,1015.4,75,,,percent of total billed charges,75% of total billed charges,9710.75,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,16022.75,165,,,Fee Schedule,165% of CMS OPPS Rate,10064.37,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,27892.83,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,38252.79,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,47915.5,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,9710.75,100,,,Fee Schedule,100% of CMS OPPS Rate,10064.37,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,189.54,14,,,percent of total billed charges,14% of total billed charges,189.54,47915.5,
Pocket Revision,,,761,RC,33224,HCPCS,Outpatient,,,1353.86,676.93,,1015.4,75,,,percent of total billed charges,75% of total billed charges,1015.4,75,,,percent of total billed charges,75% of total billed charges,9710.75,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,16022.75,165,,,Fee Schedule,165% of CMS OPPS Rate,10064.37,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,27892.83,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,38252.79,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,47915.5,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,9710.75,100,,,Fee Schedule,100% of CMS OPPS Rate,10064.37,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,189.54,14,,,percent of total billed charges,14% of total billed charges,189.54,47915.5,
33225- Insert LV lead w ICD/PPM insert,3431774,CDM,481,RC,33225,HCPCS,Outpatient,,,1257.65,628.83,,943.24,75,,,percent of total billed charges,75% of total billed charges,943.24,75,,,percent of total billed charges,75% of total billed charges,402.45,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,176.07,14,,,percent of total billed charges,14% of total billed charges,176.07,943.24,
33225-BIV LEAD INSERT NEW SYS,3431775,CDM,481,RC,33225,HCPCS,Outpatient,,,1257.65,628.83,,943.24,75,,,percent of total billed charges,75% of total billed charges,943.24,75,,,percent of total billed charges,75% of total billed charges,402.45,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,176.07,14,,,percent of total billed charges,14% of total billed charges,176.07,943.24,
33225-Defibrillator Insertion Biv,3431776,CDM,481,RC,33225,HCPCS,Outpatient,,,1257.65,628.83,,943.24,75,,,percent of total billed charges,75% of total billed charges,943.24,75,,,percent of total billed charges,75% of total billed charges,402.45,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,176.07,14,,,percent of total billed charges,14% of total billed charges,176.07,943.24,
33225-Pacemaker Insertion Biv,3431777,CDM,481,RC,33225,HCPCS,Outpatient,,,1257.65,628.83,,943.24,75,,,percent of total billed charges,75% of total billed charges,943.24,75,,,percent of total billed charges,75% of total billed charges,402.45,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,176.07,14,,,percent of total billed charges,14% of total billed charges,176.07,943.24,
33225-PF Insert LV lead w ICD/PPM insert,3580865,CDM,960,RC,33225,HCPCS,Outpatient,,,1257.65,628.83,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
Bi V Lead (Initial Initial),604669,CDM,481,RC,33225,HCPCS,Outpatient,,,1227.48,613.74,,920.61,75,,,percent of total billed charges,75% of total billed charges,920.61,75,,,percent of total billed charges,75% of total billed charges,392.79,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,171.85,14,,,percent of total billed charges,14% of total billed charges,171.85,920.61,
33226- Repos prev impltd card venous sys electrode,3569474,CDM,481,RC,33226,HCPCS,Outpatient,,,1324.43,662.22,,993.32,75,,,percent of total billed charges,75% of total billed charges,993.32,75,,,percent of total billed charges,75% of total billed charges,2800.71,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,4621.18,165,,,Fee Schedule,165% of CMS OPPS Rate,2902.7,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8044.7,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11032.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13819.53,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,2800.71,100,,,Fee Schedule,100% of CMS OPPS Rate,2902.7,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,185.42,14,,,percent of total billed charges,14% of total billed charges,185.42,13819.53,
"33226-LV Lead Reposition including removal, insert and/or repl. of existing generator",4271118,CDM,481,RC,33226,HCPCS,Outpatient,,,1031.74,515.87,,773.81,75,,,percent of total billed charges,75% of total billed charges,773.81,75,,,percent of total billed charges,75% of total billed charges,2800.71,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,4621.18,165,,,Fee Schedule,165% of CMS OPPS Rate,2902.7,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8044.7,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11032.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13819.53,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,2800.71,100,,,Fee Schedule,100% of CMS OPPS Rate,2902.7,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,144.44,14,,,percent of total billed charges,14% of total billed charges,144.44,13819.53,
"33226-PF LV Lead Reposition including removal, insert and/or repl. of existing generator",4271119,CDM,960,RC,33226,HCPCS,Outpatient,,,1031.74,515.87,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
"LV Lead Reposition including removal, insert and/or repl. of existing generator",,,761,RC,33226,HCPCS,Outpatient,,,1031.74,515.87,,773.81,75,,,percent of total billed charges,75% of total billed charges,773.81,75,,,percent of total billed charges,75% of total billed charges,2800.71,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,4621.18,165,,,Fee Schedule,165% of CMS OPPS Rate,2902.7,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8044.7,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11032.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13819.53,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,2800.71,100,,,Fee Schedule,100% of CMS OPPS Rate,2902.7,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,144.44,14,,,percent of total billed charges,14% of total billed charges,144.44,13819.53,
33227- Remove/replace PM gen only/sg lead,3430837,CDM,481,RC,33227,HCPCS,Outpatient,,,900.5,450.25,,675.38,75,,,percent of total billed charges,75% of total billed charges,675.38,75,,,percent of total billed charges,75% of total billed charges,7674.35,100,,,Fee Schedule,100% of CMS OPPS Rate,5185.65,102,,,Fee Schedule,102% of WV Medicaid Rate,12662.69,165,,,Fee Schedule,165% of CMS OPPS Rate,7953.81,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,22043.54,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,30230.97,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,37867.35,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,5083.97,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,7674.35,100,,,Fee Schedule,100% of CMS OPPS Rate,7953.81,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,126.07,14,,,percent of total billed charges,14% of total billed charges,126.07,37867.35,
33227-REMOVE & INSERT PM GEN SINGLE,3431778,CDM,481,RC,33227,HCPCS,Outpatient,,,900.5,450.25,,675.38,75,,,percent of total billed charges,75% of total billed charges,675.38,75,,,percent of total billed charges,75% of total billed charges,7674.35,100,,,Fee Schedule,100% of CMS OPPS Rate,5185.65,102,,,Fee Schedule,102% of WV Medicaid Rate,12662.69,165,,,Fee Schedule,165% of CMS OPPS Rate,7953.81,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,22043.54,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,30230.97,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,37867.35,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,5083.97,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,7674.35,100,,,Fee Schedule,100% of CMS OPPS Rate,7953.81,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,126.07,14,,,percent of total billed charges,14% of total billed charges,126.07,37867.35,
33228- Remove/replac pacer gen/dual sys,3430638,CDM,481,RC,33228,HCPCS,Outpatient,,,943.63,471.82,,707.72,75,,,percent of total billed charges,75% of total billed charges,707.72,75,,,percent of total billed charges,75% of total billed charges,9710.75,100,,,Fee Schedule,100% of CMS OPPS Rate,6201.91,102,,,Fee Schedule,102% of WV Medicaid Rate,16022.75,165,,,Fee Schedule,165% of CMS OPPS Rate,10064.37,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,27892.83,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,38252.79,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,47915.5,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,6080.3,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,9710.75,100,,,Fee Schedule,100% of CMS OPPS Rate,10064.37,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,132.11,14,,,percent of total billed charges,14% of total billed charges,132.11,47915.5,
33228-Pacemaker Change Dual,3431758,CDM,481,RC,33228,HCPCS,Outpatient,,,943.82,471.91,,707.87,75,,,percent of total billed charges,75% of total billed charges,707.87,75,,,percent of total billed charges,75% of total billed charges,9710.75,100,,,Fee Schedule,100% of CMS OPPS Rate,6201.91,102,,,Fee Schedule,102% of WV Medicaid Rate,16022.75,165,,,Fee Schedule,165% of CMS OPPS Rate,10064.37,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,27892.83,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,38252.79,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,47915.5,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,6080.3,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,9710.75,100,,,Fee Schedule,100% of CMS OPPS Rate,10064.37,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,132.13,14,,,percent of total billed charges,14% of total billed charges,132.13,47915.5,
33228-PF REMOVE & INSERT PM GEN DUAL,3580866,CDM,960,RC,33228,HCPCS,Outpatient,,,943.63,471.82,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
33228-REMOVE & INSERT PM GEN DUAL,3431779,CDM,481,RC,33228,HCPCS,Outpatient,,,943.63,471.82,,707.72,75,,,percent of total billed charges,75% of total billed charges,707.72,75,,,percent of total billed charges,75% of total billed charges,9710.75,100,,,Fee Schedule,100% of CMS OPPS Rate,6201.91,102,,,Fee Schedule,102% of WV Medicaid Rate,16022.75,165,,,Fee Schedule,165% of CMS OPPS Rate,10064.37,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,27892.83,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,38252.79,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,47915.5,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,6080.3,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,9710.75,100,,,Fee Schedule,100% of CMS OPPS Rate,10064.37,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,132.11,14,,,percent of total billed charges,14% of total billed charges,132.11,47915.5,
33228-Remove/Insert PPM Gen Dual,3560670,CDM,481,RC,33228,HCPCS,Outpatient,,,943.63,471.82,,707.72,75,,,percent of total billed charges,75% of total billed charges,707.72,75,,,percent of total billed charges,75% of total billed charges,9710.75,100,,,Fee Schedule,100% of CMS OPPS Rate,6201.91,102,,,Fee Schedule,102% of WV Medicaid Rate,16022.75,165,,,Fee Schedule,165% of CMS OPPS Rate,10064.37,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,27892.83,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,38252.79,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,47915.5,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,6080.3,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,9710.75,100,,,Fee Schedule,100% of CMS OPPS Rate,10064.37,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,132.11,14,,,percent of total billed charges,14% of total billed charges,132.11,47915.5,
33229- Remov/replac PM gen only/mult lead,3430838,CDM,481,RC,33229,HCPCS,Outpatient,,,995.34,497.67,,746.51,75,,,percent of total billed charges,75% of total billed charges,746.51,75,,,percent of total billed charges,75% of total billed charges,17554.78,100,,,Fee Schedule,100% of CMS OPPS Rate,9690.99,102,,,Fee Schedule,102% of WV Medicaid Rate,28965.4,165,,,Fee Schedule,165% of CMS OPPS Rate,18194.05,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,50423.74,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,69152.14,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,86620.07,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,9500.97,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,17554.78,100,,,Fee Schedule,100% of CMS OPPS Rate,18194.05,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,139.35,14,,,percent of total billed charges,14% of total billed charges,139.35,86620.07,
33229-REMOVE & INSERT PM GEN MULTI,3431780,CDM,481,RC,33229,HCPCS,Outpatient,,,995.34,497.67,,746.51,75,,,percent of total billed charges,75% of total billed charges,746.51,75,,,percent of total billed charges,75% of total billed charges,17554.78,100,,,Fee Schedule,100% of CMS OPPS Rate,9690.99,102,,,Fee Schedule,102% of WV Medicaid Rate,28965.4,165,,,Fee Schedule,165% of CMS OPPS Rate,18194.05,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,50423.74,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,69152.14,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,86620.07,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,9500.97,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,17554.78,100,,,Fee Schedule,100% of CMS OPPS Rate,18194.05,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,139.35,14,,,percent of total billed charges,14% of total billed charges,139.35,86620.07,
33230-Defibrillator Change Dual,3431781,CDM,481,RC,33230,HCPCS,Outpatient,,,1022.19,511.1,,766.64,75,,,percent of total billed charges,75% of total billed charges,766.64,75,,,percent of total billed charges,75% of total billed charges,21453.01,100,,,Fee Schedule,100% of CMS OPPS Rate,16756,102,,,Fee Schedule,102% of WV Medicaid Rate,35397.47,165,,,Fee Schedule,165% of CMS OPPS Rate,22234.22,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,61620.84,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,84508.08,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,105854.94,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,16427.45,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,21453.01,100,,,Fee Schedule,100% of CMS OPPS Rate,22234.22,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,143.11,14,,,percent of total billed charges,14% of total billed charges,143.11,105854.94,
Defibrillator Change Dual,,,761,RC,33230,HCPCS,Outpatient,,,1000.22,500.11,,750.17,75,,,percent of total billed charges,75% of total billed charges,750.17,75,,,percent of total billed charges,75% of total billed charges,21453.01,100,,,Fee Schedule,100% of CMS OPPS Rate,16756,102,,,Fee Schedule,102% of WV Medicaid Rate,35397.47,165,,,Fee Schedule,165% of CMS OPPS Rate,22234.22,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,61620.84,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,84508.08,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,105854.94,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,16427.45,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,21453.01,100,,,Fee Schedule,100% of CMS OPPS Rate,22234.22,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,140.03,14,,,percent of total billed charges,14% of total billed charges,140.03,105854.94,
33231-Defibrillator Change Biv,3431782,CDM,481,RC,33231,HCPCS,Outpatient,,,1061.72,530.86,,796.29,75,,,percent of total billed charges,75% of total billed charges,796.29,75,,,percent of total billed charges,75% of total billed charges,30157.08,100,,,Fee Schedule,100% of CMS OPPS Rate,21559.81,102,,,Fee Schedule,102% of WV Medicaid Rate,49759.19,165,,,Fee Schedule,165% of CMS OPPS Rate,31255.24,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,86622.1,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,118795.29,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,148803.15,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,21137.07,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,30157.08,100,,,Fee Schedule,100% of CMS OPPS Rate,31255.24,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,148.64,14,,,percent of total billed charges,14% of total billed charges,148.64,148803.15,
Defibrillator Change Biv,,,761,RC,33231,HCPCS,Outpatient,,,1042.51,521.26,,781.88,75,,,percent of total billed charges,75% of total billed charges,781.88,75,,,percent of total billed charges,75% of total billed charges,30157.08,100,,,Fee Schedule,100% of CMS OPPS Rate,21559.81,102,,,Fee Schedule,102% of WV Medicaid Rate,49759.19,165,,,Fee Schedule,165% of CMS OPPS Rate,31255.24,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,86622.1,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,118795.29,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,148803.15,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,21137.07,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,30157.08,100,,,Fee Schedule,100% of CMS OPPS Rate,31255.24,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,145.95,14,,,percent of total billed charges,14% of total billed charges,145.95,148803.15,
33233- Remove PPM generator only,3430639,CDM,481,RC,33233,HCPCS,Outpatient,,,611.09,305.55,,458.32,75,,,percent of total billed charges,75% of total billed charges,458.32,75,,,percent of total billed charges,75% of total billed charges,7674.36,100,,,Fee Schedule,100% of CMS OPPS Rate,4637.57,102,,,Fee Schedule,102% of WV Medicaid Rate,12662.7,165,,,Fee Schedule,165% of CMS OPPS Rate,7953.82,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,22043.55,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,30230.97,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,37867.36,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,4546.64,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,7674.36,100,,,Fee Schedule,100% of CMS OPPS Rate,7953.82,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,85.55,14,,,percent of total billed charges,14% of total billed charges,85.55,37867.36,
33233-PF Remove PPM generator only,3580867,CDM,960,RC,33233,HCPCS,Outpatient,,,611.09,305.55,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
33233-Remove PPM generator only,3562983,CDM,481,RC,33233,HCPCS,Outpatient,,,611.09,305.55,,458.32,75,,,percent of total billed charges,75% of total billed charges,458.32,75,,,percent of total billed charges,75% of total billed charges,7674.36,100,,,Fee Schedule,100% of CMS OPPS Rate,4637.57,102,,,Fee Schedule,102% of WV Medicaid Rate,12662.7,165,,,Fee Schedule,165% of CMS OPPS Rate,7953.82,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,22043.55,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,30230.97,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,37867.36,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,4546.64,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,7674.36,100,,,Fee Schedule,100% of CMS OPPS Rate,7953.82,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,85.55,14,,,percent of total billed charges,14% of total billed charges,85.55,37867.36,
Removal of Pacemaker,604673,CDM,481,RC,33233,HCPCS,Outpatient,,,601.34,300.67,,451.01,75,,,percent of total billed charges,75% of total billed charges,451.01,75,,,percent of total billed charges,75% of total billed charges,7674.36,100,,,Fee Schedule,100% of CMS OPPS Rate,4637.57,102,,,Fee Schedule,102% of WV Medicaid Rate,12662.7,165,,,Fee Schedule,165% of CMS OPPS Rate,7953.82,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,22043.55,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,30230.97,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,37867.36,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,4546.64,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,7674.36,100,,,Fee Schedule,100% of CMS OPPS Rate,7953.82,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,84.19,14,,,percent of total billed charges,14% of total billed charges,84.19,37867.36,
33234-Lead Revision LV or Multiples,3431783,CDM,481,RC,33234,HCPCS,Outpatient,,,1289.53,644.77,,967.15,75,,,percent of total billed charges,75% of total billed charges,967.15,75,,,percent of total billed charges,75% of total billed charges,3150.43,100,,,Fee Schedule,100% of CMS OPPS Rate,1880.2,102,,,Fee Schedule,102% of WV Medicaid Rate,5198.21,165,,,Fee Schedule,165% of CMS OPPS Rate,3265.15,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,9049.18,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,12410.23,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,15545.07,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1843.33,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,3150.43,100,,,Fee Schedule,100% of CMS OPPS Rate,3265.15,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,180.53,14,,,percent of total billed charges,14% of total billed charges,180.53,15545.07,
33234-Lead Revision RA or Multiples,3431784,CDM,481,RC,33234,HCPCS,Outpatient,,,1289.53,644.77,,967.15,75,,,percent of total billed charges,75% of total billed charges,967.15,75,,,percent of total billed charges,75% of total billed charges,3150.43,100,,,Fee Schedule,100% of CMS OPPS Rate,1880.2,102,,,Fee Schedule,102% of WV Medicaid Rate,5198.21,165,,,Fee Schedule,165% of CMS OPPS Rate,3265.15,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,9049.18,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,12410.23,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,15545.07,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1843.33,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,3150.43,100,,,Fee Schedule,100% of CMS OPPS Rate,3265.15,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,180.53,14,,,percent of total billed charges,14% of total billed charges,180.53,15545.07,
33234-Lead Revision RV or Multiples,3431785,CDM,481,RC,33234,HCPCS,Outpatient,,,1289.53,644.77,,967.15,75,,,percent of total billed charges,75% of total billed charges,967.15,75,,,percent of total billed charges,75% of total billed charges,3150.43,100,,,Fee Schedule,100% of CMS OPPS Rate,1880.2,102,,,Fee Schedule,102% of WV Medicaid Rate,5198.21,165,,,Fee Schedule,165% of CMS OPPS Rate,3265.15,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,9049.18,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,12410.23,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,15545.07,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1843.33,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,3150.43,100,,,Fee Schedule,100% of CMS OPPS Rate,3265.15,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,180.53,14,,,percent of total billed charges,14% of total billed charges,180.53,15545.07,
33234-PM LEAD-REMOVAL OF SINGLE TRANS EXT,3431786,CDM,481,RC,33234,HCPCS,Outpatient,,,1289.53,644.77,,967.15,75,,,percent of total billed charges,75% of total billed charges,967.15,75,,,percent of total billed charges,75% of total billed charges,3150.43,100,,,Fee Schedule,100% of CMS OPPS Rate,1880.2,102,,,Fee Schedule,102% of WV Medicaid Rate,5198.21,165,,,Fee Schedule,165% of CMS OPPS Rate,3265.15,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,9049.18,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,12410.23,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,15545.07,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1843.33,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,3150.43,100,,,Fee Schedule,100% of CMS OPPS Rate,3265.15,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,180.53,14,,,percent of total billed charges,14% of total billed charges,180.53,15545.07,
Device Extraction,,,761,RC,33234,HCPCS,Outpatient,,,1264.61,632.31,,948.46,75,,,percent of total billed charges,75% of total billed charges,948.46,75,,,percent of total billed charges,75% of total billed charges,3150.43,100,,,Fee Schedule,100% of CMS OPPS Rate,1880.2,102,,,Fee Schedule,102% of WV Medicaid Rate,5198.21,165,,,Fee Schedule,165% of CMS OPPS Rate,3265.15,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,9049.18,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,12410.23,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,15545.07,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1843.33,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,3150.43,100,,,Fee Schedule,100% of CMS OPPS Rate,3265.15,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,177.05,14,,,percent of total billed charges,14% of total billed charges,177.05,15545.07,
Lead Revision LV or Multiples,,,761,RC,33234,HCPCS,Outpatient,,,1264.61,632.31,,948.46,75,,,percent of total billed charges,75% of total billed charges,948.46,75,,,percent of total billed charges,75% of total billed charges,3150.43,100,,,Fee Schedule,100% of CMS OPPS Rate,1880.2,102,,,Fee Schedule,102% of WV Medicaid Rate,5198.21,165,,,Fee Schedule,165% of CMS OPPS Rate,3265.15,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,9049.18,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,12410.23,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,15545.07,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1843.33,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,3150.43,100,,,Fee Schedule,100% of CMS OPPS Rate,3265.15,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,177.05,14,,,percent of total billed charges,14% of total billed charges,177.05,15545.07,
Lead Revision RA or Multiples,,,761,RC,33234,HCPCS,Outpatient,,,1264.61,632.31,,948.46,75,,,percent of total billed charges,75% of total billed charges,948.46,75,,,percent of total billed charges,75% of total billed charges,3150.43,100,,,Fee Schedule,100% of CMS OPPS Rate,1880.2,102,,,Fee Schedule,102% of WV Medicaid Rate,5198.21,165,,,Fee Schedule,165% of CMS OPPS Rate,3265.15,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,9049.18,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,12410.23,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,15545.07,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1843.33,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,3150.43,100,,,Fee Schedule,100% of CMS OPPS Rate,3265.15,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,177.05,14,,,percent of total billed charges,14% of total billed charges,177.05,15545.07,
Lead Revision RV or Multiples,,,761,RC,33234,HCPCS,Outpatient,,,1264.61,632.31,,948.46,75,,,percent of total billed charges,75% of total billed charges,948.46,75,,,percent of total billed charges,75% of total billed charges,3150.43,100,,,Fee Schedule,100% of CMS OPPS Rate,1880.2,102,,,Fee Schedule,102% of WV Medicaid Rate,5198.21,165,,,Fee Schedule,165% of CMS OPPS Rate,3265.15,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,9049.18,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,12410.23,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,15545.07,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1843.33,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,3150.43,100,,,Fee Schedule,100% of CMS OPPS Rate,3265.15,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,177.05,14,,,percent of total billed charges,14% of total billed charges,177.05,15545.07,
Removal of Single Lead,604675,CDM,481,RC,33234,HCPCS,Outpatient,,,1264.61,632.31,,948.46,75,,,percent of total billed charges,75% of total billed charges,948.46,75,,,percent of total billed charges,75% of total billed charges,3150.43,100,,,Fee Schedule,100% of CMS OPPS Rate,1880.2,102,,,Fee Schedule,102% of WV Medicaid Rate,5198.21,165,,,Fee Schedule,165% of CMS OPPS Rate,3265.15,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,9049.18,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,12410.23,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,15545.07,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1843.33,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,3150.43,100,,,Fee Schedule,100% of CMS OPPS Rate,3265.15,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,177.05,14,,,percent of total billed charges,14% of total billed charges,177.05,15545.07,
33235-PF PPM Lead Removal- Dual,3580868,CDM,960,RC,33235,HCPCS,Outpatient,,,1692.62,846.31,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
33235-PPM Lead Removal- Dual,3570627,CDM,481,RC,33235,HCPCS,Outpatient,,,1692.62,846.31,,1269.47,75,,,percent of total billed charges,75% of total billed charges,1269.47,75,,,percent of total billed charges,75% of total billed charges,3150.43,100,,,Fee Schedule,100% of CMS OPPS Rate,1844.48,102,,,Fee Schedule,102% of WV Medicaid Rate,5198.21,165,,,Fee Schedule,165% of CMS OPPS Rate,3265.15,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,9049.18,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,12410.23,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,15545.07,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1808.31,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,3150.43,100,,,Fee Schedule,100% of CMS OPPS Rate,3265.15,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,236.97,14,,,percent of total billed charges,14% of total billed charges,236.97,15545.07,
Removal of Dual Leads,604677,CDM,481,RC,33235,HCPCS,Outpatient,,,1662.32,831.16,,1246.74,75,,,percent of total billed charges,75% of total billed charges,1246.74,75,,,percent of total billed charges,75% of total billed charges,3150.43,100,,,Fee Schedule,100% of CMS OPPS Rate,1844.48,102,,,Fee Schedule,102% of WV Medicaid Rate,5198.21,165,,,Fee Schedule,165% of CMS OPPS Rate,3265.15,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,9049.18,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,12410.23,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,15545.07,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1808.31,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,3150.43,100,,,Fee Schedule,100% of CMS OPPS Rate,3265.15,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,232.72,14,,,percent of total billed charges,14% of total billed charges,232.72,15545.07,
33238 - (PF) Removal of permanent transvenous electrode(s) by thoracotomy,3634898,CDM,510,RC,33238,HCPCS,Outpatient,,,2521.79,1260.9,,1891.34,75,,,percent of total billed charges,75% of total billed charges,1891.34,75,,,percent of total billed charges,75% of total billed charges,2521.79,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,2521.79,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2521.79,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2521.79,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2521.79,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2521.79,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,2521.79,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2521.79,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,353.05,14,,,percent of total billed charges,14% of total billed charges,353.05,2521.79,
33240- Insert ICD gen only/exist sng lead,3430640,CDM,481,RC,33240,HCPCS,Outpatient,,,976.66,488.33,,732.5,75,,,percent of total billed charges,75% of total billed charges,732.5,75,,,percent of total billed charges,75% of total billed charges,21453.01,100,,,Fee Schedule,100% of CMS OPPS Rate,16421.81,102,,,Fee Schedule,102% of WV Medicaid Rate,35397.47,165,,,Fee Schedule,165% of CMS OPPS Rate,22234.22,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,61620.84,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,84508.08,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,105854.94,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,16099.81,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,21453.01,100,,,Fee Schedule,100% of CMS OPPS Rate,22234.22,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,136.73,14,,,percent of total billed charges,14% of total billed charges,136.73,105854.94,
33240-Defibrillator Change Single,3431787,CDM,481,RC,33240,HCPCS,Outpatient,,,976.66,488.33,,732.5,75,,,percent of total billed charges,75% of total billed charges,732.5,75,,,percent of total billed charges,75% of total billed charges,21453.01,100,,,Fee Schedule,100% of CMS OPPS Rate,16421.81,102,,,Fee Schedule,102% of WV Medicaid Rate,35397.47,165,,,Fee Schedule,165% of CMS OPPS Rate,22234.22,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,61620.84,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,84508.08,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,105854.94,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,16099.81,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,21453.01,100,,,Fee Schedule,100% of CMS OPPS Rate,22234.22,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,136.73,14,,,percent of total billed charges,14% of total billed charges,136.73,105854.94,
Defibrillator Change Single,,,761,RC,33240,HCPCS,Outpatient,,,956.7,478.35,,717.53,75,,,percent of total billed charges,75% of total billed charges,717.53,75,,,percent of total billed charges,75% of total billed charges,21453.01,100,,,Fee Schedule,100% of CMS OPPS Rate,16421.81,102,,,Fee Schedule,102% of WV Medicaid Rate,35397.47,165,,,Fee Schedule,165% of CMS OPPS Rate,22234.22,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,61620.84,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,84508.08,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,105854.94,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,16099.81,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,21453.01,100,,,Fee Schedule,100% of CMS OPPS Rate,22234.22,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,133.94,14,,,percent of total billed charges,14% of total billed charges,133.94,105854.94,
33241- Remove ICD generator only,3430641,CDM,481,RC,33241,HCPCS,Outpatient,,,566.8,283.4,,425.1,75,,,percent of total billed charges,75% of total billed charges,425.1,75,,,percent of total billed charges,75% of total billed charges,3150.43,100,,,Fee Schedule,100% of CMS OPPS Rate,1405.55,102,,,Fee Schedule,102% of WV Medicaid Rate,5198.21,165,,,Fee Schedule,165% of CMS OPPS Rate,3265.15,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,9049.18,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,12410.23,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,15545.07,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1377.99,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,3150.43,100,,,Fee Schedule,100% of CMS OPPS Rate,3265.15,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,79.35,14,,,percent of total billed charges,14% of total billed charges,79.35,15545.07,
33241-PF Pulse Generator REMOVAL ONLY-Single/Dual,3948915,CDM,983,RC,33241,HCPCS,Outpatient,,,566.8,283.4,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
33241-Pulse Generator REMOVAL ONLY-Single/Dual,3948914,CDM,481,RC,33241,HCPCS,Outpatient,,,566.8,283.4,,425.1,75,,,percent of total billed charges,75% of total billed charges,425.1,75,,,percent of total billed charges,75% of total billed charges,3150.43,100,,,Fee Schedule,100% of CMS OPPS Rate,1405.55,102,,,Fee Schedule,102% of WV Medicaid Rate,5198.21,165,,,Fee Schedule,165% of CMS OPPS Rate,3265.15,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,9049.18,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,12410.23,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,15545.07,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1377.99,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,3150.43,100,,,Fee Schedule,100% of CMS OPPS Rate,3265.15,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,79.35,14,,,percent of total billed charges,14% of total billed charges,79.35,15545.07,
33241-Subcutaneous ICD Removal,3431788,CDM,481,RC,33241,HCPCS,Outpatient,,,459.19,229.6,,344.39,75,,,percent of total billed charges,75% of total billed charges,344.39,75,,,percent of total billed charges,75% of total billed charges,3150.43,100,,,Fee Schedule,100% of CMS OPPS Rate,1405.55,102,,,Fee Schedule,102% of WV Medicaid Rate,5198.21,165,,,Fee Schedule,165% of CMS OPPS Rate,3265.15,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,9049.18,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,12410.23,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,15545.07,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1377.99,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,3150.43,100,,,Fee Schedule,100% of CMS OPPS Rate,3265.15,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,64.29,14,,,percent of total billed charges,14% of total billed charges,64.29,15545.07,
Pulse Generator REMOVAL ONLY-Single/Dual,,,761,RC,33241,HCPCS,Outpatient,,,554.59,277.3,,415.94,75,,,percent of total billed charges,75% of total billed charges,415.94,75,,,percent of total billed charges,75% of total billed charges,3150.43,100,,,Fee Schedule,100% of CMS OPPS Rate,1405.55,102,,,Fee Schedule,102% of WV Medicaid Rate,5198.21,165,,,Fee Schedule,165% of CMS OPPS Rate,3265.15,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,9049.18,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,12410.23,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,15545.07,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1377.99,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,3150.43,100,,,Fee Schedule,100% of CMS OPPS Rate,3265.15,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,77.64,14,,,percent of total billed charges,14% of total billed charges,77.64,15545.07,
Removal of AICD,604681,CDM,481,RC,33241,HCPCS,Outpatient,,,554.59,277.3,,415.94,75,,,percent of total billed charges,75% of total billed charges,415.94,75,,,percent of total billed charges,75% of total billed charges,3150.43,100,,,Fee Schedule,100% of CMS OPPS Rate,1405.55,102,,,Fee Schedule,102% of WV Medicaid Rate,5198.21,165,,,Fee Schedule,165% of CMS OPPS Rate,3265.15,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,9049.18,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,12410.23,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,15545.07,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1377.99,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,3150.43,100,,,Fee Schedule,100% of CMS OPPS Rate,3265.15,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,77.64,14,,,percent of total billed charges,14% of total billed charges,77.64,15545.07,
Subcutaneous ICD Removal,,,761,RC,33241,HCPCS,Outpatient,,,554.59,277.3,,415.94,75,,,percent of total billed charges,75% of total billed charges,415.94,75,,,percent of total billed charges,75% of total billed charges,3150.43,100,,,Fee Schedule,100% of CMS OPPS Rate,1405.55,102,,,Fee Schedule,102% of WV Medicaid Rate,5198.21,165,,,Fee Schedule,165% of CMS OPPS Rate,3265.15,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,9049.18,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,12410.23,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,15545.07,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1377.99,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,3150.43,100,,,Fee Schedule,100% of CMS OPPS Rate,3265.15,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,77.64,14,,,percent of total billed charges,14% of total billed charges,77.64,15545.07,
33244- Transven remove sgn/dual ICD leads,3430642,CDM,481,RC,33244,HCPCS,Outpatient,,,2307.42,1153.71,,1730.57,75,,,percent of total billed charges,75% of total billed charges,1730.57,75,,,percent of total billed charges,75% of total billed charges,3150.43,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,5198.21,165,,,Fee Schedule,165% of CMS OPPS Rate,3265.15,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,9049.18,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,12410.23,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,15545.07,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,3150.43,100,,,Fee Schedule,100% of CMS OPPS Rate,3265.15,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,323.04,14,,,percent of total billed charges,14% of total billed charges,323.04,15545.07,
33244-ICD LEAD-REMOVAL SINGLE OR DUAL,3431789,CDM,481,RC,33244,HCPCS,Outpatient,,,2307.42,1153.71,,1730.57,75,,,percent of total billed charges,75% of total billed charges,1730.57,75,,,percent of total billed charges,75% of total billed charges,3150.43,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,5198.21,165,,,Fee Schedule,165% of CMS OPPS Rate,3265.15,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,9049.18,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,12410.23,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,15545.07,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,3150.43,100,,,Fee Schedule,100% of CMS OPPS Rate,3265.15,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,323.04,14,,,percent of total billed charges,14% of total billed charges,323.04,15545.07,
33244-Lead Extraction  RV entire system,3431790,CDM,481,RC,33244,HCPCS,Outpatient,,,2307.42,1153.71,,1730.57,75,,,percent of total billed charges,75% of total billed charges,1730.57,75,,,percent of total billed charges,75% of total billed charges,3150.43,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,5198.21,165,,,Fee Schedule,165% of CMS OPPS Rate,3265.15,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,9049.18,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,12410.23,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,15545.07,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,3150.43,100,,,Fee Schedule,100% of CMS OPPS Rate,3265.15,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,323.04,14,,,percent of total billed charges,14% of total billed charges,323.04,15545.07,
33244-Lead Extraction LV entire system,3431791,CDM,481,RC,33244,HCPCS,Outpatient,,,2307.42,1153.71,,1730.57,75,,,percent of total billed charges,75% of total billed charges,1730.57,75,,,percent of total billed charges,75% of total billed charges,3150.43,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,5198.21,165,,,Fee Schedule,165% of CMS OPPS Rate,3265.15,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,9049.18,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,12410.23,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,15545.07,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,3150.43,100,,,Fee Schedule,100% of CMS OPPS Rate,3265.15,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,323.04,14,,,percent of total billed charges,14% of total billed charges,323.04,15545.07,
33244-Lead Extraction RA entire system,3431792,CDM,481,RC,33244,HCPCS,Outpatient,,,2307.42,1153.71,,1730.57,75,,,percent of total billed charges,75% of total billed charges,1730.57,75,,,percent of total billed charges,75% of total billed charges,3150.43,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,5198.21,165,,,Fee Schedule,165% of CMS OPPS Rate,3265.15,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,9049.18,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,12410.23,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,15545.07,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,3150.43,100,,,Fee Schedule,100% of CMS OPPS Rate,3265.15,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,323.04,14,,,percent of total billed charges,14% of total billed charges,323.04,15545.07,
Lead Extraction LV entire system,,,761,RC,33244,HCPCS,Outpatient,,,2262.07,1131.04,,1696.55,75,,,percent of total billed charges,75% of total billed charges,1696.55,75,,,percent of total billed charges,75% of total billed charges,3150.43,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,5198.21,165,,,Fee Schedule,165% of CMS OPPS Rate,3265.15,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,9049.18,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,12410.23,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,15545.07,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,3150.43,100,,,Fee Schedule,100% of CMS OPPS Rate,3265.15,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,316.69,14,,,percent of total billed charges,14% of total billed charges,316.69,15545.07,
Lead Extraction RA entire system,,,761,RC,33244,HCPCS,Outpatient,,,2262.07,1131.04,,1696.55,75,,,percent of total billed charges,75% of total billed charges,1696.55,75,,,percent of total billed charges,75% of total billed charges,3150.43,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,5198.21,165,,,Fee Schedule,165% of CMS OPPS Rate,3265.15,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,9049.18,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,12410.23,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,15545.07,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,3150.43,100,,,Fee Schedule,100% of CMS OPPS Rate,3265.15,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,316.69,14,,,percent of total billed charges,14% of total billed charges,316.69,15545.07,
Lead Extraction RV entire system,,,761,RC,33244,HCPCS,Outpatient,,,2262.07,1131.04,,1696.55,75,,,percent of total billed charges,75% of total billed charges,1696.55,75,,,percent of total billed charges,75% of total billed charges,3150.43,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,5198.21,165,,,Fee Schedule,165% of CMS OPPS Rate,3265.15,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,9049.18,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,12410.23,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,15545.07,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,3150.43,100,,,Fee Schedule,100% of CMS OPPS Rate,3265.15,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,316.69,14,,,percent of total billed charges,14% of total billed charges,316.69,15545.07,
Removal ICD Single Lead,1503099,CDM,481,RC,33244,HCPCS,Outpatient,,,2262.07,1131.04,,1696.55,75,,,percent of total billed charges,75% of total billed charges,1696.55,75,,,percent of total billed charges,75% of total billed charges,3150.43,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,5198.21,165,,,Fee Schedule,165% of CMS OPPS Rate,3265.15,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,9049.18,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,12410.23,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,15545.07,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,3150.43,100,,,Fee Schedule,100% of CMS OPPS Rate,3265.15,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,316.69,14,,,percent of total billed charges,14% of total billed charges,316.69,15545.07,
33249- Insert/repla ICD w/sg or dual lead,3430643,CDM,480,RC,33249,HCPCS,Outpatient,,,2446.24,1223.12,,1834.68,75,,,percent of total billed charges,75% of total billed charges,1834.68,75,,,percent of total billed charges,75% of total billed charges,30157.08,100,,,Fee Schedule,100% of CMS OPPS Rate,21547.83,102,,,Fee Schedule,102% of WV Medicaid Rate,49759.19,165,,,Fee Schedule,165% of CMS OPPS Rate,31255.24,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,86622.1,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,118795.29,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,148803.15,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,21125.32,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,30157.08,100,,,Fee Schedule,100% of CMS OPPS Rate,31255.24,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,342.47,14,,,percent of total billed charges,14% of total billed charges,342.47,148803.15,
33249-Defibrillator Insertion  Dual,3431793,CDM,481,RC,33249,HCPCS,Outpatient,,,2446.24,1223.12,,1834.68,75,,,percent of total billed charges,75% of total billed charges,1834.68,75,,,percent of total billed charges,75% of total billed charges,30157.08,100,,,Fee Schedule,100% of CMS OPPS Rate,21547.83,102,,,Fee Schedule,102% of WV Medicaid Rate,49759.19,165,,,Fee Schedule,165% of CMS OPPS Rate,31255.24,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,86622.1,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,118795.29,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,148803.15,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,21125.32,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,30157.08,100,,,Fee Schedule,100% of CMS OPPS Rate,31255.24,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,342.47,14,,,percent of total billed charges,14% of total billed charges,342.47,148803.15,
33249-Defibrillator Insertion Biv,3431794,CDM,480,RC,33249,HCPCS,Outpatient,,,2446.24,1223.12,,1834.68,75,,,percent of total billed charges,75% of total billed charges,1834.68,75,,,percent of total billed charges,75% of total billed charges,30157.08,100,,,Fee Schedule,100% of CMS OPPS Rate,21547.83,102,,,Fee Schedule,102% of WV Medicaid Rate,49759.19,165,,,Fee Schedule,165% of CMS OPPS Rate,31255.24,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,86622.1,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,118795.29,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,148803.15,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,21125.32,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,30157.08,100,,,Fee Schedule,100% of CMS OPPS Rate,31255.24,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,342.47,14,,,percent of total billed charges,14% of total billed charges,342.47,148803.15,
33249-Defibrillator Insertion Single,3431795,CDM,480,RC,33249,HCPCS,Outpatient,,,2446.24,1223.12,,1834.68,75,,,percent of total billed charges,75% of total billed charges,1834.68,75,,,percent of total billed charges,75% of total billed charges,30157.08,100,,,Fee Schedule,100% of CMS OPPS Rate,21547.83,102,,,Fee Schedule,102% of WV Medicaid Rate,49759.19,165,,,Fee Schedule,165% of CMS OPPS Rate,31255.24,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,86622.1,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,118795.29,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,148803.15,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,21125.32,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,30157.08,100,,,Fee Schedule,100% of CMS OPPS Rate,31255.24,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,342.47,14,,,percent of total billed charges,14% of total billed charges,342.47,148803.15,
33249-ICD Sys Dual/Single w Lead Ins/Repl,3560659,CDM,481,RC,33249,HCPCS,Outpatient,,,2446.24,1223.12,,1834.68,75,,,percent of total billed charges,75% of total billed charges,1834.68,75,,,percent of total billed charges,75% of total billed charges,30157.08,100,,,Fee Schedule,100% of CMS OPPS Rate,21547.83,102,,,Fee Schedule,102% of WV Medicaid Rate,49759.19,165,,,Fee Schedule,165% of CMS OPPS Rate,31255.24,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,86622.1,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,118795.29,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,148803.15,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,21125.32,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,30157.08,100,,,Fee Schedule,100% of CMS OPPS Rate,31255.24,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,342.47,14,,,percent of total billed charges,14% of total billed charges,342.47,148803.15,
33249-ICD SYS SINGLE/DUAL INSERT/REPLACE,3431796,CDM,480,RC,33249,HCPCS,Outpatient,,,2446.24,1223.12,,1834.68,75,,,percent of total billed charges,75% of total billed charges,1834.68,75,,,percent of total billed charges,75% of total billed charges,30157.08,100,,,Fee Schedule,100% of CMS OPPS Rate,21547.83,102,,,Fee Schedule,102% of WV Medicaid Rate,49759.19,165,,,Fee Schedule,165% of CMS OPPS Rate,31255.24,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,86622.1,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,118795.29,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,148803.15,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,21125.32,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,30157.08,100,,,Fee Schedule,100% of CMS OPPS Rate,31255.24,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,342.47,14,,,percent of total billed charges,14% of total billed charges,342.47,148803.15,
Defibrillator Insertion Biv,,,761,RC,33249,HCPCS,Outpatient,,,2393.43,1196.72,,1795.07,75,,,percent of total billed charges,75% of total billed charges,1795.07,75,,,percent of total billed charges,75% of total billed charges,30157.08,100,,,Fee Schedule,100% of CMS OPPS Rate,21547.83,102,,,Fee Schedule,102% of WV Medicaid Rate,49759.19,165,,,Fee Schedule,165% of CMS OPPS Rate,31255.24,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,86622.1,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,118795.29,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,148803.15,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,21125.32,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,30157.08,100,,,Fee Schedule,100% of CMS OPPS Rate,31255.24,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,335.08,14,,,percent of total billed charges,14% of total billed charges,335.08,148803.15,
Defibrillator Insertion Dual,,,761,RC,33249,HCPCS,Outpatient,,,2393.43,1196.72,,1795.07,75,,,percent of total billed charges,75% of total billed charges,1795.07,75,,,percent of total billed charges,75% of total billed charges,30157.08,100,,,Fee Schedule,100% of CMS OPPS Rate,21547.83,102,,,Fee Schedule,102% of WV Medicaid Rate,49759.19,165,,,Fee Schedule,165% of CMS OPPS Rate,31255.24,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,86622.1,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,118795.29,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,148803.15,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,21125.32,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,30157.08,100,,,Fee Schedule,100% of CMS OPPS Rate,31255.24,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,335.08,14,,,percent of total billed charges,14% of total billed charges,335.08,148803.15,
Defibrillator Insertion Single,3427131,CDM,960,RC,33249,HCPCS,Outpatient,,,2393.43,1196.72,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
33254- Modified Maze/limited,3430839,CDM,510,RC,33254,HCPCS,Outpatient,,,3644.77,1822.39,,2733.58,75,,,percent of total billed charges,75% of total billed charges,2733.58,75,,,percent of total billed charges,75% of total billed charges,3644.77,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,3644.77,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3644.77,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3644.77,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3644.77,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3644.77,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,3644.77,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3644.77,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,510.27,14,,,percent of total billed charges,14% of total billed charges,510.27,3644.77,
33257- Modified Maze/limited /w other op,3430644,CDM,510,RC,33257,HCPCS,Outpatient,,,1546.81,773.41,,1160.11,75,,,percent of total billed charges,75% of total billed charges,1160.11,75,,,percent of total billed charges,75% of total billed charges,1546.81,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,1546.81,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1546.81,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1546.81,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1546.81,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1546.81,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,1546.81,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1546.81,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,216.55,14,,,percent of total billed charges,14% of total billed charges,216.55,1546.81,
33259- Maze/extensive/w/card/pulm bypass,3430645,CDM,510,RC,33259,HCPCS,Outpatient,,,2250.7,1125.35,,1688.03,75,,,percent of total billed charges,75% of total billed charges,1688.03,75,,,percent of total billed charges,75% of total billed charges,2250.7,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,2250.7,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2250.7,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2250.7,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2250.7,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2250.7,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,2250.7,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2250.7,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,315.1,14,,,percent of total billed charges,14% of total billed charges,315.1,2250.7,
33262- Remove/replac ICD gen only/sg lead,3430840,CDM,481,RC,33262,HCPCS,Outpatient,,,992.44,496.22,,744.33,75,,,percent of total billed charges,75% of total billed charges,744.33,75,,,percent of total billed charges,75% of total billed charges,21453.01,100,,,Fee Schedule,100% of CMS OPPS Rate,15952.32,102,,,Fee Schedule,102% of WV Medicaid Rate,35397.47,165,,,Fee Schedule,165% of CMS OPPS Rate,22234.22,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,61620.84,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,84508.08,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,105854.94,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,15639.53,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,21453.01,100,,,Fee Schedule,100% of CMS OPPS Rate,22234.22,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,138.94,14,,,percent of total billed charges,14% of total billed charges,138.94,105854.94,
33262-REMOVE & INSERT ICD GEN SINGLE,3431797,CDM,481,RC,33262,HCPCS,Outpatient,,,992.44,496.22,,744.33,75,,,percent of total billed charges,75% of total billed charges,744.33,75,,,percent of total billed charges,75% of total billed charges,21453.01,100,,,Fee Schedule,100% of CMS OPPS Rate,15952.32,102,,,Fee Schedule,102% of WV Medicaid Rate,35397.47,165,,,Fee Schedule,165% of CMS OPPS Rate,22234.22,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,61620.84,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,84508.08,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,105854.94,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,15639.53,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,21453.01,100,,,Fee Schedule,100% of CMS OPPS Rate,22234.22,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,138.94,14,,,percent of total billed charges,14% of total billed charges,138.94,105854.94,
33262-Subcutaneous ICD Change,3431798,CDM,481,RC,33262,HCPCS,Outpatient,,,811.88,405.94,,608.91,75,,,percent of total billed charges,75% of total billed charges,608.91,75,,,percent of total billed charges,75% of total billed charges,21453.01,100,,,Fee Schedule,100% of CMS OPPS Rate,15952.32,102,,,Fee Schedule,102% of WV Medicaid Rate,35397.47,165,,,Fee Schedule,165% of CMS OPPS Rate,22234.22,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,61620.84,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,84508.08,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,105854.94,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,15639.53,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,21453.01,100,,,Fee Schedule,100% of CMS OPPS Rate,22234.22,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,113.66,14,,,percent of total billed charges,14% of total billed charges,113.66,105854.94,
Subcutaneous ICD Change,,,761,RC,33262,HCPCS,Outpatient,,,972.69,486.35,,729.52,75,,,percent of total billed charges,75% of total billed charges,729.52,75,,,percent of total billed charges,75% of total billed charges,21453.01,100,,,Fee Schedule,100% of CMS OPPS Rate,15952.32,102,,,Fee Schedule,102% of WV Medicaid Rate,35397.47,165,,,Fee Schedule,165% of CMS OPPS Rate,22234.22,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,61620.84,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,84508.08,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,105854.94,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,15639.53,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,21453.01,100,,,Fee Schedule,100% of CMS OPPS Rate,22234.22,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,136.18,14,,,percent of total billed charges,14% of total billed charges,136.18,105854.94,
33263- Remov/replac ICD gen/dual lead sys,3430646,CDM,481,RC,33263,HCPCS,Outpatient,,,1032.89,516.45,,774.67,75,,,percent of total billed charges,75% of total billed charges,774.67,75,,,percent of total billed charges,75% of total billed charges,21453.01,100,,,Fee Schedule,100% of CMS OPPS Rate,16108.51,102,,,Fee Schedule,102% of WV Medicaid Rate,35397.47,165,,,Fee Schedule,165% of CMS OPPS Rate,22234.22,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,61620.84,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,84508.08,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,105854.94,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,15792.66,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,21453.01,100,,,Fee Schedule,100% of CMS OPPS Rate,22234.22,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,144.6,14,,,percent of total billed charges,14% of total billed charges,144.6,105854.94,
33263-PF REMOVE & INSERT ICD GEN DUAL,3580869,CDM,960,RC,33263,HCPCS,Outpatient,,,1032.89,516.45,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
33263-PF Subcutaneous ICD Change,3580870,CDM,960,RC,33263,HCPCS,Outpatient,,,1032.89,516.45,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
33263-REMOVE & INSERT ICD GEN DUAL,3431799,CDM,481,RC,33263,HCPCS,Outpatient,,,1032.89,516.45,,774.67,75,,,percent of total billed charges,75% of total billed charges,774.67,75,,,percent of total billed charges,75% of total billed charges,21453.01,100,,,Fee Schedule,100% of CMS OPPS Rate,16108.51,102,,,Fee Schedule,102% of WV Medicaid Rate,35397.47,165,,,Fee Schedule,165% of CMS OPPS Rate,22234.22,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,61620.84,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,84508.08,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,105854.94,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,15792.66,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,21453.01,100,,,Fee Schedule,100% of CMS OPPS Rate,22234.22,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,144.6,14,,,percent of total billed charges,14% of total billed charges,144.6,105854.94,
33263-Subcutaneous ICD Change,3431800,CDM,481,RC,33263,HCPCS,Outpatient,,,844.52,422.26,,633.39,75,,,percent of total billed charges,75% of total billed charges,633.39,75,,,percent of total billed charges,75% of total billed charges,21453.01,100,,,Fee Schedule,100% of CMS OPPS Rate,16108.51,102,,,Fee Schedule,102% of WV Medicaid Rate,35397.47,165,,,Fee Schedule,165% of CMS OPPS Rate,22234.22,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,61620.84,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,84508.08,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,105854.94,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,15792.66,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,21453.01,100,,,Fee Schedule,100% of CMS OPPS Rate,22234.22,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,118.23,14,,,percent of total billed charges,14% of total billed charges,118.23,105854.94,
33264- Remov/replac ICD gen/mult lead sys,3430647,CDM,481,RC,33264,HCPCS,Outpatient,,,1076.51,538.26,,807.38,75,,,percent of total billed charges,75% of total billed charges,807.38,75,,,percent of total billed charges,75% of total billed charges,30157.08,100,,,Fee Schedule,100% of CMS OPPS Rate,21462.74,102,,,Fee Schedule,102% of WV Medicaid Rate,49759.19,165,,,Fee Schedule,165% of CMS OPPS Rate,31255.24,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,86622.1,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,118795.29,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,148803.15,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,21041.9,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,30157.08,100,,,Fee Schedule,100% of CMS OPPS Rate,31255.24,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,150.71,14,,,percent of total billed charges,14% of total billed charges,150.71,148803.15,
33264-PF REMOVE & INSERT ICD GEN MULTI,3580871,CDM,960,RC,33264,HCPCS,Outpatient,,,1076.51,538.26,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
33264-PF Subcutaneous ICD Change,3580872,CDM,960,RC,33264,HCPCS,Outpatient,,,1076.51,538.26,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
33264-REMOVE & INSERT ICD GEN MULTI,3431801,CDM,481,RC,33264,HCPCS,Outpatient,,,1076.51,538.26,,807.38,75,,,percent of total billed charges,75% of total billed charges,807.38,75,,,percent of total billed charges,75% of total billed charges,30157.08,100,,,Fee Schedule,100% of CMS OPPS Rate,21462.74,102,,,Fee Schedule,102% of WV Medicaid Rate,49759.19,165,,,Fee Schedule,165% of CMS OPPS Rate,31255.24,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,86622.1,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,118795.29,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,148803.15,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,21041.9,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,30157.08,100,,,Fee Schedule,100% of CMS OPPS Rate,31255.24,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,150.71,14,,,percent of total billed charges,14% of total billed charges,150.71,148803.15,
33264-Subcutaneous ICD Change,3431802,CDM,481,RC,33264,HCPCS,Outpatient,,,883.59,441.8,,662.69,75,,,percent of total billed charges,75% of total billed charges,662.69,75,,,percent of total billed charges,75% of total billed charges,30157.08,100,,,Fee Schedule,100% of CMS OPPS Rate,21462.74,102,,,Fee Schedule,102% of WV Medicaid Rate,49759.19,165,,,Fee Schedule,165% of CMS OPPS Rate,31255.24,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,86622.1,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,118795.29,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,148803.15,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,21041.9,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,30157.08,100,,,Fee Schedule,100% of CMS OPPS Rate,31255.24,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,123.7,14,,,percent of total billed charges,14% of total billed charges,123.7,148803.15,
33268 - PF Excl LAA Opn TM Strnt/Thrcm Any Method,4301614,CDM,960,RC,33268,HCPCS,Outpatient,,,277.49,138.75,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
33269 - PF Exclusion L ATR Appendage Thorascopic-Any method,4361840,CDM,960,RC,33269,HCPCS,Outpatient,,,1645.64,822.82,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
33270- Inser/repla ICD w/lead/ thres test,3430648,CDM,481,RC,33270,HCPCS,Outpatient,,,1501.09,750.55,,1125.82,75,,,percent of total billed charges,75% of total billed charges,1125.82,75,,,percent of total billed charges,75% of total billed charges,30157.08,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,49759.19,165,,,Fee Schedule,165% of CMS OPPS Rate,31255.24,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,86622.1,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,118795.29,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,148803.15,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,30157.08,100,,,Fee Schedule,100% of CMS OPPS Rate,31255.24,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,210.15,14,,,percent of total billed charges,14% of total billed charges,210.15,148803.15,
33270-INSERT/REPLACE OF S-ICD SYSTEM,3431803,CDM,481,RC,33270,HCPCS,Outpatient,,,1501.09,750.55,,1125.82,75,,,percent of total billed charges,75% of total billed charges,1125.82,75,,,percent of total billed charges,75% of total billed charges,30157.08,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,49759.19,165,,,Fee Schedule,165% of CMS OPPS Rate,31255.24,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,86622.1,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,118795.29,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,148803.15,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,30157.08,100,,,Fee Schedule,100% of CMS OPPS Rate,31255.24,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,210.15,14,,,percent of total billed charges,14% of total billed charges,210.15,148803.15,
33270-Subcutaneous ICD Insertion,3431804,CDM,481,RC,33270,HCPCS,Outpatient,,,1236.24,618.12,,927.18,75,,,percent of total billed charges,75% of total billed charges,927.18,75,,,percent of total billed charges,75% of total billed charges,30157.08,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,49759.19,165,,,Fee Schedule,165% of CMS OPPS Rate,31255.24,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,86622.1,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,118795.29,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,148803.15,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,30157.08,100,,,Fee Schedule,100% of CMS OPPS Rate,31255.24,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,173.07,14,,,percent of total billed charges,14% of total billed charges,173.07,148803.15,
Subcutaneous ICD Insertion,,,761,RC,33270,HCPCS,Outpatient,,,1471.23,735.62,,1103.42,75,,,percent of total billed charges,75% of total billed charges,1103.42,75,,,percent of total billed charges,75% of total billed charges,30157.08,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,49759.19,165,,,Fee Schedule,165% of CMS OPPS Rate,31255.24,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,86622.1,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,118795.29,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,148803.15,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,30157.08,100,,,Fee Schedule,100% of CMS OPPS Rate,31255.24,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,205.97,14,,,percent of total billed charges,14% of total billed charges,205.97,148803.15,
33271-Lead Insert Subq defib lead only no gen,3431805,CDM,481,RC,33271,HCPCS,Outpatient,,,1209.28,604.64,,906.96,75,,,percent of total billed charges,75% of total billed charges,906.96,75,,,percent of total billed charges,75% of total billed charges,7674.35,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,12662.69,165,,,Fee Schedule,165% of CMS OPPS Rate,7953.81,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,22043.54,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,30230.97,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,37867.35,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,7674.35,100,,,Fee Schedule,100% of CMS OPPS Rate,7953.81,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,169.3,14,,,percent of total billed charges,14% of total billed charges,169.3,37867.35,
Lead Insert Subq defib lead only no gen,,,761,RC,33271,HCPCS,Outpatient,,,1186.14,593.07,,889.61,75,,,percent of total billed charges,75% of total billed charges,889.61,75,,,percent of total billed charges,75% of total billed charges,7674.35,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,12662.69,165,,,Fee Schedule,165% of CMS OPPS Rate,7953.81,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,22043.54,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,30230.97,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,37867.35,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,7674.35,100,,,Fee Schedule,100% of CMS OPPS Rate,7953.81,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,166.06,14,,,percent of total billed charges,14% of total billed charges,166.06,37867.35,
33272-PF Subcutaneous ICD Removal,3580873,CDM,960,RC,33272,HCPCS,Outpatient,,,922.44,461.22,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
33272-Subcutaneous ICD Removal,3431806,CDM,481,RC,33272,HCPCS,Outpatient,,,922.44,461.22,,691.83,75,,,percent of total billed charges,75% of total billed charges,691.83,75,,,percent of total billed charges,75% of total billed charges,3150.43,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,5198.21,165,,,Fee Schedule,165% of CMS OPPS Rate,3265.15,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,9049.18,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,12410.23,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,15545.07,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,3150.43,100,,,Fee Schedule,100% of CMS OPPS Rate,3265.15,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,129.14,14,,,percent of total billed charges,14% of total billed charges,129.14,15545.07,
33273- Repos prev implntd SQ implantable defib elect,3569418,CDM,510,RC,33273,HCPCS,Outpatient,,,1063.94,531.97,,797.96,75,,,percent of total billed charges,75% of total billed charges,797.96,75,,,percent of total billed charges,75% of total billed charges,3150.43,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,5198.2,165,,,Fee Schedule,165% of CMS OPPS Rate,3265.15,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,9049.17,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,12410.22,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,15545.07,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,3150.43,100,,,Fee Schedule,100% of CMS OPPS Rate,3265.15,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,148.95,14,,,percent of total billed charges,14% of total billed charges,148.95,15545.07,
33273-PF Reposition of previously implanted SubQ ICD lead,4271122,CDM,960,RC,33273,HCPCS,Outpatient,,,836.98,418.49,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
33273-Reposition of previously implanted SubQ ICD lead,4271121,CDM,481,RC,33273,HCPCS,Outpatient,,,836.98,418.49,,627.74,75,,,percent of total billed charges,75% of total billed charges,627.74,75,,,percent of total billed charges,75% of total billed charges,3150.43,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,5198.2,165,,,Fee Schedule,165% of CMS OPPS Rate,3265.15,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,9049.17,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,12410.22,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,15545.07,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,3150.43,100,,,Fee Schedule,100% of CMS OPPS Rate,3265.15,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,117.18,14,,,percent of total billed charges,14% of total billed charges,117.18,15545.07,
Reposition of previously implanted SubQ ICD lead,,,761,RC,33273,HCPCS,Outpatient,,,836.98,418.49,,627.74,75,,,percent of total billed charges,75% of total billed charges,627.74,75,,,percent of total billed charges,75% of total billed charges,3150.43,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,5198.2,165,,,Fee Schedule,165% of CMS OPPS Rate,3265.15,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,9049.17,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,12410.22,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,15545.07,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,3150.43,100,,,Fee Schedule,100% of CMS OPPS Rate,3265.15,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,117.18,14,,,percent of total billed charges,14% of total billed charges,117.18,15545.07,
33274 - Single Chamber Leadless Pacemaker Insertion/Replacem,4185320,CDM,481,RC,33274,HCPCS,Outpatient,,,2293.29,1146.65,,1719.97,75,,,percent of total billed charges,75% of total billed charges,1719.97,75,,,percent of total billed charges,75% of total billed charges,16149.79,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,26647.16,165,,,Fee Schedule,165% of CMS OPPS Rate,16737.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,46388.09,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,63617.56,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,79687.45,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,16149.79,100,,,Fee Schedule,100% of CMS OPPS Rate,16737.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,321.06,14,,,percent of total billed charges,14% of total billed charges,321.06,79687.45,
33274-PF Single Chamber Leadless Pacemaker Insertion/Replace,4185321,CDM,960,RC,33274,HCPCS,Outpatient,,,2293.29,1146.65,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
Single Chamber Leadless Pacemaker Insertion/Replacement/ or Removal and Replacement,,,761,RC,33274,HCPCS,Outpatient,,,2293.29,1146.65,,1719.97,75,,,percent of total billed charges,75% of total billed charges,1719.97,75,,,percent of total billed charges,75% of total billed charges,16149.79,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,26647.16,165,,,Fee Schedule,165% of CMS OPPS Rate,16737.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,46388.09,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,63617.56,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,79687.45,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,16149.79,100,,,Fee Schedule,100% of CMS OPPS Rate,16737.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,321.06,14,,,percent of total billed charges,14% of total billed charges,321.06,79687.45,
33275 - PF Removal of Permanent Leadless Pacemaker,4185324,CDM,960,RC,33275,HCPCS,Outpatient,,,2406.65,1203.33,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
33275 - Removal of Permanent Leadless Pacemaker,4185323,CDM,481,RC,33275,HCPCS,Outpatient,,,2406.65,1203.33,,1804.99,75,,,percent of total billed charges,75% of total billed charges,1804.99,75,,,percent of total billed charges,75% of total billed charges,2800.71,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,4621.18,165,,,Fee Schedule,165% of CMS OPPS Rate,2902.7,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8044.7,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11032.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13819.53,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,2800.71,100,,,Fee Schedule,100% of CMS OPPS Rate,2902.7,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,336.93,14,,,percent of total billed charges,14% of total billed charges,336.93,13819.53,
Removal of Permanent Leadless Pacemaker,,,761,RC,33275,HCPCS,Outpatient,,,2406.65,1203.33,,1804.99,75,,,percent of total billed charges,75% of total billed charges,1804.99,75,,,percent of total billed charges,75% of total billed charges,2800.71,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,4621.18,165,,,Fee Schedule,165% of CMS OPPS Rate,2902.7,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8044.7,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11032.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13819.53,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,2800.71,100,,,Fee Schedule,100% of CMS OPPS Rate,2902.7,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,336.93,14,,,percent of total billed charges,14% of total billed charges,336.93,13819.53,
"33285 - PF Insertion, subcutaneous cardiac rhythm monitor, including programming",3712970,CDM,510,RC,33285,HCPCS,Outpatient,,,10857.77,5428.89,,8143.33,75,,,percent of total billed charges,75% of total billed charges,8143.33,75,,,percent of total billed charges,75% of total billed charges,7674.35,100,,,Fee Schedule,100% of CMS OPPS Rate,5679.83,102,,,Fee Schedule,102% of WV Medicaid Rate,12662.69,165,,,Fee Schedule,165% of CMS OPPS Rate,7953.81,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,22043.54,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,30230.97,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,37867.35,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,5568.46,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,7674.35,100,,,Fee Schedule,100% of CMS OPPS Rate,7953.81,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1520.09,14,,,percent of total billed charges,14% of total billed charges,1520.09,37867.35,
33285-Loop Recorder Insertion,3431807,CDM,481,RC,33285,HCPCS,Outpatient,,,10857.77,5428.89,,8143.33,75,,,percent of total billed charges,75% of total billed charges,8143.33,75,,,percent of total billed charges,75% of total billed charges,7674.35,100,,,Fee Schedule,100% of CMS OPPS Rate,5679.83,102,,,Fee Schedule,102% of WV Medicaid Rate,12662.69,165,,,Fee Schedule,165% of CMS OPPS Rate,7953.81,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,22043.54,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,30230.97,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,37867.35,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,5568.46,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,7674.35,100,,,Fee Schedule,100% of CMS OPPS Rate,7953.81,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1520.09,14,,,percent of total billed charges,14% of total billed charges,1520.09,37867.35,
Loop Recorder Insertion,,,761,RC,33285,HCPCS,Outpatient,,,10106.52,5053.26,,7579.89,75,,,percent of total billed charges,75% of total billed charges,7579.89,75,,,percent of total billed charges,75% of total billed charges,7674.35,100,,,Fee Schedule,100% of CMS OPPS Rate,5679.83,102,,,Fee Schedule,102% of WV Medicaid Rate,12662.69,165,,,Fee Schedule,165% of CMS OPPS Rate,7953.81,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,22043.54,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,30230.97,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,37867.35,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,5568.46,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,7674.35,100,,,Fee Schedule,100% of CMS OPPS Rate,7953.81,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1414.91,14,,,percent of total billed charges,14% of total billed charges,1414.91,37867.35,
"33286 - PF Removal, subcutaneous cardiac rhythm monitor",3712971,CDM,510,RC,33286,HCPCS,Outpatient,,,345.28,172.64,,258.96,75,,,percent of total billed charges,75% of total billed charges,258.96,75,,,percent of total billed charges,75% of total billed charges,610.13,100,,,Fee Schedule,100% of CMS OPPS Rate,254,102,,,Fee Schedule,102% of WV Medicaid Rate,1006.73,165,,,Fee Schedule,165% of CMS OPPS Rate,632.35,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1752.54,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2403.47,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,3010.59,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,249.02,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,610.13,100,,,Fee Schedule,100% of CMS OPPS Rate,632.35,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,48.34,14,,,percent of total billed charges,14% of total billed charges,48.34,3010.59,
33286-Loop Recorder Removal,3431808,CDM,481,RC,33286,HCPCS,Outpatient,,,345.28,172.64,,258.96,75,,,percent of total billed charges,75% of total billed charges,258.96,75,,,percent of total billed charges,75% of total billed charges,610.13,100,,,Fee Schedule,100% of CMS OPPS Rate,254,102,,,Fee Schedule,102% of WV Medicaid Rate,1006.73,165,,,Fee Schedule,165% of CMS OPPS Rate,632.35,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1752.54,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2403.47,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,3010.59,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,249.02,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,610.13,100,,,Fee Schedule,100% of CMS OPPS Rate,632.35,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,48.34,14,,,percent of total billed charges,14% of total billed charges,48.34,3010.59,
Loop Recorder Removal,,,761,RC,33286,HCPCS,Outpatient,,,335.54,167.77,,251.66,75,,,percent of total billed charges,75% of total billed charges,251.66,75,,,percent of total billed charges,75% of total billed charges,610.13,100,,,Fee Schedule,100% of CMS OPPS Rate,254,102,,,Fee Schedule,102% of WV Medicaid Rate,1006.73,165,,,Fee Schedule,165% of CMS OPPS Rate,632.35,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1752.54,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2403.47,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,3010.59,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,249.02,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,610.13,100,,,Fee Schedule,100% of CMS OPPS Rate,632.35,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,46.98,14,,,percent of total billed charges,14% of total billed charges,46.98,3010.59,
33289-CARDIO MEMS IMPLANT,3431809,CDM,483,RC,33289,HCPCS,Outpatient,,,897.79,448.9,,673.34,75,,,percent of total billed charges,75% of total billed charges,673.34,75,,,percent of total billed charges,75% of total billed charges,25671.4,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,42357.82,165,,,Fee Schedule,165% of CMS OPPS Rate,26606.21,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,73737.58,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,101125.22,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,126669.59,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,25671.4,100,,,Fee Schedule,100% of CMS OPPS Rate,26606.21,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,125.69,14,,,percent of total billed charges,14% of total billed charges,125.69,126669.59,
33289-CardioMEMS,3431810,CDM,481,RC,33289,HCPCS,Outpatient,,,897.79,448.9,,673.34,75,,,percent of total billed charges,75% of total billed charges,673.34,75,,,percent of total billed charges,75% of total billed charges,25671.4,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,42357.82,165,,,Fee Schedule,165% of CMS OPPS Rate,26606.21,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,73737.58,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,101125.22,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,126669.59,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,25671.4,100,,,Fee Schedule,100% of CMS OPPS Rate,26606.21,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,125.69,14,,,percent of total billed charges,14% of total billed charges,125.69,126669.59,
CardioMEMS,3427123,CDM,960,RC,33289,HCPCS,Outpatient,,,877.31,438.66,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
33300 - PF Repair of cardiac wound; without bypass,3715389,CDM,510,RC,33300,HCPCS,Outpatient,,,6578.49,3289.25,,4933.87,75,,,percent of total billed charges,75% of total billed charges,4933.87,75,,,percent of total billed charges,75% of total billed charges,6578.49,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,6578.49,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6578.49,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6578.49,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6578.49,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6578.49,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,6578.49,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6578.49,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,920.99,14,,,percent of total billed charges,14% of total billed charges,920.99,6578.49,
33310 - Cardiot Expl W/Rmbl FB Atr/Ventr Thrmb w/o BYP,4113108,CDM,975,RC,33310,HCPCS,Outpatient,,,2794.84,1397.42,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
33322 - Suture repair of aorta or great vessels; with cardiopulmonary bypass,3783269,CDM,510,RC,33322,HCPCS,Outpatient,,,3722.87,1861.44,,2792.15,75,,,percent of total billed charges,75% of total billed charges,2792.15,75,,,percent of total billed charges,75% of total billed charges,3722.87,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,3722.87,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3722.87,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3722.87,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3722.87,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3722.87,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,3722.87,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3722.87,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,521.2,14,,,percent of total billed charges,14% of total billed charges,521.2,3722.87,
33340 - PF - Percutaneous transcatheter closure of the left atrial appendage with endocardial implan,3640908,CDM,510,RC,33340,HCPCS,Outpatient,,,2110.39,1055.2,,1582.79,75,,,percent of total billed charges,75% of total billed charges,1582.79,75,,,percent of total billed charges,75% of total billed charges,2110.39,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,2110.39,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2110.39,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2110.39,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2110.39,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2110.39,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,2110.39,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2110.39,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,295.45,14,,,percent of total billed charges,14% of total billed charges,295.45,2110.39,
33340 -Peri-Device Leak,4123188,CDM,481,RC,33340,HCPCS,Outpatient,,,1884.28,942.14,,1413.21,75,,,percent of total billed charges,75% of total billed charges,1413.21,75,,,percent of total billed charges,75% of total billed charges,1884.28,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,1884.28,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1884.28,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1884.28,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1884.28,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1884.28,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,1884.28,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1884.28,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,263.8,14,,,percent of total billed charges,14% of total billed charges,263.8,1884.28,
33340-LAAO Closure (Amulet),3431812,CDM,481,RC,33340,HCPCS,Outpatient,,,2110.39,1055.2,,1582.79,75,,,percent of total billed charges,75% of total billed charges,1582.79,75,,,percent of total billed charges,75% of total billed charges,2110.39,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,2110.39,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2110.39,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2110.39,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2110.39,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2110.39,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,2110.39,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2110.39,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,295.45,14,,,percent of total billed charges,14% of total billed charges,295.45,2110.39,
33340-LAAO Closure (Watchman),3431811,CDM,481,RC,33340,HCPCS,Outpatient,,,2110.39,1055.2,,1582.79,75,,,percent of total billed charges,75% of total billed charges,1582.79,75,,,percent of total billed charges,75% of total billed charges,2110.39,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,2110.39,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2110.39,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2110.39,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2110.39,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2110.39,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,2110.39,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2110.39,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,295.45,14,,,percent of total billed charges,14% of total billed charges,295.45,2110.39,
33340-PF Peri-Device Leak,4123189,CDM,960,RC,33340,HCPCS,Outpatient,,,1884.28,942.14,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
LAAO Closure,,,761,RC,33340,HCPCS,Outpatient,,,2062.58,1031.29,,1546.94,75,,,percent of total billed charges,75% of total billed charges,1546.94,75,,,percent of total billed charges,75% of total billed charges,2062.58,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,2062.58,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2062.58,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2062.58,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2062.58,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2062.58,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,2062.58,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2062.58,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,288.76,14,,,percent of total billed charges,14% of total billed charges,288.76,2062.58,
Peri-Device Leak,,,761,RC,33340,HCPCS,Outpatient,,,2062.58,1031.29,,1546.94,75,,,percent of total billed charges,75% of total billed charges,1546.94,75,,,percent of total billed charges,75% of total billed charges,2062.58,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,2062.58,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2062.58,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2062.58,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2062.58,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2062.58,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,2062.58,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2062.58,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,288.76,14,,,percent of total billed charges,14% of total billed charges,288.76,2062.58,
33361- TAVR w/value percut fem approach,3560643,CDM,481,RC,33361,HCPCS,Outpatient,,,3260.42,1630.21,,2445.32,75,,,percent of total billed charges,75% of total billed charges,2445.32,75,,,percent of total billed charges,75% of total billed charges,3260.42,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,3260.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3260.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3260.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3260.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3260.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,3260.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3260.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,456.46,14,,,percent of total billed charges,14% of total billed charges,456.46,3260.42,
33361- TAVR/perc femoral artery,3430649,CDM,360,RC,33361,HCPCS,Outpatient,,,3260.42,1630.21,,2445.32,75,,,percent of total billed charges,75% of total billed charges,2445.32,75,,,percent of total billed charges,75% of total billed charges,3260.42,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,3260.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3260.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3260.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3260.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3260.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,3260.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3260.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,456.46,14,,,percent of total billed charges,14% of total billed charges,456.46,3260.42,
33361-TAVR Femoral,3431813,CDM,360,RC,33361,HCPCS,Outpatient,,,3260.42,1630.21,,2445.32,75,,,percent of total billed charges,75% of total billed charges,2445.32,75,,,percent of total billed charges,75% of total billed charges,3260.42,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,3260.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3260.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3260.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3260.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3260.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,3260.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3260.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,456.46,14,,,percent of total billed charges,14% of total billed charges,456.46,3260.42,
TAVR Femoral,3427284,CDM,960,RC,33361,HCPCS,Outpatient,,,3195.4,1597.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
33362-TAVR Open Femoral,3431814,CDM,481,RC,33362,HCPCS,Outpatient,,,3556.08,1778.04,,2667.06,75,,,percent of total billed charges,75% of total billed charges,2667.06,75,,,percent of total billed charges,75% of total billed charges,3556.08,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,3556.08,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3556.08,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3556.08,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3556.08,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3556.08,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,3556.08,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3556.08,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,497.85,14,,,percent of total billed charges,14% of total billed charges,497.85,3556.08,
"33362-TAVR, OPEN FEMORAL ARTERY APPROACH",3430845,CDM,510,RC,33362,HCPCS,Outpatient,,,3556.08,1778.04,,2667.06,75,,,percent of total billed charges,75% of total billed charges,2667.06,75,,,percent of total billed charges,75% of total billed charges,3556.08,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,3556.08,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3556.08,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3556.08,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3556.08,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3556.08,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,3556.08,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3556.08,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,497.85,14,,,percent of total billed charges,14% of total billed charges,497.85,3556.08,
TAVR Open Femoral,,,960,RC,33362,HCPCS,Outpatient,,,3556.08,1778.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
33363-TAVR Open Axillary,3431815,CDM,481,RC,33363,HCPCS,Outpatient,,,3687.26,1843.63,,2765.45,75,,,percent of total billed charges,75% of total billed charges,2765.45,75,,,percent of total billed charges,75% of total billed charges,3687.26,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,3687.26,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3687.26,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3687.26,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3687.26,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3687.26,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,3687.26,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3687.26,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,516.22,14,,,percent of total billed charges,14% of total billed charges,516.22,3687.26,
"33363-TAVR,OPEN AXILLARY APPROACH",3430846,CDM,510,RC,33363,HCPCS,Outpatient,,,3687.26,1843.63,,2765.45,75,,,percent of total billed charges,75% of total billed charges,2765.45,75,,,percent of total billed charges,75% of total billed charges,3687.26,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,3687.26,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3687.26,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3687.26,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3687.26,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3687.26,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,3687.26,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3687.26,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,516.22,14,,,percent of total billed charges,14% of total billed charges,516.22,3687.26,
TAVR Open Axillary,3427286,CDM,960,RC,33363,HCPCS,Outpatient,,,3687.26,1843.63,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
33364-TAVR Open Illiac,3431816,CDM,481,RC,33364,HCPCS,Outpatient,,,3694.07,1847.04,,2770.55,75,,,percent of total billed charges,75% of total billed charges,2770.55,75,,,percent of total billed charges,75% of total billed charges,3694.07,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,3694.07,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3694.07,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3694.07,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3694.07,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3694.07,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,3694.07,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3694.07,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,517.17,14,,,percent of total billed charges,14% of total billed charges,517.17,3694.07,
TAVR Open Illiac,,,960,RC,33364,HCPCS,Outpatient,,,3694.07,1847.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
33365-TAVR Transaortic Approach,3431817,CDM,481,RC,33365,HCPCS,Outpatient,,,3845.84,1922.92,,2884.38,75,,,percent of total billed charges,75% of total billed charges,2884.38,75,,,percent of total billed charges,75% of total billed charges,3845.84,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,3845.84,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3845.84,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3845.84,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3845.84,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3845.84,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,3845.84,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3845.84,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,538.42,14,,,percent of total billed charges,14% of total billed charges,538.42,3845.84,
TAVR Transaortic Approach,,,960,RC,33365,HCPCS,Outpatient,,,3845.84,1922.92,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
33366-TAVR Transapical Perfusion,3431818,CDM,481,RC,33366,HCPCS,Outpatient,,,4239.75,2119.88,,3179.81,75,,,percent of total billed charges,75% of total billed charges,3179.81,75,,,percent of total billed charges,75% of total billed charges,4239.75,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,4239.75,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4239.75,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4239.75,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4239.75,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4239.75,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,4239.75,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4239.75,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,593.57,14,,,percent of total billed charges,14% of total billed charges,593.57,4239.75,
TAVR Transapical Perfusion,,,761,RC,33366,HCPCS,Outpatient,,,4239.75,2119.88,,3179.81,75,,,percent of total billed charges,75% of total billed charges,3179.81,75,,,percent of total billed charges,75% of total billed charges,4239.75,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,4239.75,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4239.75,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4239.75,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4239.75,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4239.75,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,4239.75,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4239.75,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,593.57,14,,,percent of total billed charges,14% of total billed charges,593.57,4239.75,
33367-TAVR w Perc Cannulation,3431819,CDM,481,RC,33367,HCPCS,Outpatient,,,1659.1,829.55,,1244.33,75,,,percent of total billed charges,75% of total billed charges,1244.33,75,,,percent of total billed charges,75% of total billed charges,1659.1,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,1659.1,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1659.1,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1659.1,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1659.1,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1659.1,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,1659.1,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1659.1,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,232.27,14,,,percent of total billed charges,14% of total billed charges,232.27,1659.1,
TAVR w Perc Cannulation,,,960,RC,33367,HCPCS,Outpatient,,,1659.1,829.55,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
33368-TAVR w Perfusion w Open Peripheral,3431820,CDM,481,RC,33368,HCPCS,Outpatient,,,2010.43,1005.22,,1507.82,75,,,percent of total billed charges,75% of total billed charges,1507.82,75,,,percent of total billed charges,75% of total billed charges,2010.43,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,2010.43,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2010.43,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2010.43,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2010.43,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2010.43,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,2010.43,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2010.43,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,281.46,14,,,percent of total billed charges,14% of total billed charges,281.46,2010.43,
TAVR w Perfusion w Open Peripheral,,,960,RC,33368,HCPCS,Outpatient,,,2010.43,1005.22,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
33369-TAVR w Perfusion w Central Cannulation,3431821,CDM,481,RC,33369,HCPCS,Outpatient,,,2652.14,1326.07,,1989.11,75,,,percent of total billed charges,75% of total billed charges,1989.11,75,,,percent of total billed charges,75% of total billed charges,2652.14,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,2652.14,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2652.14,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2652.14,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2652.14,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2652.14,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,2652.14,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2652.14,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,371.3,14,,,percent of total billed charges,14% of total billed charges,371.3,2652.14,
TAVR w Perfusion w Central Cannulation,,,960,RC,33369,HCPCS,Outpatient,,,2652.14,1326.07,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
33370-Cerebral Embolic Protection (Plcmnt and Rmvl) during TAVR,4271124,CDM,481,RC,33370,HCPCS,Outpatient,,,283.68,141.84,,212.76,75,,,percent of total billed charges,75% of total billed charges,212.76,75,,,percent of total billed charges,75% of total billed charges,90.78,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.72,14,,,percent of total billed charges,14% of total billed charges,39.72,212.76,
33370-PF Cerebral Embolic Protection (Plcmnt and Rmvl) during TAVR,4271125,CDM,960,RC,33370,HCPCS,Outpatient,,,283.68,141.84,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
Cerebral Embolic Protection (Plcmnt and Rmvl) during TAVR,,,960,RC,33370,HCPCS,Outpatient,,,283.68,141.84,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
33390-VALVULOPLASTY AORTIC VALVE,3430848,CDM,960,RC,33390,HCPCS,Outpatient,,,4076.25,2038.13,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
33405- Replac AV w/bypas/other pros valve,3430650,CDM,510,RC,33405,HCPCS,Outpatient,,,6104.03,3052.02,,4578.02,75,,,percent of total billed charges,75% of total billed charges,4578.02,75,,,percent of total billed charges,75% of total billed charges,6104.03,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,6104.03,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6104.03,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6104.03,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6104.03,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6104.03,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,6104.03,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6104.03,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,854.56,14,,,percent of total billed charges,14% of total billed charges,854.56,6104.03,
33410- Replace AV w/bypas/stentless valve,3430651,CDM,510,RC,33410,HCPCS,Outpatient,,,6833.44,3416.72,,5125.08,75,,,percent of total billed charges,75% of total billed charges,5125.08,75,,,percent of total billed charges,75% of total billed charges,6833.44,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,6833.44,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6833.44,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6833.44,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6833.44,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6833.44,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,6833.44,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6833.44,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,956.68,14,,,percent of total billed charges,14% of total billed charges,956.68,6833.44,
33411-REPLACE AORTIC VALVE W/AORTIC ANN,3430851,CDM,960,RC,33411,HCPCS,Outpatient,,,7103.8,3551.9,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
33415- Resect/incis/subva tissue/subva AS,3430853,CDM,510,RC,33415,HCPCS,Outpatient,,,5459.96,2729.98,,4094.97,75,,,percent of total billed charges,75% of total billed charges,4094.97,75,,,percent of total billed charges,75% of total billed charges,5459.96,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,5459.96,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5459.96,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5459.96,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5459.96,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5459.96,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,5459.96,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5459.96,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,764.39,14,,,percent of total billed charges,14% of total billed charges,764.39,5459.96,
33416- Ventriculomyotomy/IHSS,3430854,CDM,510,RC,33416,HCPCS,Outpatient,,,5431.94,2715.97,,4073.96,75,,,percent of total billed charges,75% of total billed charges,4073.96,75,,,percent of total billed charges,75% of total billed charges,5431.94,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,5431.94,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5431.94,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5431.94,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5431.94,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5431.94,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,5431.94,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5431.94,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,760.47,14,,,percent of total billed charges,14% of total billed charges,760.47,5431.94,
"33418 Transcatheter mitral valve repair, percutaneous approach, including transseptal puncture when",3623384,CDM,510,RC,33418,HCPCS,Outpatient,,,4824.81,2412.41,,3618.61,75,,,percent of total billed charges,75% of total billed charges,3618.61,75,,,percent of total billed charges,75% of total billed charges,4824.81,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,4824.81,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4824.81,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4824.81,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4824.81,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4824.81,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,4824.81,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4824.81,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,675.47,14,,,percent of total billed charges,14% of total billed charges,675.47,4824.81,
33418-Transcatheter mitral valve repair; initial prosthesis,3561520,CDM,481,RC,33418,HCPCS,Outpatient,,,4824.81,2412.41,,3618.61,75,,,percent of total billed charges,75% of total billed charges,3618.61,75,,,percent of total billed charges,75% of total billed charges,4824.81,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,4824.81,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4824.81,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4824.81,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4824.81,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4824.81,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,4824.81,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4824.81,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,675.47,14,,,percent of total billed charges,14% of total billed charges,675.47,4824.81,
Mitra Clip,,,761,RC,33418,HCPCS,Outpatient,,,4724.08,2362.04,,3543.06,75,,,percent of total billed charges,75% of total billed charges,3543.06,75,,,percent of total billed charges,75% of total billed charges,4724.08,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,4724.08,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4724.08,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4724.08,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4724.08,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4724.08,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,4724.08,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4724.08,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,661.37,14,,,percent of total billed charges,14% of total billed charges,661.37,4724.08,
33419-PF Transcatheter mitral valve repair; additional prosthesis,3580874,CDM,960,RC,33419,HCPCS,Outpatient,,,1142.85,571.43,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
33419-Transcatheter mitral valve repair; additional prosthesis,3561521,CDM,481,RC,33419,HCPCS,Outpatient,,,1142.85,571.43,,857.14,75,,,percent of total billed charges,75% of total billed charges,857.14,75,,,percent of total billed charges,75% of total billed charges,365.71,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,160,14,,,percent of total billed charges,14% of total billed charges,160,857.14,
33422- Valvotomy/MV/open ht/bypass,3430855,CDM,510,RC,33422,HCPCS,Outpatient,,,4464.79,2232.4,,3348.59,75,,,percent of total billed charges,75% of total billed charges,3348.59,75,,,percent of total billed charges,75% of total billed charges,4464.79,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,4464.79,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4464.79,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4464.79,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4464.79,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4464.79,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,4464.79,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4464.79,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,625.07,14,,,percent of total billed charges,14% of total billed charges,625.07,4464.79,
33426- TMVR w/prosthetic ring,3430652,CDM,510,RC,33426,HCPCS,Outpatient,,,4948.42,2474.21,,3711.32,75,,,percent of total billed charges,75% of total billed charges,3711.32,75,,,percent of total billed charges,75% of total billed charges,4948.42,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,4948.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4948.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4948.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4948.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4948.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,4948.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4948.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,692.78,14,,,percent of total billed charges,14% of total billed charges,692.78,4948.42,
33427- TMVR w/rad reconst w or w/o ring,3430653,CDM,510,RC,33427,HCPCS,Outpatient,,,6550.88,3275.44,,4913.16,75,,,percent of total billed charges,75% of total billed charges,4913.16,75,,,percent of total billed charges,75% of total billed charges,6550.88,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,6550.88,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6550.88,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6550.88,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6550.88,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6550.88,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,6550.88,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6550.88,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,917.12,14,,,percent of total billed charges,14% of total billed charges,917.12,6550.88,
33430- Mitral valve replacement w/bypass,3430654,CDM,510,RC,33430,HCPCS,Outpatient,,,7530.23,3765.12,,5647.67,75,,,percent of total billed charges,75% of total billed charges,5647.67,75,,,percent of total billed charges,75% of total billed charges,7530.23,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,7530.23,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,7530.23,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,7530.23,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,7530.23,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,7530.23,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,7530.23,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,7530.23,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1054.23,14,,,percent of total billed charges,14% of total billed charges,1054.23,7530.23,
33463- Valvuloplasty/TV w/o ring insert,3430655,CDM,510,RC,33463,HCPCS,Outpatient,,,8239.5,4119.75,,6179.63,75,,,percent of total billed charges,75% of total billed charges,6179.63,75,,,percent of total billed charges,75% of total billed charges,8239.5,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,8239.5,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,8239.5,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,8239.5,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,8239.5,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,8239.5,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,8239.5,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,8239.5,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1153.53,14,,,percent of total billed charges,14% of total billed charges,1153.53,8239.5,
33464- Valvuloplasty/TV w/ring insertion,3430656,CDM,510,RC,33464,HCPCS,Outpatient,,,6549.21,3274.61,,4911.91,75,,,percent of total billed charges,75% of total billed charges,4911.91,75,,,percent of total billed charges,75% of total billed charges,6549.21,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,6549.21,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6549.21,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6549.21,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6549.21,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6549.21,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,6549.21,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6549.21,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,916.89,14,,,percent of total billed charges,14% of total billed charges,916.89,6549.21,
"33465 - Replacement, tricuspid valve, with cardiopulmonary bypass",4169572,CDM,983,RC,33465,HCPCS,Outpatient,,,6612.87,3306.44,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
33465-REPLACE TRICUSPID VALVE,3430856,CDM,510,RC,33465,HCPCS,Outpatient,,,7406.42,3703.21,,5554.82,75,,,percent of total billed charges,75% of total billed charges,5554.82,75,,,percent of total billed charges,75% of total billed charges,7406.42,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,7406.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,7406.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,7406.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,7406.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,7406.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,7406.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,7406.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1036.9,14,,,percent of total billed charges,14% of total billed charges,1036.9,7406.42,
33508- Endoscopy/surgical/vein harvest,3430657,CDM,510,RC,33508,HCPCS,Outpatient,,,44.46,22.23,,33.35,75,,,percent of total billed charges,75% of total billed charges,33.35,75,,,percent of total billed charges,75% of total billed charges,14.23,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.22,14,,,percent of total billed charges,14% of total billed charges,6.22,33.35,
"33510- CABG,single coronary venous graft",3430658,CDM,510,RC,33510,HCPCS,Outpatient,,,5198.06,2599.03,,3898.55,75,,,percent of total billed charges,75% of total billed charges,3898.55,75,,,percent of total billed charges,75% of total billed charges,5198.06,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,5198.06,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5198.06,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5198.06,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5198.06,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5198.06,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,5198.06,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5198.06,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,727.73,14,,,percent of total billed charges,14% of total billed charges,727.73,5198.06,
33511- CABG/vein only/2 cor venous gfts,3430857,CDM,510,RC,33511,HCPCS,Outpatient,,,5707.6,2853.8,,4280.7,75,,,percent of total billed charges,75% of total billed charges,4280.7,75,,,percent of total billed charges,75% of total billed charges,5707.6,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,5707.6,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5707.6,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5707.6,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5707.6,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5707.6,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,5707.6,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5707.6,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,799.06,14,,,percent of total billed charges,14% of total billed charges,799.06,5707.6,
33512- CABG/vein only/3 cor venous gfts,3430858,CDM,510,RC,33512,HCPCS,Outpatient,,,6509.71,3254.86,,4882.28,75,,,percent of total billed charges,75% of total billed charges,4882.28,75,,,percent of total billed charges,75% of total billed charges,6509.71,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,6509.71,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6509.71,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6509.71,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6509.71,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6509.71,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,6509.71,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6509.71,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,911.36,14,,,percent of total billed charges,14% of total billed charges,911.36,6509.71,
33513- CABG/vein only/4 cor venous gfts,3430859,CDM,510,RC,33513,HCPCS,Outpatient,,,6672.45,3336.23,,5004.34,75,,,percent of total billed charges,75% of total billed charges,5004.34,75,,,percent of total billed charges,75% of total billed charges,6672.45,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,6672.45,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6672.45,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6672.45,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6672.45,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6672.45,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,6672.45,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6672.45,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,934.14,14,,,percent of total billed charges,14% of total billed charges,934.14,6672.45,
33517- CABG venous & art 1 vein graft,3430659,CDM,510,RC,33517,HCPCS,Outpatient,,,508.39,254.2,,381.29,75,,,percent of total billed charges,75% of total billed charges,381.29,75,,,percent of total billed charges,75% of total billed charges,508.39,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,508.39,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,508.39,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,508.39,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,508.39,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,508.39,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,508.39,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,508.39,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,71.17,14,,,percent of total billed charges,14% of total billed charges,71.17,508.39,
33518- CABG venous & art 2 vein graft,3430660,CDM,510,RC,33518,HCPCS,Outpatient,,,1111.41,555.71,,833.56,75,,,percent of total billed charges,75% of total billed charges,833.56,75,,,percent of total billed charges,75% of total billed charges,1111.41,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,1111.41,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1111.41,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1111.41,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1111.41,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1111.41,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,1111.41,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1111.41,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,155.6,14,,,percent of total billed charges,14% of total billed charges,155.6,1111.41,
33519- CABG venous & art 3 vein graft,3430661,CDM,510,RC,33519,HCPCS,Outpatient,,,1473.32,736.66,,1104.99,75,,,percent of total billed charges,75% of total billed charges,1104.99,75,,,percent of total billed charges,75% of total billed charges,1473.32,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,1473.32,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1473.32,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1473.32,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1473.32,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1473.32,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,1473.32,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1473.32,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,206.26,14,,,percent of total billed charges,14% of total billed charges,206.26,1473.32,
33521- CABG venous & art 4 vein graft,3430662,CDM,510,RC,33521,HCPCS,Outpatient,,,1766.42,883.21,,1324.82,75,,,percent of total billed charges,75% of total billed charges,1324.82,75,,,percent of total billed charges,75% of total billed charges,1766.42,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,1766.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1766.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1766.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1766.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1766.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,1766.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1766.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,247.3,14,,,percent of total billed charges,14% of total billed charges,247.3,1766.42,
33522- CABG venous & art 5 vein graft,3430663,CDM,510,RC,33522,HCPCS,Outpatient,,,1982.69,991.35,,1487.02,75,,,percent of total billed charges,75% of total billed charges,1487.02,75,,,percent of total billed charges,75% of total billed charges,1982.69,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,1982.69,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1982.69,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1982.69,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1982.69,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1982.69,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,1982.69,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1982.69,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,277.58,14,,,percent of total billed charges,14% of total billed charges,277.58,1982.69,
33523- CABG venous & art 6 vein graft,3430664,CDM,510,RC,33523,HCPCS,Outpatient,,,2244.48,1122.24,,1683.36,75,,,percent of total billed charges,75% of total billed charges,1683.36,75,,,percent of total billed charges,75% of total billed charges,2244.48,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,2244.48,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2244.48,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2244.48,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2244.48,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2244.48,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,2244.48,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2244.48,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,314.23,14,,,percent of total billed charges,14% of total billed charges,314.23,2244.48,
33530- CABG/valve reop >1 mo p org proced,3430665,CDM,510,RC,33530,HCPCS,Outpatient,,,1420.17,710.09,,1065.13,75,,,percent of total billed charges,75% of total billed charges,1065.13,75,,,percent of total billed charges,75% of total billed charges,1420.17,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,1420.17,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1420.17,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1420.17,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1420.17,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1420.17,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,1420.17,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1420.17,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,198.82,14,,,percent of total billed charges,14% of total billed charges,198.82,1420.17,
"33533- CABG,single artery graft",3430666,CDM,510,RC,33533,HCPCS,Outpatient,,,5027.93,2513.97,,3770.95,75,,,percent of total billed charges,75% of total billed charges,3770.95,75,,,percent of total billed charges,75% of total billed charges,5027.93,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,5027.93,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5027.93,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5027.93,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5027.93,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5027.93,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,5027.93,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5027.93,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,703.91,14,,,percent of total billed charges,14% of total billed charges,703.91,5027.93,
"33534- CABG, 2 arterial grafts",3430667,CDM,510,RC,33534,HCPCS,Outpatient,,,5907.17,2953.59,,4430.38,75,,,percent of total billed charges,75% of total billed charges,4430.38,75,,,percent of total billed charges,75% of total billed charges,5907.17,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,5907.17,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5907.17,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5907.17,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5907.17,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5907.17,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,5907.17,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5907.17,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,827,14,,,percent of total billed charges,14% of total billed charges,827,5907.17,
"33535- CABG, 3 arterial grafts",3430668,CDM,510,RC,33535,HCPCS,Outpatient,,,6581.65,3290.83,,4936.24,75,,,percent of total billed charges,75% of total billed charges,4936.24,75,,,percent of total billed charges,75% of total billed charges,6581.65,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,6581.65,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6581.65,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6581.65,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6581.65,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6581.65,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,6581.65,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6581.65,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,921.43,14,,,percent of total billed charges,14% of total billed charges,921.43,6581.65,
33545- Rpr postinfarc VSD/w w/o myo resec,3430862,CDM,510,RC,33545,HCPCS,Outpatient,,,8270.99,4135.5,,6203.24,75,,,percent of total billed charges,75% of total billed charges,6203.24,75,,,percent of total billed charges,75% of total billed charges,8270.99,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,8270.99,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,8270.99,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,8270.99,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,8270.99,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,8270.99,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,8270.99,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,8270.99,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1157.94,14,,,percent of total billed charges,14% of total billed charges,1157.94,8270.99,
33548- Ventricular restoration proc/surg,3430863,CDM,510,RC,33548,HCPCS,Outpatient,,,7989.63,3994.82,,5992.22,75,,,percent of total billed charges,75% of total billed charges,5992.22,75,,,percent of total billed charges,75% of total billed charges,7989.63,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,7989.63,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,7989.63,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,7989.63,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,7989.63,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,7989.63,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,7989.63,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,7989.63,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1118.55,14,,,percent of total billed charges,14% of total billed charges,1118.55,7989.63,
33572- Open cor endarterect w CABG/ea ves,3430669,CDM,510,RC,33572,HCPCS,Outpatient,,,622.76,311.38,,467.07,75,,,percent of total billed charges,75% of total billed charges,467.07,75,,,percent of total billed charges,75% of total billed charges,622.76,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,622.76,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,622.76,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,622.76,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,622.76,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,622.76,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,622.76,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,622.76,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,87.19,14,,,percent of total billed charges,14% of total billed charges,87.19,622.76,
33641- ASD repair/CP bypass w w/o patch,3430670,CDM,510,RC,33641,HCPCS,Outpatient,,,4401.08,2200.54,,3300.81,75,,,percent of total billed charges,75% of total billed charges,3300.81,75,,,percent of total billed charges,75% of total billed charges,4401.08,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,4401.08,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4401.08,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4401.08,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4401.08,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4401.08,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,4401.08,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4401.08,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,616.15,14,,,percent of total billed charges,14% of total billed charges,616.15,4401.08,
33735 - (PF) Atrial septectomy or septostomy; closed heart (Blalock-Hanlon type operation),3634899,CDM,510,RC,33735,HCPCS,Outpatient,,,3466.59,1733.3,,2599.94,75,,,percent of total billed charges,75% of total billed charges,2599.94,75,,,percent of total billed charges,75% of total billed charges,3466.59,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,3466.59,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3466.59,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3466.59,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3466.59,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3466.59,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,3466.59,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3466.59,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,485.32,14,,,percent of total billed charges,14% of total billed charges,485.32,3466.59,
33858 - ASCEND AORTIC GRFT W/CARIOPUL BYPASS,3429669,CDM,960,RC,33858,HCPCS,Outpatient,,,9150.6,4575.3,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
ASCEND AORTIC GRFT W/ CARDIOPUL BYP,3527865,CDM,481,RC,33858,HCPCS,Outpatient,,,9150.6,4575.3,,6862.95,75,,,percent of total billed charges,75% of total billed charges,6862.95,75,,,percent of total billed charges,75% of total billed charges,9150.6,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,9150.6,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,9150.6,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,9150.6,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,9150.6,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,9150.6,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,9150.6,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,9150.6,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1281.08,14,,,percent of total billed charges,14% of total billed charges,1281.08,9150.6,
33859 - ASCEND AORTIC GRFT W/ CARDIOPULBYPASS,3429672,CDM,960,RC,33859,HCPCS,Outpatient,,,6568.41,3284.21,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
ASCEND AORTIC GRFT W/CARDIOPUL BYP,3527866,CDM,481,RC,33859,HCPCS,Outpatient,,,6568.41,3284.21,,4926.31,75,,,percent of total billed charges,75% of total billed charges,4926.31,75,,,percent of total billed charges,75% of total billed charges,6568.41,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,6568.41,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6568.41,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6568.41,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6568.41,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6568.41,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,6568.41,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6568.41,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,919.58,14,,,percent of total billed charges,14% of total billed charges,919.58,6568.41,
33863- AA graft w/BP/aortic root replace,3430671,CDM,510,RC,33863,HCPCS,Outpatient,,,8482.33,4241.17,,6361.75,75,,,percent of total billed charges,75% of total billed charges,6361.75,75,,,percent of total billed charges,75% of total billed charges,8482.33,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,8482.33,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,8482.33,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,8482.33,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,8482.33,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,8482.33,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,8482.33,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,8482.33,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1187.53,14,,,percent of total billed charges,14% of total billed charges,1187.53,8482.33,
33864- Asc aort gft/CP/root rem/cor recon,3430866,CDM,510,RC,33864,HCPCS,Outpatient,,,8680.04,4340.02,,6510.03,75,,,percent of total billed charges,75% of total billed charges,6510.03,75,,,percent of total billed charges,75% of total billed charges,8680.04,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,8680.04,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,8680.04,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,8680.04,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,8680.04,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,8680.04,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,8680.04,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,8680.04,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1215.21,14,,,percent of total billed charges,14% of total billed charges,1215.21,8680.04,
33880- Descend thora aorta rpr/lt sub art,3430867,CDM,510,RC,33880,HCPCS,Outpatient,,,4850.93,2425.47,,3638.2,75,,,percent of total billed charges,75% of total billed charges,3638.2,75,,,percent of total billed charges,75% of total billed charges,4850.93,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,4850.93,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4850.93,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4850.93,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4850.93,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4850.93,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,4850.93,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4850.93,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,679.13,14,,,percent of total billed charges,14% of total billed charges,679.13,4850.93,
33880-PF TEVAR - Endovasc TAA Repair INCL Subcl,4213467,CDM,960,RC,33880,HCPCS,Outpatient,,,3812.18,1906.09,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
33880-TEVAR - Endovasc TAA Repair INCL Subcl,4213466,CDM,481,RC,33880,HCPCS,Outpatient,,,3812.18,1906.09,,2859.14,75,,,percent of total billed charges,75% of total billed charges,2859.14,75,,,percent of total billed charges,75% of total billed charges,3812.18,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,3812.18,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3812.18,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3812.18,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3812.18,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3812.18,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,3812.18,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3812.18,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,533.71,14,,,percent of total billed charges,14% of total billed charges,533.71,3812.18,
TEVAR - Endovasc TAA Repair INCL Subcl,,,761,RC,33880,HCPCS,Outpatient,,,3812.18,1906.09,,2859.14,75,,,percent of total billed charges,75% of total billed charges,2859.14,75,,,percent of total billed charges,75% of total billed charges,3812.18,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,3812.18,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3812.18,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3812.18,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3812.18,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3812.18,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,3812.18,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3812.18,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,533.71,14,,,percent of total billed charges,14% of total billed charges,533.71,3812.18,
33881- Des thora aorta rpr w/o lt sub art,3430868,CDM,510,RC,33881,HCPCS,Outpatient,,,4156.29,2078.15,,3117.22,75,,,percent of total billed charges,75% of total billed charges,3117.22,75,,,percent of total billed charges,75% of total billed charges,4156.29,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,4156.29,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4156.29,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4156.29,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4156.29,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4156.29,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,4156.29,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4156.29,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,581.88,14,,,percent of total billed charges,14% of total billed charges,581.88,4156.29,
33881-PF TEVAR - Endovasc TAA Repair WO Subcl,4213464,CDM,960,RC,33881,HCPCS,Outpatient,,,3264.46,1632.23,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
33881-TEVAR - Endovasc TAA Repair WO Subcl,4213463,CDM,481,RC,33881,HCPCS,Outpatient,,,3264.46,1632.23,,2448.35,75,,,percent of total billed charges,75% of total billed charges,2448.35,75,,,percent of total billed charges,75% of total billed charges,3264.46,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,3264.46,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3264.46,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3264.46,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3264.46,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3264.46,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,3264.46,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3264.46,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,457.02,14,,,percent of total billed charges,14% of total billed charges,457.02,3264.46,
TEVAR - Endovasc TAA Repair WO Subcl,,,761,RC,33881,HCPCS,Outpatient,,,3264.46,1632.23,,2448.35,75,,,percent of total billed charges,75% of total billed charges,2448.35,75,,,percent of total billed charges,75% of total billed charges,3264.46,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,3264.46,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3264.46,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3264.46,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3264.46,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3264.46,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,3264.46,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3264.46,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,457.02,14,,,percent of total billed charges,14% of total billed charges,457.02,3264.46,
33883- Prox ext prosth/rpr descend thorac aorta/initial,3430869,CDM,510,RC,33883,HCPCS,Outpatient,,,3002.73,1501.37,,2252.05,75,,,percent of total billed charges,75% of total billed charges,2252.05,75,,,percent of total billed charges,75% of total billed charges,3002.73,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,3002.73,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3002.73,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3002.73,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3002.73,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3002.73,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,3002.73,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3002.73,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,420.38,14,,,percent of total billed charges,14% of total billed charges,420.38,3002.73,
33883-PF Placement of prox ext. prosthesis for endovasc repair of descend  thoracic aorta,4271128,CDM,960,RC,33883,HCPCS,Outpatient,,,2359.64,1179.82,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
33883-Placement of prox ext prosthesis for endovasc repair of descend  thoracic aorta,4271127,CDM,481,RC,33883,HCPCS,Outpatient,,,2359.64,1179.82,,1769.73,75,,,percent of total billed charges,75% of total billed charges,1769.73,75,,,percent of total billed charges,75% of total billed charges,2359.64,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,2359.64,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2359.64,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2359.64,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2359.64,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2359.64,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,2359.64,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2359.64,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,330.35,14,,,percent of total billed charges,14% of total billed charges,330.35,2359.64,
33884- Prox ext prosth/rpr descend thorac aorta/ea add prox ext,3430870,CDM,510,RC,33884,HCPCS,Outpatient,,,1082.99,541.5,,812.24,75,,,percent of total billed charges,75% of total billed charges,812.24,75,,,percent of total billed charges,75% of total billed charges,1082.99,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,1082.99,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1082.99,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1082.99,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1082.99,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1082.99,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,1082.99,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1082.99,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,151.62,14,,,percent of total billed charges,14% of total billed charges,151.62,1082.99,
33884-PF Placement of prox ext. prosthesis for endovasc repair of descend thoracic aorta- each add't,4271130,CDM,960,RC,33884,HCPCS,Outpatient,,,849.78,424.89,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
33884-Placement of prox ext. prosthesis for endovasc repair of descend thoracic aorta- each add't,4271129,CDM,481,RC,33884,HCPCS,Outpatient,,,849.78,424.89,,637.34,75,,,percent of total billed charges,75% of total billed charges,637.34,75,,,percent of total billed charges,75% of total billed charges,849.78,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,849.78,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,849.78,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,849.78,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,849.78,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,849.78,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,849.78,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,849.78,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,118.97,14,,,percent of total billed charges,14% of total billed charges,118.97,849.78,
33895 - Evasc St Rpr Coarcj Thrc/AA XCRSG Maj Side Brnch,4201241,CDM,983,RC,33895,HCPCS,Outpatient,,,1649.95,824.98,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
33915-Percutaneous Pulmonary Embolectomy,3431822,CDM,360,RC,33915,HCPCS,Outpatient,,,3703.25,1851.63,,2777.44,75,,,percent of total billed charges,75% of total billed charges,2777.44,75,,,percent of total billed charges,75% of total billed charges,3703.25,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,3703.25,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3703.25,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3703.25,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3703.25,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3703.25,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,3703.25,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3703.25,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,518.46,14,,,percent of total billed charges,14% of total billed charges,518.46,3703.25,
Percutaneous Pulmonary Embolectomy,3427261,CDM,960,RC,33915,HCPCS,Outpatient,,,3703.25,1851.63,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
33947-Ecmo/ecls initiation artery.,3754893,CDM,481,RC,33947,HCPCS,Outpatient,,,923.54,461.77,,692.66,75,,,percent of total billed charges,75% of total billed charges,692.66,75,,,percent of total billed charges,75% of total billed charges,923.54,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,923.54,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,923.54,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,923.54,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,923.54,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,923.54,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,923.54,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,923.54,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,129.3,14,,,percent of total billed charges,14% of total billed charges,129.3,923.54,
33947-PF Ecmo/ecls initiation artery,3754894,CDM,960,RC,33947,HCPCS,Outpatient,,,923.54,461.77,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
33948- ECMO/ECLS/daily mgmt/venous,3430672,CDM,510,RC,33948,HCPCS,Outpatient,,,637.04,318.52,,477.78,75,,,percent of total billed charges,75% of total billed charges,477.78,75,,,percent of total billed charges,75% of total billed charges,637.04,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,637.04,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,637.04,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,637.04,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,637.04,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,637.04,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,637.04,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,637.04,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,89.19,14,,,percent of total billed charges,14% of total billed charges,89.19,637.04,
33952- Extracorporeal membrane oxygenation (ECMO)/extracorpo,3566782,CDM,510,RC,33952,HCPCS,Outpatient,,,1152.52,576.26,,864.39,75,,,percent of total billed charges,75% of total billed charges,864.39,75,,,percent of total billed charges,75% of total billed charges,1152.52,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,1152.52,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1152.52,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1152.52,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1152.52,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1152.52,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,1152.52,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1152.52,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,161.35,14,,,percent of total billed charges,14% of total billed charges,161.35,1152.52,
33952-Ecmo/ecls insj prph cannula,3754895,CDM,481,RC,33952,HCPCS,Outpatient,,,1152.52,576.26,,864.39,75,,,percent of total billed charges,75% of total billed charges,864.39,75,,,percent of total billed charges,75% of total billed charges,1152.52,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,1152.52,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1152.52,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1152.52,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1152.52,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1152.52,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,1152.52,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1152.52,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,161.35,14,,,percent of total billed charges,14% of total billed charges,161.35,1152.52,
33952-PF Ecmo/ecls insj prph cannula,3754896,CDM,960,RC,33952,HCPCS,Outpatient,,,1152.52,576.26,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
"33967- Insert IABP, percutaneous",3430674,CDM,481,RC,33967,HCPCS,Outpatient,,,696.98,348.49,,522.74,75,,,percent of total billed charges,75% of total billed charges,522.74,75,,,percent of total billed charges,75% of total billed charges,696.98,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,696.98,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,696.98,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,696.98,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,696.98,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,696.98,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,696.98,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,696.98,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,97.58,14,,,percent of total billed charges,14% of total billed charges,97.58,696.98,
33967-INSERTION INTRA AORTIC BALLOON PUMP,3431823,CDM,481,RC,33967,HCPCS,Outpatient,,,696.98,348.49,,522.74,75,,,percent of total billed charges,75% of total billed charges,522.74,75,,,percent of total billed charges,75% of total billed charges,696.98,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,696.98,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,696.98,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,696.98,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,696.98,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,696.98,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,696.98,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,696.98,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,97.58,14,,,percent of total billed charges,14% of total billed charges,97.58,696.98,
33967-PF INSERTION INTRA AORTIC BALLOON PUMP,3580875,CDM,960,RC,33967,HCPCS,Outpatient,,,696.98,348.49,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
33967-PF INSERTION INTRA-AORTIC BALLOON ASSIST DEV PERQ,4321419,CDM,981,RC,33967,HCPCS,Outpatient,,,513.98,256.99,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
Intra Aortic Balloon Pump Insertion,634101,CDM,481,RC,33967,HCPCS,Outpatient,,,681.03,340.52,,510.77,75,,,percent of total billed charges,75% of total billed charges,510.77,75,,,percent of total billed charges,75% of total billed charges,681.03,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,681.03,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,681.03,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,681.03,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,681.03,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,681.03,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,681.03,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,681.03,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,95.34,14,,,percent of total billed charges,14% of total billed charges,95.34,681.03,
33968- Remove IABP/percutaneous,3430873,CDM,510,RC,33968,HCPCS,Outpatient,,,88.72,44.36,,66.54,75,,,percent of total billed charges,75% of total billed charges,66.54,75,,,percent of total billed charges,75% of total billed charges,88.72,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,88.72,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,88.72,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,88.72,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,88.72,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,88.72,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,88.72,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,88.72,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,12.42,14,,,percent of total billed charges,14% of total billed charges,12.42,88.72,
33968-PF Removal of Intra-aortic balloon pump,4271132,CDM,960,RC,33968,HCPCS,Outpatient,,,88.72,44.36,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
33968-Removal of Intra-aortic balloon pump,4271131,CDM,481,RC,33968,HCPCS,Outpatient,,,88.72,44.36,,66.54,75,,,percent of total billed charges,75% of total billed charges,66.54,75,,,percent of total billed charges,75% of total billed charges,88.72,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,88.72,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,88.72,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,88.72,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,88.72,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,88.72,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,88.72,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,88.72,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,12.42,14,,,percent of total billed charges,14% of total billed charges,12.42,88.72,
Removal of Balloon Pump,,,960,RC,33968,HCPCS,Outpatient,,,89.6,44.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
33970 - Insj Intra-Aort Balo Assist Dev Via Fem Art Open,4107503,CDM,960,RC,33970,HCPCS,Outpatient,,,853.48,426.74,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
Insert Balloon Pump,,,960,RC,33973,HCPCS,Outpatient,,,1332.66,666.33,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
33975 - PF Insert Ventric Assist Device Xtrcorp Sngl Ventricle,4361838,CDM,960,RC,33975,HCPCS,Outpatient,,,2608.36,1304.18,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
33977 - PF Remove Ventric Assist Device Xtrcorp Sngl Ventricle,4361839,CDM,960,RC,33977,HCPCS,Outpatient,,,2233.88,1116.94,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
33979- Insert VAD/intracorporeal/sgn vent,3430675,CDM,510,RC,33979,HCPCS,Outpatient,,,5260.02,2630.01,,3945.02,75,,,percent of total billed charges,75% of total billed charges,3945.02,75,,,percent of total billed charges,75% of total billed charges,5260.02,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,5260.02,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5260.02,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5260.02,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5260.02,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5260.02,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,5260.02,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5260.02,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,736.4,14,,,percent of total billed charges,14% of total billed charges,736.4,5260.02,
33990- VAD insert/perc/arterial/S&I Left Heart,3430676,CDM,481,RC,33990,HCPCS,Outpatient,,,973.4,486.7,,730.05,75,,,percent of total billed charges,75% of total billed charges,730.05,75,,,percent of total billed charges,75% of total billed charges,973.4,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,973.4,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,973.4,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,973.4,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,973.4,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,973.4,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,973.4,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,973.4,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,136.28,14,,,percent of total billed charges,14% of total billed charges,136.28,973.4,
33990-IMPELLA(INSERT PERCUTANEOUS VENTRIC) LEFT HEART,3431824,CDM,481,RC,33990,HCPCS,Outpatient,,,973.4,486.7,,730.05,75,,,percent of total billed charges,75% of total billed charges,730.05,75,,,percent of total billed charges,75% of total billed charges,973.4,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,973.4,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,973.4,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,973.4,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,973.4,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,973.4,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,973.4,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,973.4,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,136.28,14,,,percent of total billed charges,14% of total billed charges,136.28,973.4,
33990-PF IMPELLA(INSERT PERCUTANEOUS VENTRIC,3580876,CDM,960,RC,33990,HCPCS,Outpatient,,,973.4,486.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
33992-Impella Removal Left Heart,3560671,CDM,481,RC,33992,HCPCS,Outpatient,,,1019.64,509.82,,764.73,75,,,percent of total billed charges,75% of total billed charges,764.73,75,,,percent of total billed charges,75% of total billed charges,1019.64,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,1019.64,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1019.64,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1019.64,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1019.64,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1019.64,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,1019.64,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1019.64,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,142.75,14,,,percent of total billed charges,14% of total billed charges,142.75,1019.64,
33992-PF Impella Removal (In CCL),3580877,CDM,960,RC,33992,HCPCS,Outpatient,,,1019.64,509.82,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
"33992-Removal percutaneous LHV device, arterial or A&V cannu",4197203,CDM,480,RC,33992,HCPCS,Outpatient,,,445.7,222.85,,334.28,75,,,percent of total billed charges,75% of total billed charges,334.28,75,,,percent of total billed charges,75% of total billed charges,445.7,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,445.7,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,445.7,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,445.7,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,445.7,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,445.7,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,445.7,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,445.7,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,62.4,14,,,percent of total billed charges,14% of total billed charges,62.4,445.7,
Impella Removal (In  CCL),,,960,RC,33992,HCPCS,Outpatient,,,1019.64,509.82,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
33993-Impella Reposition (in CCL),4181457,CDM,481,RC,33993,HCPCS,Outpatient,,,891.4,445.7,,668.55,75,,,percent of total billed charges,75% of total billed charges,668.55,75,,,percent of total billed charges,75% of total billed charges,891.4,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,891.4,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,891.4,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,891.4,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,891.4,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,891.4,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,891.4,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,891.4,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,124.8,14,,,percent of total billed charges,14% of total billed charges,124.8,891.4,
33993-PF Impella Reposition ( In  CCL),4181472,CDM,960,RC,33993,HCPCS,Outpatient,,,891.4,445.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
33993-Repositioning percutaneous Left or Right HV device w/,4197204,CDM,480,RC,33993,HCPCS,Outpatient,,,445.7,222.85,,334.28,75,,,percent of total billed charges,75% of total billed charges,334.28,75,,,percent of total billed charges,75% of total billed charges,445.7,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,445.7,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,445.7,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,445.7,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,445.7,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,445.7,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,445.7,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,445.7,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,62.4,14,,,percent of total billed charges,14% of total billed charges,62.4,445.7,
Impella Reposition (in CCL),,,761,RC,33993,HCPCS,Outpatient,,,891.4,445.7,,668.55,75,,,percent of total billed charges,75% of total billed charges,668.55,75,,,percent of total billed charges,75% of total billed charges,891.4,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,891.4,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,891.4,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,891.4,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,891.4,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,891.4,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,891.4,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,891.4,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,124.8,14,,,percent of total billed charges,14% of total billed charges,124.8,891.4,
"33999 - Unlisted procedure, cardiac surgery",4169575,CDM,983,RC,33999,HCPCS,Outpatient,,,4748.8,2374.4,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
33999-PF TAVR Other,4249295,CDM,960,RC,33999,HCPCS,Outpatient,,,3531.92,1765.96,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
33999-RV Impella Placement,3670897,CDM,481,RC,33999,HCPCS,Outpatient,,,1068.24,534.12,,801.18,75,,,percent of total billed charges,75% of total billed charges,801.18,75,,,percent of total billed charges,75% of total billed charges,543.88,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,897.4,165,,,Fee Schedule,165% of CMS OPPS Rate,563.67,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1562.23,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2142.48,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,2683.68,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,543.88,100,,,Fee Schedule,100% of CMS OPPS Rate,563.67,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,149.55,14,,,percent of total billed charges,14% of total billed charges,149.55,2683.68,
33999-TAVR-Other,4249294,CDM,481,RC,33999,HCPCS,Outpatient,,,3531.92,1765.96,,2648.94,75,,,percent of total billed charges,75% of total billed charges,2648.94,75,,,percent of total billed charges,75% of total billed charges,543.88,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,897.4,165,,,Fee Schedule,165% of CMS OPPS Rate,563.67,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1562.23,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2142.48,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,2683.68,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,543.88,100,,,Fee Schedule,100% of CMS OPPS Rate,563.67,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,494.47,14,,,percent of total billed charges,14% of total billed charges,494.47,2683.68,
SURG AST OTHER CARDIAC PROCEDURE,3527879,CDM,960,RC,33999,HCPCS,Outpatient,,,148.92,74.46,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
TAVR-Other,,,761,RC,33999,HCPCS,Outpatient,,,3531.92,1765.96,,2648.94,75,,,percent of total billed charges,75% of total billed charges,2648.94,75,,,percent of total billed charges,75% of total billed charges,543.88,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,897.4,165,,,Fee Schedule,165% of CMS OPPS Rate,563.67,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1562.23,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2142.48,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,2683.68,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,543.88,100,,,Fee Schedule,100% of CMS OPPS Rate,563.67,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,494.47,14,,,percent of total billed charges,14% of total billed charges,494.47,2683.68,
"34101-Arterial Embolectomy or thrombectomy by arm incision (axillary, brachial, innominate, subclavi",4271133,CDM,481,RC,34101,HCPCS,Outpatient,,,1267.8,633.9,,950.85,75,,,percent of total billed charges,75% of total billed charges,950.85,75,,,percent of total billed charges,75% of total billed charges,4832.22,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,7973.16,165,,,Fee Schedule,165% of CMS OPPS Rate,5008.18,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,13879.91,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,19035.18,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,23843.51,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,4832.22,100,,,Fee Schedule,100% of CMS OPPS Rate,5008.18,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,177.49,14,,,percent of total billed charges,14% of total billed charges,177.49,23843.51,
"34101-PF Arterial Embolectomy or thrombectomy by arm incision (axillary, brachial, innominate, subcl",4271134,CDM,960,RC,34101,HCPCS,Outpatient,,,1267.8,633.9,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
34111-Arterial Embolectomy or thrombectomy by arm incision (radial or ulnar),4271135,CDM,481,RC,34111,HCPCS,Outpatient,,,1270.94,635.47,,953.21,75,,,percent of total billed charges,75% of total billed charges,953.21,75,,,percent of total billed charges,75% of total billed charges,4832.22,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,7973.16,165,,,Fee Schedule,165% of CMS OPPS Rate,5008.18,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,13879.91,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,19035.18,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,23843.51,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,4832.22,100,,,Fee Schedule,100% of CMS OPPS Rate,5008.18,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,177.93,14,,,percent of total billed charges,14% of total billed charges,177.93,23843.51,
34111-PF Arterial Embolectomy or thrombectomy by arm incision (radial or ulnar),4271136,CDM,960,RC,34111,HCPCS,Outpatient,,,1270.94,635.47,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
34201- Emb/throm/fempop/aor/ilia/leg inc,3430678,CDM,510,RC,34201,HCPCS,Outpatient,,,2774.53,1387.27,,2080.9,75,,,percent of total billed charges,75% of total billed charges,2080.9,75,,,percent of total billed charges,75% of total billed charges,4832.22,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,7973.16,165,,,Fee Schedule,165% of CMS OPPS Rate,5008.18,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,13879.91,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,19035.18,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,23843.51,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,4832.22,100,,,Fee Schedule,100% of CMS OPPS Rate,5008.18,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,388.43,14,,,percent of total billed charges,14% of total billed charges,388.43,23843.51,
34201-Arterial Embolectomy or thrombectomy by leg incision (fempop or aortoiliac),4271137,CDM,481,RC,34201,HCPCS,Outpatient,,,2176.29,1088.15,,1632.22,75,,,percent of total billed charges,75% of total billed charges,1632.22,75,,,percent of total billed charges,75% of total billed charges,4832.22,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,7973.16,165,,,Fee Schedule,165% of CMS OPPS Rate,5008.18,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,13879.91,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,19035.18,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,23843.51,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,4832.22,100,,,Fee Schedule,100% of CMS OPPS Rate,5008.18,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,304.68,14,,,percent of total billed charges,14% of total billed charges,304.68,23843.51,
34201-PF Arterial Embolectomy or thrombectomy by leg incision (fempop or aortoiliac),4271138,CDM,960,RC,34201,HCPCS,Outpatient,,,2176.29,1088.15,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
34203- Emb/throm/pop-tib-pero art/leg inc,3430679,CDM,510,RC,34203,HCPCS,Outpatient,,,2570.61,1285.31,,1927.96,75,,,percent of total billed charges,75% of total billed charges,1927.96,75,,,percent of total billed charges,75% of total billed charges,4832.22,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,7973.16,165,,,Fee Schedule,165% of CMS OPPS Rate,5008.18,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,13879.91,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,19035.18,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,23843.51,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,4832.22,100,,,Fee Schedule,100% of CMS OPPS Rate,5008.18,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,359.89,14,,,percent of total billed charges,14% of total billed charges,359.89,23843.51,
34203-Arterial Embolectomy or thrombectomy by leg incision (popliteal-tibio-peroneal),4271139,CDM,481,RC,34203,HCPCS,Outpatient,,,2016.42,1008.21,,1512.32,75,,,percent of total billed charges,75% of total billed charges,1512.32,75,,,percent of total billed charges,75% of total billed charges,4832.22,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,7973.16,165,,,Fee Schedule,165% of CMS OPPS Rate,5008.18,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,13879.91,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,19035.18,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,23843.51,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,4832.22,100,,,Fee Schedule,100% of CMS OPPS Rate,5008.18,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,282.3,14,,,percent of total billed charges,14% of total billed charges,282.3,23843.51,
34203-PF Arterial Embolectomy or thrombectomy by leg incision (popliteal-tibio-peroneal),4271140,CDM,960,RC,34203,HCPCS,Outpatient,,,2016.42,1008.21,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
34421 - THRMBC DIR/W/CATH V/C ILIAC FEMPOP VEIN LEG INC,4037488,CDM,983,RC,34421,HCPCS,Outpatient,,,1889.56,944.78,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
34701 - EVASC RPR DPLMNT AORTO-AORTIC NDGFT,4037491,CDM,983,RC,34701,HCPCS,Outpatient,,,3356.87,1678.44,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
34701- EVASC RPR A-AO NDGFT,3556815,CDM,481,RC,34701,HCPCS,Outpatient,,,3356.87,1678.44,,2517.65,75,,,percent of total billed charges,75% of total billed charges,2517.65,75,,,percent of total billed charges,75% of total billed charges,3356.87,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,3356.87,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3356.87,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3356.87,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3356.87,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3356.87,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,3356.87,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3356.87,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,469.96,14,,,percent of total billed charges,14% of total billed charges,469.96,3356.87,
34701-EVASC RPR A-AO NDGFT,,,960,RC,34701,HCPCS,Outpatient,,,3285.77,1642.89,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
EVASC RPR A-AO NDGFT,3527868,CDM,960,RC,34701,HCPCS,Outpatient,,,3356.87,1678.44,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
34702 - Endovascular repair of infrarenal aorta by deployment of an aorto-aortic tube endograft incl,3783518,CDM,510,RC,34702,HCPCS,Outpatient,,,5019.67,2509.84,,3764.75,75,,,percent of total billed charges,75% of total billed charges,3764.75,75,,,percent of total billed charges,75% of total billed charges,5019.67,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,5019.67,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5019.67,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5019.67,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5019.67,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5019.67,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,5019.67,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5019.67,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,702.75,14,,,percent of total billed charges,14% of total billed charges,702.75,5019.67,
34702- EVASC RPR A-AO NDGFT RPT,3556816,CDM,481,RC,34702,HCPCS,Outpatient,,,5019.67,2509.84,,3764.75,75,,,percent of total billed charges,75% of total billed charges,3764.75,75,,,percent of total billed charges,75% of total billed charges,5019.67,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,5019.67,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5019.67,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5019.67,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5019.67,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5019.67,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,5019.67,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5019.67,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,702.75,14,,,percent of total billed charges,14% of total billed charges,702.75,5019.67,
34702-EVASC RPR A-AO NDGFT RPT,,,960,RC,34702,HCPCS,Outpatient,,,4920.1,2460.05,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
EVASC RPR A-AO NDGFT RPT,3527869,CDM,960,RC,34702,HCPCS,Outpatient,,,5019.67,2509.84,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
34703 Endovascular repair of infrarenal aorta and/or iliac artery(ies) by deployment of an aorto-uni,3623200,CDM,510,RC,34703,HCPCS,Outpatient,,,3726.28,1863.14,,2794.71,75,,,percent of total billed charges,75% of total billed charges,2794.71,75,,,percent of total billed charges,75% of total billed charges,3726.28,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,3726.28,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3726.28,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3726.28,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3726.28,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3726.28,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,3726.28,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3726.28,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,521.68,14,,,percent of total billed charges,14% of total billed charges,521.68,3726.28,
34703- EVASC RPR A-UNILAC NDGFT,3556817,CDM,481,RC,34703,HCPCS,Outpatient,,,3726.28,1863.14,,2794.71,75,,,percent of total billed charges,75% of total billed charges,2794.71,75,,,percent of total billed charges,75% of total billed charges,3726.28,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,3726.28,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3726.28,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3726.28,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3726.28,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3726.28,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,3726.28,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3726.28,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,521.68,14,,,percent of total billed charges,14% of total billed charges,521.68,3726.28,
34703-EVASC RPR A-UNILAC NDGFT,,,960,RC,34703,HCPCS,Outpatient,,,3661.54,1830.77,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
EVASC RPR A-UNILAC NDGFT,3527870,CDM,960,RC,34703,HCPCS,Outpatient,,,3726.28,1863.14,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
34704- EVASC RPR A-UNILAC NDGFT RPT,3556818,CDM,481,RC,34704,HCPCS,Outpatient,,,6216.64,3108.32,,4662.48,75,,,percent of total billed charges,75% of total billed charges,4662.48,75,,,percent of total billed charges,75% of total billed charges,6216.64,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,6216.64,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6216.64,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6216.64,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6216.64,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6216.64,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,6216.64,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6216.64,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,870.33,14,,,percent of total billed charges,14% of total billed charges,870.33,6216.64,
34704-EVASC RPR A-UNILAC  NDGFT RPT,,,960,RC,34704,HCPCS,Outpatient,,,6107.24,3053.62,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
EVASC RPR A-UNILAC NDGFT RPT,3527871,CDM,960,RC,34704,HCPCS,Outpatient,,,6216.64,3108.32,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
34705- EVAC RPR A-BIILIAC NDGFT,3556819,CDM,481,RC,34705,HCPCS,Outpatient,,,4141.43,2070.72,,3106.07,75,,,percent of total billed charges,75% of total billed charges,3106.07,75,,,percent of total billed charges,75% of total billed charges,4141.43,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,4141.43,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4141.43,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4141.43,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4141.43,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4141.43,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,4141.43,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4141.43,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,579.8,14,,,percent of total billed charges,14% of total billed charges,579.8,4141.43,
34705-EVAC RPR A-BIILIAC NDGFT,3430882,CDM,960,RC,34705,HCPCS,Outpatient,,,4141.43,2070.72,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
34706- EVASC RPR A-BIILIAC RPT,3556820,CDM,481,RC,34706,HCPCS,Outpatient,,,6206.71,3103.36,,4655.03,75,,,percent of total billed charges,75% of total billed charges,4655.03,75,,,percent of total billed charges,75% of total billed charges,6206.71,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,6206.71,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6206.71,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6206.71,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6206.71,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6206.71,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,6206.71,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6206.71,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,868.94,14,,,percent of total billed charges,14% of total billed charges,868.94,6206.71,
34706-EVASC RPR A-BIILIAC RPT,,,960,RC,34706,HCPCS,Outpatient,,,6076.13,3038.07,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
EVASC RPR A-BIILIAC RPT,3527872,CDM,960,RC,34706,HCPCS,Outpatient,,,6206.71,3103.36,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
34707- EVASC RPR ILIO-ILIAC NDGFT,3556821,CDM,481,RC,34707,HCPCS,Outpatient,,,3133.14,1566.57,,2349.86,75,,,percent of total billed charges,75% of total billed charges,2349.86,75,,,percent of total billed charges,75% of total billed charges,3133.14,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,3133.14,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3133.14,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3133.14,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3133.14,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3133.14,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,3133.14,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3133.14,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,438.64,14,,,percent of total billed charges,14% of total billed charges,438.64,3133.14,
34707-EVASC RPR ILIO-ILIAC NDGFT,,,960,RC,34707,HCPCS,Outpatient,,,3097.4,1548.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
EVASC RPR ILIO-ILIAC NDGFT,3527873,CDM,960,RC,34707,HCPCS,Outpatient,,,3133.14,1566.57,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
34708- EVASC RPR ILIO-ILIAC RPT,3556822,CDM,481,RC,34708,HCPCS,Outpatient,,,5017.12,2508.56,,3762.84,75,,,percent of total billed charges,75% of total billed charges,3762.84,75,,,percent of total billed charges,75% of total billed charges,5017.12,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,5017.12,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5017.12,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5017.12,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5017.12,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5017.12,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,5017.12,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5017.12,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,702.4,14,,,percent of total billed charges,14% of total billed charges,702.4,5017.12,
34708-EVASC RPR ILIO-ILIAC RPT,,,960,RC,34708,HCPCS,Outpatient,,,4871.18,2435.59,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
EVASC RPR ILIO-ILIAC RPT,3527874,CDM,960,RC,34708,HCPCS,Outpatient,,,5017.12,2508.56,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
34709 - Placement of extension prosthesis(es) distal to the common iliac artery(ies) or proximal to,3783521,CDM,510,RC,34709,HCPCS,Outpatient,,,878.05,439.03,,658.54,75,,,percent of total billed charges,75% of total billed charges,658.54,75,,,percent of total billed charges,75% of total billed charges,878.05,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,878.05,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,878.05,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,878.05,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,878.05,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,878.05,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,878.05,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,878.05,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,122.93,14,,,percent of total billed charges,14% of total billed charges,122.93,878.05,
34709- PLMT XTN PROSTH EVASC RPR,3556823,CDM,481,RC,34709,HCPCS,Outpatient,,,878.05,439.03,,658.54,75,,,percent of total billed charges,75% of total billed charges,658.54,75,,,percent of total billed charges,75% of total billed charges,878.05,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,878.05,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,878.05,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,878.05,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,878.05,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,878.05,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,878.05,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,878.05,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,122.93,14,,,percent of total billed charges,14% of total billed charges,122.93,878.05,
34709-PLMT XTN PROSTH EVASC RPR,,,960,RC,34709,HCPCS,Outpatient,,,863.05,431.53,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
PLMT XTN PROSTH EVASC RPR,3527875,CDM,960,RC,34709,HCPCS,Outpatient,,,878.05,439.03,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
34710- DLYD PLMT XTN PROSTH 1ST VSL,3556824,CDM,481,RC,34710,HCPCS,Outpatient,,,2148.47,1074.24,,1611.35,75,,,percent of total billed charges,75% of total billed charges,1611.35,75,,,percent of total billed charges,75% of total billed charges,2148.47,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,2148.47,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2148.47,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2148.47,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2148.47,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2148.47,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,2148.47,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2148.47,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,300.79,14,,,percent of total billed charges,14% of total billed charges,300.79,2148.47,
34710-DLYD PLMT XTN PROSTH 1ST VSL,,,960,RC,34710,HCPCS,Outpatient,,,2107.49,1053.75,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
DLYD PLMT XTN PROSTH 1ST VSL,3527876,CDM,960,RC,34710,HCPCS,Outpatient,,,2148.47,1074.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
34711- DLYD PLMT XTN PROSTH EA ADDL,3556825,CDM,481,RC,34711,HCPCS,Outpatient,,,803.81,401.91,,602.86,75,,,percent of total billed charges,75% of total billed charges,602.86,75,,,percent of total billed charges,75% of total billed charges,803.81,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,803.81,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,803.81,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,803.81,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,803.81,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,803.81,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,803.81,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,803.81,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,112.53,14,,,percent of total billed charges,14% of total billed charges,112.53,803.81,
34711-DLYD PLMT XTN PROSTH EA ADDL,,,960,RC,34711,HCPCS,Outpatient,,,787.56,393.78,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
DLYD PLMT XTN PROSTH EA ADDL,3527877,CDM,960,RC,34711,HCPCS,Outpatient,,,803.81,401.91,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
"34712 - Transcatheter delivery of enhanced fixation device(s) to the endograft (eg, anchor, screw, t",3572786,CDM,960,RC,34712,HCPCS,Outpatient,,,1386.73,693.37,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
"34712-PF Transcatheter delivery of enhanced fixation device(s) to the endograft (eg, anchor, screw,",4271142,CDM,481,RC,34712,HCPCS,Outpatient,,,1386.73,693.37,,1040.05,75,,,percent of total billed charges,75% of total billed charges,1040.05,75,,,percent of total billed charges,75% of total billed charges,1386.73,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,1386.73,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1386.73,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1386.73,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1386.73,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1386.73,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,1386.73,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1386.73,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,194.14,14,,,percent of total billed charges,14% of total billed charges,194.14,1386.73,
"34712-Transcatheter delivery of enhanced fixation device(s) to the endograft (eg, anchor, screw, tac",4271141,CDM,481,RC,34712,HCPCS,Outpatient,,,1386.73,693.37,,1040.05,75,,,percent of total billed charges,75% of total billed charges,1040.05,75,,,percent of total billed charges,75% of total billed charges,1386.73,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,1386.73,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1386.73,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1386.73,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1386.73,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1386.73,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,1386.73,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1386.73,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,194.14,14,,,percent of total billed charges,14% of total billed charges,194.14,1386.73,
34713-Add On Code: Unilateral perc access and closure of fem. art for delivery of endograft through,4271143,CDM,481,RC,34713,HCPCS,Outpatient,,,336.49,168.25,,252.37,75,,,percent of total billed charges,75% of total billed charges,252.37,75,,,percent of total billed charges,75% of total billed charges,107.68,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.11,14,,,percent of total billed charges,14% of total billed charges,47.11,252.37,
34713-PERCUTANEOUS ACCESS & CLOSURE,3430890,CDM,510,RC,34713,HCPCS,Outpatient,,,336.49,168.25,,252.37,75,,,percent of total billed charges,75% of total billed charges,252.37,75,,,percent of total billed charges,75% of total billed charges,107.68,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.11,14,,,percent of total billed charges,14% of total billed charges,47.11,252.37,
34713-PF Add On Code: Unilateral perc access and closure of fem. art for delivery of endograft throu,4271144,CDM,960,RC,34713,HCPCS,Outpatient,,,336.49,168.25,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
34716 - PF Opn Ax/Subcla Art Expos w/ Cndt Crt,4363204,CDM,960,RC,34716,HCPCS,Outpatient,,,743.8,371.9,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
34717-Add On Code: Repair of iliac art. at time of aorto-iliac graft placement of an iliac branched,4271145,CDM,481,RC,34717,HCPCS,Outpatient,,,947.53,473.77,,710.65,75,,,percent of total billed charges,75% of total billed charges,710.65,75,,,percent of total billed charges,75% of total billed charges,947.53,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,947.53,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,947.53,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,947.53,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,947.53,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,947.53,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,947.53,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,947.53,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,132.65,14,,,percent of total billed charges,14% of total billed charges,132.65,947.53,
34717-PF Add On Code: Repair of iliac art. at time of aorto-iliac graft placement of an iliac branch,4271146,CDM,960,RC,34717,HCPCS,Outpatient,,,947.53,473.77,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
34718-PF Repair of iliac art not at time of aorto-iliac graft placement of an iliac branched endogra,4271148,CDM,960,RC,34718,HCPCS,Outpatient,,,2629.18,1314.59,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
34718-Repair of iliac art not at time of aorto-iliac graft placement of an iliac branched endograft,4271147,CDM,481,RC,34718,HCPCS,Outpatient,,,2629.18,1314.59,,1971.89,75,,,percent of total billed charges,75% of total billed charges,1971.89,75,,,percent of total billed charges,75% of total billed charges,2629.18,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,2629.18,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2629.18,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2629.18,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2629.18,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2629.18,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,2629.18,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2629.18,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,368.09,14,,,percent of total billed charges,14% of total billed charges,368.09,2629.18,
34808-Add on code: Endovascular placement of iliac artery occlusion device,4271252,CDM,481,RC,34808,HCPCS,Outpatient,,,433.92,216.96,,325.44,75,,,percent of total billed charges,75% of total billed charges,325.44,75,,,percent of total billed charges,75% of total billed charges,433.92,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,433.92,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,433.92,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,433.92,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,433.92,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,433.92,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,433.92,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,433.92,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,60.75,14,,,percent of total billed charges,14% of total billed charges,60.75,433.92,
34808-PF Add on code: Endovascular placement of iliac artery occlusion device,4271253,CDM,960,RC,34808,HCPCS,Outpatient,,,433.92,216.96,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
34812- Open fem art/endovas prosthes/uni,3430681,CDM,481,RC,34812,HCPCS,Outpatient,,,561.42,280.71,,421.07,75,,,percent of total billed charges,75% of total billed charges,421.07,75,,,percent of total billed charges,75% of total billed charges,561.42,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,561.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,561.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,561.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,561.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,561.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,561.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,561.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,78.6,14,,,percent of total billed charges,14% of total billed charges,78.6,561.42,
34812-FEM CUTDOWN AAA STENT,3431825,CDM,481,RC,34812,HCPCS,Outpatient,,,561.42,280.71,,421.07,75,,,percent of total billed charges,75% of total billed charges,421.07,75,,,percent of total billed charges,75% of total billed charges,561.42,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,561.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,561.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,561.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,561.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,561.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,561.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,561.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,78.6,14,,,percent of total billed charges,14% of total billed charges,78.6,561.42,
34812-PF FEM CUTDOWN AAA STENT,3580879,CDM,960,RC,34812,HCPCS,Outpatient,,,561.42,280.71,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
34813 - Placement of femoral-femoral prosthetic graft during endovascular aortic aneurysm repair (Li,3572794,CDM,960,RC,34813,HCPCS,Outpatient,,,645.15,322.58,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
34813-Add On Code: Placement fem/fem graft during EVAR,4271149,CDM,481,RC,34813,HCPCS,Outpatient,,,505.26,252.63,,378.95,75,,,percent of total billed charges,75% of total billed charges,378.95,75,,,percent of total billed charges,75% of total billed charges,505.26,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,505.26,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,505.26,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,505.26,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,505.26,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,505.26,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,505.26,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,505.26,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,70.74,14,,,percent of total billed charges,14% of total billed charges,70.74,505.26,
34813-PF Add On Code: Placement fem/fem graft during EVAR,4271150,CDM,960,RC,34813,HCPCS,Outpatient,,,505.26,252.63,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
34841-EVAR by deployment of a fenestrated visceral aortic endograft with 1 artery prostheses,4271151,CDM,481,RC,34841,HCPCS,Outpatient,,,3690.92,1845.46,,2768.19,75,,,percent of total billed charges,75% of total billed charges,2768.19,75,,,percent of total billed charges,75% of total billed charges,3690.92,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,3690.92,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3690.92,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3690.92,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3690.92,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3690.92,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,3690.92,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3690.92,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,516.73,14,,,percent of total billed charges,14% of total billed charges,516.73,3690.92,
34841-PF EVAR by deployment of a fenestrated visceral aortic endograft with 1 artery prostheses,4271152,CDM,960,RC,34841,HCPCS,Outpatient,,,3690.92,1845.46,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
34842-EVAR by deployment of a fenestrated visceral aortic endograft with 2 artery prostheses,4271153,CDM,481,RC,34842,HCPCS,Outpatient,,,5307.42,2653.71,,3980.57,75,,,percent of total billed charges,75% of total billed charges,3980.57,75,,,percent of total billed charges,75% of total billed charges,5307.42,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,5307.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5307.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5307.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5307.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5307.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,5307.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5307.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,743.04,14,,,percent of total billed charges,14% of total billed charges,743.04,5307.42,
34842-PF EVAR by deployment of a fenestrated visceral aortic endograft with 2 artery prostheses,4271154,CDM,960,RC,34842,HCPCS,Outpatient,,,5307.42,2653.71,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
34843-EVAR by deployment of a fenestrated visceral aortic endograft with 3 artery prostheses,4271155,CDM,481,RC,34843,HCPCS,Outpatient,,,5307.42,2653.71,,3980.57,75,,,percent of total billed charges,75% of total billed charges,3980.57,75,,,percent of total billed charges,75% of total billed charges,5307.42,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,5307.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5307.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5307.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5307.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5307.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,5307.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5307.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,743.04,14,,,percent of total billed charges,14% of total billed charges,743.04,5307.42,
34843-PF EVAR by deployment of a fenestrated visceral aortic endograft with 3 artery prostheses,4271156,CDM,960,RC,34843,HCPCS,Outpatient,,,5307.42,2653.71,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
34844-EVAR by deployment of a fenestrated visceral aortic endograft with 4 or more artery prostheses,4271157,CDM,481,RC,34844,HCPCS,Outpatient,,,5307.42,2653.71,,3980.57,75,,,percent of total billed charges,75% of total billed charges,3980.57,75,,,percent of total billed charges,75% of total billed charges,5307.42,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,5307.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5307.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5307.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5307.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5307.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,5307.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5307.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,743.04,14,,,percent of total billed charges,14% of total billed charges,743.04,5307.42,
34844-PF EVAR by deployment of a fenestrated visceral aortic endograft with 4 or more artery prosthe,4271158,CDM,960,RC,34844,HCPCS,Outpatient,,,5307.42,2653.71,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
34846-EVAR and infrarenal abd aorta repair with a fenestrated visceral aortic endograft with 2 arter,4271159,CDM,481,RC,34846,HCPCS,Outpatient,,,5099.66,2549.83,,3824.75,75,,,percent of total billed charges,75% of total billed charges,3824.75,75,,,percent of total billed charges,75% of total billed charges,5099.66,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,5099.66,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5099.66,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5099.66,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5099.66,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5099.66,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,5099.66,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5099.66,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,713.95,14,,,percent of total billed charges,14% of total billed charges,713.95,5099.66,
34846-PF EVAR and infrarenal abd aorta repair with a fenestrated visceral aortic endograft with 2 ar,4271160,CDM,960,RC,34846,HCPCS,Outpatient,,,5099.66,2549.83,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
34847-EVAR and infrarenal abd aorta repair with a fenestrated visceral aortic endograft with 3 arter,4271161,CDM,481,RC,34847,HCPCS,Outpatient,,,4996.84,2498.42,,3747.63,75,,,percent of total billed charges,75% of total billed charges,3747.63,75,,,percent of total billed charges,75% of total billed charges,4996.84,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,4996.84,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4996.84,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4996.84,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4996.84,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4996.84,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,4996.84,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4996.84,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,699.56,14,,,percent of total billed charges,14% of total billed charges,699.56,4996.84,
34847-PF EVAR and infrarenal abd aorta repair with a fenestrated visceral aortic endograft with 3 ar,4271162,CDM,960,RC,34847,HCPCS,Outpatient,,,4996.84,2498.42,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
34848-EVAR and infrarenal abd aorta repair with a fenestrated visceral aortic endograft with 4 or mo,4271163,CDM,481,RC,34848,HCPCS,Outpatient,,,4860.1,2430.05,,3645.08,75,,,percent of total billed charges,75% of total billed charges,3645.08,75,,,percent of total billed charges,75% of total billed charges,4860.1,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,4860.1,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4860.1,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4860.1,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4860.1,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4860.1,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,4860.1,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4860.1,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,680.41,14,,,percent of total billed charges,14% of total billed charges,680.41,4860.1,
34848-PF EVAR and infrarenal abd aorta repair with a fenestrated visceral aortic endograft with 4 or,4271164,CDM,960,RC,34848,HCPCS,Outpatient,,,4860.1,2430.05,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
35011 - Rpr Defect of Artery-Dir Rpr Aneurysm Axil-Brachial Arm Incision,3899025,CDM,983,RC,35011,HCPCS,Outpatient,,,2729.35,1364.68,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
"35045 - Direct repair of aneurysm, pseudoaneurysm, or excision (partial or total) and graft insertio",3783530,CDM,510,RC,35045,HCPCS,Outpatient,,,2630.85,1315.43,,1973.14,75,,,percent of total billed charges,75% of total billed charges,1973.14,75,,,percent of total billed charges,75% of total billed charges,4832.22,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,7973.16,165,,,Fee Schedule,165% of CMS OPPS Rate,5008.18,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,13879.91,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,19035.18,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,23843.51,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,4832.22,100,,,Fee Schedule,100% of CMS OPPS Rate,5008.18,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,368.32,14,,,percent of total billed charges,14% of total billed charges,368.32,23843.51,
35141 - DIR RPR Aneurysm & Graft Common Femoral Artery,4169578,CDM,983,RC,35141,HCPCS,Outpatient,,,2656.43,1328.22,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
35151 - PF Dir Rpr Aneurysm & Graft Popliteal Artery,4309236,CDM,960,RC,35151,HCPCS,Outpatient,,,2640.97,1320.49,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
"35201- Repair blood ves, direct neck",3430683,CDM,510,RC,35201,HCPCS,Outpatient,,,2532.04,1266.02,,1899.03,75,,,percent of total billed charges,75% of total billed charges,1899.03,75,,,percent of total billed charges,75% of total billed charges,4832.22,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,7973.16,165,,,Fee Schedule,165% of CMS OPPS Rate,5008.18,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,13879.91,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,19035.18,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,23843.51,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,4832.22,100,,,Fee Schedule,100% of CMS OPPS Rate,5008.18,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,354.49,14,,,percent of total billed charges,14% of total billed charges,354.49,23843.51,
35206- Repair blood vessel direct/up ext,3430684,CDM,510,RC,35206,HCPCS,Outpatient,,,2104.04,1052.02,,1578.03,75,,,percent of total billed charges,75% of total billed charges,1578.03,75,,,percent of total billed charges,75% of total billed charges,2800.71,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,4621.18,165,,,Fee Schedule,165% of CMS OPPS Rate,2902.7,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8044.7,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11032.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13819.53,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,2800.71,100,,,Fee Schedule,100% of CMS OPPS Rate,2902.7,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,294.57,14,,,percent of total billed charges,14% of total billed charges,294.57,13819.53,
35206-PF REPAIR BLOOD VESSEL DIRECT UPPER EXTREMITY,4321672,CDM,981,RC,35206,HCPCS,Outpatient,,,1565.82,782.91,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
35207- Repair blood vess/direct/hand/fing,3430685,CDM,510,RC,35207,HCPCS,Outpatient,,,1971.57,985.79,,1478.68,75,,,percent of total billed charges,75% of total billed charges,1478.68,75,,,percent of total billed charges,75% of total billed charges,2800.71,100,,,Fee Schedule,100% of CMS OPPS Rate,1102.62,102,,,Fee Schedule,102% of WV Medicaid Rate,4621.18,165,,,Fee Schedule,165% of CMS OPPS Rate,2902.7,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8044.7,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11032.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13819.53,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1081,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2800.71,100,,,Fee Schedule,100% of CMS OPPS Rate,2902.7,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,276.02,14,,,percent of total billed charges,14% of total billed charges,276.02,13819.53,
35207-PF REPAIR BLOOD VESSEL DIRECT HAND FINGER,4321671,CDM,981,RC,35207,HCPCS,Outpatient,,,1483.06,741.53,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
35221- Repair blood vess/direct/intra/abd,3430686,CDM,510,RC,35221,HCPCS,Outpatient,,,3980.09,1990.05,,2985.07,75,,,percent of total billed charges,75% of total billed charges,2985.07,75,,,percent of total billed charges,75% of total billed charges,3980.09,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,3980.09,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3980.09,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3980.09,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3980.09,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3980.09,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,3980.09,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3980.09,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,557.21,14,,,percent of total billed charges,14% of total billed charges,557.21,3980.09,
35226- Repair blood vessel direct/low ext,3430687,CDM,510,RC,35226,HCPCS,Outpatient,,,2248.04,1124.02,,1686.03,75,,,percent of total billed charges,75% of total billed charges,1686.03,75,,,percent of total billed charges,75% of total billed charges,610.13,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1006.72,165,,,Fee Schedule,165% of CMS OPPS Rate,632.35,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1752.53,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2403.46,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,3010.58,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,610.13,100,,,Fee Schedule,100% of CMS OPPS Rate,632.35,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,314.73,14,,,percent of total billed charges,14% of total billed charges,314.73,3010.58,
35226-PF RPR BLOOD VESSEL DIRECT LOWER EXTREMITY,4321670,CDM,981,RC,35226,HCPCS,Outpatient,,,1666.04,833.02,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
35236- Rpr blood ves w/vein graft/up ext,3430688,CDM,510,RC,35236,HCPCS,Outpatient,,,2690.1,1345.05,,2017.58,75,,,percent of total billed charges,75% of total billed charges,2017.58,75,,,percent of total billed charges,75% of total billed charges,4832.22,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,7973.16,165,,,Fee Schedule,165% of CMS OPPS Rate,5008.18,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,13879.91,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,19035.18,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,23843.51,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,4832.22,100,,,Fee Schedule,100% of CMS OPPS Rate,5008.18,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,376.61,14,,,percent of total billed charges,14% of total billed charges,376.61,23843.51,
35256 - (50) Repair blood vessel with vein graft; lower extremity,3698997,CDM,510,RC,35256,HCPCS,Outpatient,,,2752.35,1376.18,,2064.26,75,,,percent of total billed charges,75% of total billed charges,2064.26,75,,,percent of total billed charges,75% of total billed charges,4832.22,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,7973.16,165,,,Fee Schedule,165% of CMS OPPS Rate,5008.18,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,13879.91,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,19035.18,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,23843.51,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,4832.22,100,,,Fee Schedule,100% of CMS OPPS Rate,5008.18,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,385.33,14,,,percent of total billed charges,14% of total billed charges,385.33,23843.51,
35256 - PF Repair blood vessel with vein graft; lower extremity,3698994,CDM,510,RC,35256,HCPCS,Outpatient,,,2752.35,1376.18,,2064.26,75,,,percent of total billed charges,75% of total billed charges,2064.26,75,,,percent of total billed charges,75% of total billed charges,4832.22,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,7973.16,165,,,Fee Schedule,165% of CMS OPPS Rate,5008.18,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,13879.91,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,19035.18,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,23843.51,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,4832.22,100,,,Fee Schedule,100% of CMS OPPS Rate,5008.18,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,385.33,14,,,percent of total billed charges,14% of total billed charges,385.33,23843.51,
35266 - (50) Repair blood vessel with graft other than vein; upper extremity,3713007,CDM,510,RC,35266,HCPCS,Outpatient,,,2330.26,1165.13,,1747.7,75,,,percent of total billed charges,75% of total billed charges,1747.7,75,,,percent of total billed charges,75% of total billed charges,4832.22,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,7973.16,165,,,Fee Schedule,165% of CMS OPPS Rate,5008.18,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,13879.91,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,19035.18,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,23843.51,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,4832.22,100,,,Fee Schedule,100% of CMS OPPS Rate,5008.18,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,326.24,14,,,percent of total billed charges,14% of total billed charges,326.24,23843.51,
35266 - PF Repair blood vessel with graft other than vein; upper extremity,3713004,CDM,510,RC,35266,HCPCS,Outpatient,,,2330.26,1165.13,,1747.7,75,,,percent of total billed charges,75% of total billed charges,1747.7,75,,,percent of total billed charges,75% of total billed charges,4832.22,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,7973.16,165,,,Fee Schedule,165% of CMS OPPS Rate,5008.18,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,13879.91,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,19035.18,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,23843.51,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,4832.22,100,,,Fee Schedule,100% of CMS OPPS Rate,5008.18,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,326.24,14,,,percent of total billed charges,14% of total billed charges,326.24,23843.51,
35271- Rpr bld ves/gft no vn/intrathor/BP,3430689,CDM,510,RC,35271,HCPCS,Outpatient,,,3711.36,1855.68,,2783.52,75,,,percent of total billed charges,75% of total billed charges,2783.52,75,,,percent of total billed charges,75% of total billed charges,3711.36,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,3711.36,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3711.36,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3711.36,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3711.36,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3711.36,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,3711.36,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3711.36,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,519.59,14,,,percent of total billed charges,14% of total billed charges,519.59,3711.36,
35301- Thromb/endar/neck inc/car/vert/sub,3430690,CDM,510,RC,35301,HCPCS,Outpatient,,,3059.61,1529.81,,2294.71,75,,,percent of total billed charges,75% of total billed charges,2294.71,75,,,percent of total billed charges,75% of total billed charges,3059.61,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,3059.61,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3059.61,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3059.61,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3059.61,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3059.61,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,3059.61,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3059.61,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,428.35,14,,,percent of total billed charges,14% of total billed charges,428.35,3059.61,
35302- Thromboendarterectomy SF femoral art,3569391,CDM,510,RC,35302,HCPCS,Outpatient,,,3040.46,1520.23,,2280.35,75,,,percent of total billed charges,75% of total billed charges,2280.35,75,,,percent of total billed charges,75% of total billed charges,3040.46,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,3040.46,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3040.46,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3040.46,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3040.46,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3040.46,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,3040.46,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3040.46,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,425.66,14,,,percent of total billed charges,14% of total billed charges,425.66,3040.46,
"35303 - Thromboendarterectomy, including patch graft, if performed; popliteal artery",3783512,CDM,975,RC,35303,HCPCS,Outpatient,,,3346.84,1673.42,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
"35305 Thromboendarterectomy, including patch graft, if performed; tibial or peroneal artery, initial",3622973,CDM,510,RC,35305,HCPCS,Outpatient,,,3328.55,1664.28,,2496.41,75,,,percent of total billed charges,75% of total billed charges,2496.41,75,,,percent of total billed charges,75% of total billed charges,3328.55,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,3328.55,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3328.55,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3328.55,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3328.55,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3328.55,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,3328.55,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3328.55,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,466,14,,,percent of total billed charges,14% of total billed charges,466,3328.55,
35341- Thromboendarterectomy;mesen/celiac/renal,3569380,CDM,510,RC,35341,HCPCS,Outpatient,,,3748.58,1874.29,,2811.44,75,,,percent of total billed charges,75% of total billed charges,2811.44,75,,,percent of total billed charges,75% of total billed charges,3748.58,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,3748.58,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3748.58,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3748.58,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3748.58,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3748.58,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,3748.58,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3748.58,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,524.8,14,,,percent of total billed charges,14% of total billed charges,524.8,3748.58,
"35351 - (50)  Thromboendarterectomy, including patch graft, if performed; iliac",3699122,CDM,510,RC,35351,HCPCS,Outpatient,,,3494.35,1747.18,,2620.76,75,,,percent of total billed charges,75% of total billed charges,2620.76,75,,,percent of total billed charges,75% of total billed charges,3494.35,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,3494.35,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3494.35,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3494.35,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3494.35,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3494.35,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,3494.35,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3494.35,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,489.21,14,,,percent of total billed charges,14% of total billed charges,489.21,3494.35,
"35351 - (PF) Thromboendarterectomy, including patch graft, if performed; iliac",3634901,CDM,510,RC,35351,HCPCS,Outpatient,,,3494.35,1747.18,,2620.76,75,,,percent of total billed charges,75% of total billed charges,2620.76,75,,,percent of total billed charges,75% of total billed charges,3494.35,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,3494.35,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3494.35,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3494.35,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3494.35,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3494.35,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,3494.35,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3494.35,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,489.21,14,,,percent of total billed charges,14% of total billed charges,489.21,3494.35,
35371- Thromboendarterectomy/com femoral,3430691,CDM,510,RC,35371,HCPCS,Outpatient,,,2207.4,1103.7,,1655.55,75,,,percent of total billed charges,75% of total billed charges,1655.55,75,,,percent of total billed charges,75% of total billed charges,2207.4,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,2207.4,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2207.4,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2207.4,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2207.4,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2207.4,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,2207.4,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2207.4,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,309.04,14,,,percent of total billed charges,14% of total billed charges,309.04,2207.4,
"35372 - Thromboendarterectomy, including patch graft, if performed; deep (profunda) femoral",3572787,CDM,960,RC,35372,HCPCS,Outpatient,,,2641.89,1320.95,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
35509 - Bypass W/ Vein Carotid-Contraleteral Carotid,4113111,CDM,975,RC,35509,HCPCS,Outpatient,,,3439.09,1719.55,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
"35521 - Bypass graft, with vein; axillary-femoral",3899028,CDM,983,RC,35521,HCPCS,Outpatient,,,3345.03,1672.52,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
35526- Vein BG/aorto/subclav/innom/caroti,3430694,CDM,510,RC,35526,HCPCS,Outpatient,,,4657.12,2328.56,,3492.84,75,,,percent of total billed charges,75% of total billed charges,3492.84,75,,,percent of total billed charges,75% of total billed charges,4657.12,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,4657.12,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4657.12,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4657.12,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4657.12,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4657.12,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,4657.12,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4657.12,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,652,14,,,percent of total billed charges,14% of total billed charges,652,4657.12,
35531 Bypass graft with vein aortoceliac or aortomesenteri,3623346,CDM,510,RC,35531,HCPCS,Outpatient,,,5325.01,2662.51,,3993.76,75,,,percent of total billed charges,75% of total billed charges,3993.76,75,,,percent of total billed charges,75% of total billed charges,5325.01,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,5325.01,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5325.01,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5325.01,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5325.01,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5325.01,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,5325.01,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5325.01,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,745.5,14,,,percent of total billed charges,14% of total billed charges,745.5,5325.01,
"35540 - (50) Bypass graft, with vein; aortobifemoral",3696902,CDM,510,RC,35540,HCPCS,Outpatient,,,6675.88,3337.94,,5006.91,75,,,percent of total billed charges,75% of total billed charges,5006.91,75,,,percent of total billed charges,75% of total billed charges,6675.88,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,6675.88,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6675.88,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6675.88,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6675.88,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6675.88,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,6675.88,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6675.88,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,934.62,14,,,percent of total billed charges,14% of total billed charges,934.62,6675.88,
"35540 - PF Bypass graft, with vein; aortobifemoral",3696899,CDM,510,RC,35540,HCPCS,Outpatient,,,6675.88,3337.94,,5006.91,75,,,percent of total billed charges,75% of total billed charges,5006.91,75,,,percent of total billed charges,75% of total billed charges,6675.88,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,6675.88,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6675.88,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6675.88,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6675.88,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6675.88,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,6675.88,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6675.88,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,934.62,14,,,percent of total billed charges,14% of total billed charges,934.62,6675.88,
Bypass w/Vein Femoral - Popliteal PF,4223274,CDM,983,RC,35556,HCPCS,Outpatient,,,3021.51,1510.76,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
"35558 - Bypass Graft, with vein femoral-femoral",3800922,CDM,983,RC,35558,HCPCS,Outpatient,,,3333.94,1666.97,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
35566- Vein gft fem A/P tib/pero/dis art,3430695,CDM,510,RC,35566,HCPCS,Outpatient,,,4530.78,2265.39,,3398.09,75,,,percent of total billed charges,75% of total billed charges,3398.09,75,,,percent of total billed charges,75% of total billed charges,4530.78,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,4530.78,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4530.78,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4530.78,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4530.78,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4530.78,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,4530.78,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4530.78,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,634.31,14,,,percent of total billed charges,14% of total billed charges,634.31,4530.78,
"35570 Bypass graft, with vein; tibial-tibial, peroneal-tibial, or tibial/peroneal trunk-tibial",3623374,CDM,510,RC,35570,HCPCS,Outpatient,,,4017,2008.5,,3012.75,75,,,percent of total billed charges,75% of total billed charges,3012.75,75,,,percent of total billed charges,75% of total billed charges,4017,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,4017,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4017,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4017,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4017,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4017,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,4017,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4017,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,562.38,14,,,percent of total billed charges,14% of total billed charges,562.38,4017,
"35571 - (50) Bypass graft, with vein; popliteal-tibial, -peroneal artery or other distal vessels",3714919,CDM,510,RC,35571,HCPCS,Outpatient,,,3599.51,1799.76,,2699.63,75,,,percent of total billed charges,75% of total billed charges,2699.63,75,,,percent of total billed charges,75% of total billed charges,3599.51,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,3599.51,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3599.51,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3599.51,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3599.51,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3599.51,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,3599.51,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3599.51,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,503.93,14,,,percent of total billed charges,14% of total billed charges,503.93,3599.51,
"35571 - PF Bypass graft, with vein; popliteal-tibial, -peroneal artery or other distal vessels",3714916,CDM,510,RC,35571,HCPCS,Outpatient,,,3599.51,1799.76,,2699.63,75,,,percent of total billed charges,75% of total billed charges,2699.63,75,,,percent of total billed charges,75% of total billed charges,3599.51,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,3599.51,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3599.51,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3599.51,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3599.51,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3599.51,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,3599.51,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3599.51,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,503.93,14,,,percent of total billed charges,14% of total billed charges,503.93,3599.51,
"35600- Upper ext harvest for CABG,1 seg",3430696,CDM,510,RC,35600,HCPCS,Outpatient,,,505.75,252.88,,379.31,75,,,percent of total billed charges,75% of total billed charges,379.31,75,,,percent of total billed charges,75% of total billed charges,505.75,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,505.75,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,505.75,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,505.75,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,505.75,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,505.75,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,505.75,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,505.75,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,70.81,14,,,percent of total billed charges,14% of total billed charges,70.81,505.75,
"35606 - (50) Bypass graft, with other than vein; carotid-subclavian",3696913,CDM,510,RC,35606,HCPCS,Outpatient,,,3177.45,1588.73,,2383.09,75,,,percent of total billed charges,75% of total billed charges,2383.09,75,,,percent of total billed charges,75% of total billed charges,3177.45,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,3177.45,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3177.45,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3177.45,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3177.45,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3177.45,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,3177.45,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3177.45,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,444.84,14,,,percent of total billed charges,14% of total billed charges,444.84,3177.45,
"35606 - PF Bypass graft, with other than vein; carotid-subclavian",3696910,CDM,510,RC,35606,HCPCS,Outpatient,,,3177.45,1588.73,,2383.09,75,,,percent of total billed charges,75% of total billed charges,2383.09,75,,,percent of total billed charges,75% of total billed charges,3177.45,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,3177.45,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3177.45,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3177.45,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3177.45,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3177.45,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,3177.45,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3177.45,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,444.84,14,,,percent of total billed charges,14% of total billed charges,444.84,3177.45,
"35621 - Bypass graft, with other than vein; axillary-femoral",3760898,CDM,983,RC,35621,HCPCS,Outpatient,,,2978.81,1489.41,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
"35636 - PF Bypass graft, with other than vein; splenorenal (splenic to renal arterial anastomosis",3696914,CDM,510,RC,35636,HCPCS,Outpatient,,,4351.62,2175.81,,3263.72,75,,,percent of total billed charges,75% of total billed charges,3263.72,75,,,percent of total billed charges,75% of total billed charges,4351.62,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,4351.62,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4351.62,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4351.62,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4351.62,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4351.62,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,4351.62,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4351.62,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,609.23,14,,,percent of total billed charges,14% of total billed charges,609.23,4351.62,
"35646 - (PF) Bypass graft, with other than vein; aortobifemoral",3634902,CDM,510,RC,35646,HCPCS,Outpatient,,,4635.95,2317.98,,3476.96,75,,,percent of total billed charges,75% of total billed charges,3476.96,75,,,percent of total billed charges,75% of total billed charges,4635.95,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,4635.95,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4635.95,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4635.95,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4635.95,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4635.95,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,4635.95,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4635.95,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,649.03,14,,,percent of total billed charges,14% of total billed charges,649.03,4635.95,
"35647 - (50) Bypass graft, with other than vein; aortofemoral",3714920,CDM,510,RC,35647,HCPCS,Outpatient,,,4204.14,2102.07,,3153.11,75,,,percent of total billed charges,75% of total billed charges,3153.11,75,,,percent of total billed charges,75% of total billed charges,4204.14,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,4204.14,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4204.14,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4204.14,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4204.14,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4204.14,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,4204.14,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4204.14,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,588.58,14,,,percent of total billed charges,14% of total billed charges,588.58,4204.14,
"35647 - PF Bypass graft, with other than vein; aortofemoral",3699125,CDM,510,RC,35647,HCPCS,Outpatient,,,4204.14,2102.07,,3153.11,75,,,percent of total billed charges,75% of total billed charges,3153.11,75,,,percent of total billed charges,75% of total billed charges,4204.14,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,4204.14,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4204.14,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4204.14,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4204.14,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4204.14,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,4204.14,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4204.14,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,588.58,14,,,percent of total billed charges,14% of total billed charges,588.58,4204.14,
35656 - PF Bypass Graft w/Other Than Vein Femoral-Popliteal,4315551,CDM,960,RC,35656,HCPCS,Outpatient,,,2287.48,1143.74,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
"35661 - (50) Bypass graft, with other than vein; femoral-femoral",3699131,CDM,510,RC,35661,HCPCS,Outpatient,,,2933.5,1466.75,,2200.13,75,,,percent of total billed charges,75% of total billed charges,2200.13,75,,,percent of total billed charges,75% of total billed charges,2933.5,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,2933.5,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2933.5,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2933.5,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2933.5,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2933.5,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,2933.5,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2933.5,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,410.69,14,,,percent of total billed charges,14% of total billed charges,410.69,2933.5,
"35661 - PF Bypass graft, with other than vein; femoral-femoral",3699128,CDM,510,RC,35661,HCPCS,Outpatient,,,2933.5,1466.75,,2200.13,75,,,percent of total billed charges,75% of total billed charges,2200.13,75,,,percent of total billed charges,75% of total billed charges,2933.5,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,2933.5,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2933.5,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2933.5,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2933.5,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2933.5,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,2933.5,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2933.5,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,410.69,14,,,percent of total billed charges,14% of total billed charges,410.69,2933.5,
35665 - BYP Oth/Thn Vein Iliofemoral,4113114,CDM,975,RC,35665,HCPCS,Outpatient,,,2834.04,1417.02,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
35666- Fem-Pop Bypass Graft. Oth Than Vein,3569382,CDM,510,RC,35666,HCPCS,Outpatient,,,3480.74,1740.37,,2610.56,75,,,percent of total billed charges,75% of total billed charges,2610.56,75,,,percent of total billed charges,75% of total billed charges,3480.74,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,3480.74,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3480.74,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3480.74,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3480.74,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3480.74,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,3480.74,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3480.74,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,487.3,14,,,percent of total billed charges,14% of total billed charges,487.3,3480.74,
"35671 Bypass graft, with other than vein; popliteal-tibial or -peroneal artery",3622963,CDM,510,RC,35671,HCPCS,Outpatient,,,3068.12,1534.06,,2301.09,75,,,percent of total billed charges,75% of total billed charges,2301.09,75,,,percent of total billed charges,75% of total billed charges,3068.12,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,3068.12,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3068.12,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3068.12,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3068.12,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3068.12,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,3068.12,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3068.12,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,429.54,14,,,percent of total billed charges,14% of total billed charges,429.54,3068.12,
"35697 - (PF) Bypass graft, with other than vein; aortofemoral",3634903,CDM,510,RC,35697,HCPCS,Outpatient,,,400.79,200.4,,300.59,75,,,percent of total billed charges,75% of total billed charges,300.59,75,,,percent of total billed charges,75% of total billed charges,400.79,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,400.79,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,400.79,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,400.79,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,400.79,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,400.79,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,400.79,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,400.79,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,56.11,14,,,percent of total billed charges,14% of total billed charges,56.11,400.79,
"35701 Exploration not followed by surgical repair, artery; neck (eg, carotid, subclavian)",3621969,CDM,510,RC,35701,HCPCS,Outpatient,,,1155.4,577.7,,866.55,75,,,percent of total billed charges,75% of total billed charges,866.55,75,,,percent of total billed charges,75% of total billed charges,1155.4,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,1155.4,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1155.4,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1155.4,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1155.4,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1155.4,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,1155.4,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1155.4,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,161.76,14,,,percent of total billed charges,14% of total billed charges,161.76,1155.4,
"35702 - Exploration not followed by surgical repair, artery; upper extremity (eg, axillary, brachial",3783515,CDM,975,RC,35702,HCPCS,Outpatient,,,1090.94,545.47,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
35702PF Exploration Not Followed By Surgical Repair Artery U,4273264,CDM,960,RC,35702,HCPCS,Outpatient,,,971.13,485.57,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
"35703 Exploration not followed by surgical repair, artery; lower extremity (eg, common femoral, deep",3621877,CDM,960,RC,35703,HCPCS,Outpatient,,,1126.53,563.27,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
35800 - EXPL PO HEMRRG THROMBOSIS/INFCTJ NCK,4249118,CDM,983,RC,35800,HCPCS,Outpatient,,,1914.41,957.21,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
35820PF Exploration Post Operative Hemorrhage Thrombosis/Inf,4273265,CDM,960,RC,35820,HCPCS,Outpatient,,,4778.5,2389.25,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
35840PF Exploration Postoperative Hemorrhage Thrombosis or I,4273266,CDM,960,RC,35840,HCPCS,Outpatient,,,2882.5,1441.25,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
35860-PF EXPL PO HEMRRG THROMBOSIS/INFCTJ XTR,4321669,CDM,981,RC,35860,HCPCS,Outpatient,,,1681.3,840.65,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
35860PF Exploration Postoperative Hemorrhage Thrombosis or I,4273267,CDM,960,RC,35860,HCPCS,Outpatient,,,1996.04,998.02,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
35876 - Thrmbc Artl/Ven GRF XCP HEMO GRF/FSTL W/REVJ GRF,4169581,CDM,983,RC,35876,HCPCS,Outpatient,,,2281.34,1140.67,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
35879 - Revise Grft w/ Vein - lower extremity arterial bypass,3899033,CDM,983,RC,35879,HCPCS,Outpatient,,,2498.28,1249.14,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
"35881 - PF Revision, lower extremity arterial bypass, without thrombectomy, open; with segmental vei",3715392,CDM,510,RC,35881,HCPCS,Outpatient,,,2770.46,1385.23,,2077.85,75,,,percent of total billed charges,75% of total billed charges,2077.85,75,,,percent of total billed charges,75% of total billed charges,4832.22,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,7973.16,165,,,Fee Schedule,165% of CMS OPPS Rate,5008.18,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,13879.91,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,19035.18,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,23843.51,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,4832.22,100,,,Fee Schedule,100% of CMS OPPS Rate,5008.18,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,387.86,14,,,percent of total billed charges,14% of total billed charges,387.86,23843.51,
35903- Excision of infected graft; extremity,3569423,CDM,510,RC,35903,HCPCS,Outpatient,,,1515.45,757.73,,1136.59,75,,,percent of total billed charges,75% of total billed charges,1136.59,75,,,percent of total billed charges,75% of total billed charges,2800.71,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,4621.18,165,,,Fee Schedule,165% of CMS OPPS Rate,2902.7,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8044.7,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11032.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13819.53,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,2800.71,100,,,Fee Schedule,100% of CMS OPPS Rate,2902.7,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,212.16,14,,,percent of total billed charges,14% of total billed charges,212.16,13819.53,
36002- Extremity pseudoaneurysm injection,3430899,CDM,320,RC,36002,HCPCS,Outpatient,,,386.85,193.43,,290.14,75,,,percent of total billed charges,75% of total billed charges,290.14,75,,,percent of total billed charges,75% of total billed charges,543.88,100,,,Fee Schedule,100% of CMS OPPS Rate,220.64,102,,,Fee Schedule,102% of WV Medicaid Rate,897.4,165,,,Fee Schedule,165% of CMS OPPS Rate,563.67,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1562.23,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2142.48,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,2683.68,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,216.31,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,543.88,100,,,Fee Schedule,100% of CMS OPPS Rate,563.67,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,54.16,14,,,percent of total billed charges,14% of total billed charges,54.16,2683.68,
36002-PF Thrombin injection treatment of extremity pseudoaneurysm,4271166,CDM,960,RC,36002,HCPCS,Outpatient,,,308.33,154.17,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
36002-Thrombin injection treatment of extremity pseudoaneurysm,4271165,CDM,481,RC,36002,HCPCS,Outpatient,,,308.33,154.17,,231.25,75,,,percent of total billed charges,75% of total billed charges,231.25,75,,,percent of total billed charges,75% of total billed charges,543.88,100,,,Fee Schedule,100% of CMS OPPS Rate,220.64,102,,,Fee Schedule,102% of WV Medicaid Rate,897.4,165,,,Fee Schedule,165% of CMS OPPS Rate,563.67,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1562.23,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2142.48,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,2683.68,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,216.31,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,543.88,100,,,Fee Schedule,100% of CMS OPPS Rate,563.67,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,43.17,14,,,percent of total billed charges,14% of total billed charges,43.17,2683.68,
US Thrombin Injection,1879101,CDM,320,RC,36002,HCPCS,Outpatient,,,385.42,192.71,,289.07,75,,,percent of total billed charges,75% of total billed charges,289.07,75,,,percent of total billed charges,75% of total billed charges,543.88,100,,,Fee Schedule,100% of CMS OPPS Rate,220.64,102,,,Fee Schedule,102% of WV Medicaid Rate,897.4,165,,,Fee Schedule,165% of CMS OPPS Rate,563.67,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1562.23,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2142.48,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,2683.68,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,216.31,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,543.88,100,,,Fee Schedule,100% of CMS OPPS Rate,563.67,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,53.96,14,,,percent of total billed charges,14% of total billed charges,53.96,2683.68,
36005- Injection for extremity venography,3430698,CDM,510,RC,36005,HCPCS,Outpatient,,,643.75,321.88,,482.81,75,,,percent of total billed charges,75% of total billed charges,482.81,75,,,percent of total billed charges,75% of total billed charges,206,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,90.13,14,,,percent of total billed charges,14% of total billed charges,90.13,482.81,
36005-Injection Proced for Extrem Venography,3431826,CDM,481,RC,36005,HCPCS,Outpatient,,,643.75,321.88,,482.81,75,,,percent of total billed charges,75% of total billed charges,482.81,75,,,percent of total billed charges,75% of total billed charges,206,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,90.13,14,,,percent of total billed charges,14% of total billed charges,90.13,482.81,
Injection Proced for Extrem Venography,3427271,CDM,960,RC,36005,HCPCS,Outpatient,,,613.58,306.79,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
"36010 - (50)  Introduction of catheter, superior or inferior vena cava",3699136,CDM,510,RC,36010,HCPCS,Outpatient,,,1374.34,687.17,,1030.76,75,,,percent of total billed charges,75% of total billed charges,1030.76,75,,,percent of total billed charges,75% of total billed charges,439.79,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,192.41,14,,,percent of total billed charges,14% of total billed charges,192.41,1030.76,
"36010 - PF - Introduction of catheter, superior or inferior vena cava",3640894,CDM,510,RC,36010,HCPCS,Outpatient,,,1374.34,687.17,,1030.76,75,,,percent of total billed charges,75% of total billed charges,1030.76,75,,,percent of total billed charges,75% of total billed charges,439.79,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,192.41,14,,,percent of total billed charges,14% of total billed charges,192.41,1030.76,
36010-Introduction of Catheter SVC or IVC,3431827,CDM,481,RC,36010,HCPCS,Outpatient,,,1374.34,687.17,,1030.76,75,,,percent of total billed charges,75% of total billed charges,1030.76,75,,,percent of total billed charges,75% of total billed charges,439.79,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,192.41,14,,,percent of total billed charges,14% of total billed charges,192.41,1030.76,
Introduction of Catheter SVC or IVC,,,761,RC,36010,HCPCS,Outpatient,,,1299.33,649.67,,974.5,75,,,percent of total billed charges,75% of total billed charges,974.5,75,,,percent of total billed charges,75% of total billed charges,415.79,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,181.91,14,,,percent of total billed charges,14% of total billed charges,181.91,974.5,
36011- Cath placement/venous/1st order,3430900,CDM,510,RC,36011,HCPCS,Outpatient,,,2051.09,1025.55,,1538.32,75,,,percent of total billed charges,75% of total billed charges,1538.32,75,,,percent of total billed charges,75% of total billed charges,656.35,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,287.15,14,,,percent of total billed charges,14% of total billed charges,287.15,1538.32,
36011-Cath Placement venous 1st order branch,3431828,CDM,481,RC,36011,HCPCS,Outpatient,,,2051.09,1025.55,,1538.32,75,,,percent of total billed charges,75% of total billed charges,1538.32,75,,,percent of total billed charges,75% of total billed charges,656.35,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,287.15,14,,,percent of total billed charges,14% of total billed charges,287.15,1538.32,
Cath Placement venous 1st order branch,,,761,RC,36011,HCPCS,Outpatient,,,1930.87,965.44,,1448.15,75,,,percent of total billed charges,75% of total billed charges,1448.15,75,,,percent of total billed charges,75% of total billed charges,617.88,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,270.32,14,,,percent of total billed charges,14% of total billed charges,270.32,1448.15,
"36012 - PF - Selective catheter placement, venous system; second order, or more selective, branch (e",3640913,CDM,510,RC,36012,HCPCS,Outpatient,,,2103.26,1051.63,,1577.45,75,,,percent of total billed charges,75% of total billed charges,1577.45,75,,,percent of total billed charges,75% of total billed charges,673.04,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,294.46,14,,,percent of total billed charges,14% of total billed charges,294.46,1577.45,
36012-Catheter 2nd order or more selective,3431829,CDM,481,RC,36012,HCPCS,Outpatient,,,2103.26,1051.63,,1577.45,75,,,percent of total billed charges,75% of total billed charges,1577.45,75,,,percent of total billed charges,75% of total billed charges,673.04,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,294.46,14,,,percent of total billed charges,14% of total billed charges,294.46,1577.45,
Catheter 2nd order or more selective,,,761,RC,36012,HCPCS,Outpatient,,,2004.17,1002.09,,1503.13,75,,,percent of total billed charges,75% of total billed charges,1503.13,75,,,percent of total billed charges,75% of total billed charges,641.33,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,280.58,14,,,percent of total billed charges,14% of total billed charges,280.58,1503.13,
36013-Cath Placement Main PA,3431830,CDM,481,RC,36013,HCPCS,Outpatient,,,1951.76,975.88,,1463.82,75,,,percent of total billed charges,75% of total billed charges,1463.82,75,,,percent of total billed charges,75% of total billed charges,624.56,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,273.25,14,,,percent of total billed charges,14% of total billed charges,273.25,1463.82,
36013-Right Heart Cath,3431831,CDM,481,RC,36013,HCPCS,Outpatient,,,1951.76,975.88,,1463.82,75,,,percent of total billed charges,75% of total billed charges,1463.82,75,,,percent of total billed charges,75% of total billed charges,624.56,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,273.25,14,,,percent of total billed charges,14% of total billed charges,273.25,1463.82,
Cath Placement Main PA,,,761,RC,36013,HCPCS,Outpatient,,,1873.63,936.82,,1405.22,75,,,percent of total billed charges,75% of total billed charges,1405.22,75,,,percent of total billed charges,75% of total billed charges,599.56,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,262.31,14,,,percent of total billed charges,14% of total billed charges,262.31,1405.22,
Right Heart Cath,604623,CDM,481,RC,36013,HCPCS,Outpatient,,,1873.63,936.82,,1405.22,75,,,percent of total billed charges,75% of total billed charges,1405.22,75,,,percent of total billed charges,75% of total billed charges,599.56,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,262.31,14,,,percent of total billed charges,14% of total billed charges,262.31,1405.22,
"36014 - Selective catheter placement, left or right pulmonary artery",3760896,CDM,983,RC,36014,HCPCS,Outpatient,,,1987.31,993.66,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
36014-Cath Placement Pulm Artery,3431832,CDM,481,RC,36014,HCPCS,Outpatient,,,1987.31,993.66,,1490.48,75,,,percent of total billed charges,75% of total billed charges,1490.48,75,,,percent of total billed charges,75% of total billed charges,635.94,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278.22,14,,,percent of total billed charges,14% of total billed charges,278.22,1490.48,
36014-Cath Placement Pulm Artery RT,3431833,CDM,481,RC,36014,HCPCS,Outpatient,,,1987.31,993.66,,1490.48,75,,,percent of total billed charges,75% of total billed charges,1490.48,75,,,percent of total billed charges,75% of total billed charges,635.94,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278.22,14,,,percent of total billed charges,14% of total billed charges,278.22,1490.48,
Cath Placement Pulm Artery LT,,,761,RC,36014,HCPCS,Outpatient,,,1883.12,941.56,,1412.34,75,,,percent of total billed charges,75% of total billed charges,1412.34,75,,,percent of total billed charges,75% of total billed charges,602.6,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,263.64,14,,,percent of total billed charges,14% of total billed charges,263.64,1412.34,
Cath Placement Pulm Artery RT,,,761,RC,36014,HCPCS,Outpatient,,,1883.12,941.56,,1412.34,75,,,percent of total billed charges,75% of total billed charges,1412.34,75,,,percent of total billed charges,75% of total billed charges,602.6,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,263.64,14,,,percent of total billed charges,14% of total billed charges,263.64,1412.34,
36015-Cath Placement Segmen Subseg Pulm Artery,3431834,CDM,320,RC,36015,HCPCS,Outpatient,,,2146.89,1073.45,,1610.17,75,,,percent of total billed charges,75% of total billed charges,1610.17,75,,,percent of total billed charges,75% of total billed charges,687,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,300.56,14,,,percent of total billed charges,14% of total billed charges,300.56,1610.17,
Cath Placement Segmen Subseg Pulm Artery,,,761,RC,36015,HCPCS,Outpatient,,,2039.18,1019.59,,1529.39,75,,,percent of total billed charges,75% of total billed charges,1529.39,75,,,percent of total billed charges,75% of total billed charges,652.54,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,285.49,14,,,percent of total billed charges,14% of total billed charges,285.49,1529.39,
36140- Intro of needle/intracath/ext art,3430901,CDM,510,RC,36140,HCPCS,Outpatient,,,1288.66,644.33,,966.5,75,,,percent of total billed charges,75% of total billed charges,966.5,75,,,percent of total billed charges,75% of total billed charges,412.37,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,180.41,14,,,percent of total billed charges,14% of total billed charges,180.41,966.5,
"36140-Arterial Vascular Cathterization Extremity Artery, Nee",4217141,CDM,481,RC,36140,HCPCS,Outpatient,,,975.67,487.84,,731.75,75,,,percent of total billed charges,75% of total billed charges,731.75,75,,,percent of total billed charges,75% of total billed charges,312.21,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,136.59,14,,,percent of total billed charges,14% of total billed charges,136.59,731.75,
"36140-Arterial Vascular Cathterization Extremity Artery, Nee",4217144,CDM,481,RC,36140,HCPCS,Outpatient,,,975.67,487.84,,731.75,75,,,percent of total billed charges,75% of total billed charges,731.75,75,,,percent of total billed charges,75% of total billed charges,312.21,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,136.59,14,,,percent of total billed charges,14% of total billed charges,136.59,731.75,
"36140-PF Arterial Vascular Cathterization Extremity Artery,",4217142,CDM,960,RC,36140,HCPCS,Outpatient,,,975.67,487.84,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
"36140-PF Arterial Vascular Cathterization Extremity Artery,",4217145,CDM,960,RC,36140,HCPCS,Outpatient,,,975.67,487.84,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
Art Line Placement,3428391,CDM,981,RC,36140,HCPCS,Outpatient,,,1288.66,644.33,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
"Arterial Vascular Cathterization Extremity Artery, Needle, (Lt)",,,761,RC,36140,HCPCS,Outpatient,,,975.67,487.84,,731.75,75,,,percent of total billed charges,75% of total billed charges,731.75,75,,,percent of total billed charges,75% of total billed charges,312.21,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,136.59,14,,,percent of total billed charges,14% of total billed charges,136.59,731.75,
"Arterial Vascular Cathterization Extremity Artery, Needle, (Rt)",,,761,RC,36140,HCPCS,Outpatient,,,975.67,487.84,,731.75,75,,,percent of total billed charges,75% of total billed charges,731.75,75,,,percent of total billed charges,75% of total billed charges,312.21,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,136.59,14,,,percent of total billed charges,14% of total billed charges,136.59,731.75,
36200- Intro of cath/aorta,3430700,CDM,510,RC,36200,HCPCS,Outpatient,,,1510.24,755.12,,1132.68,75,,,percent of total billed charges,75% of total billed charges,1132.68,75,,,percent of total billed charges,75% of total billed charges,483.28,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,211.43,14,,,percent of total billed charges,14% of total billed charges,211.43,1132.68,
"36200-Introduction of catheter, aorta",4271167,CDM,481,RC,36200,HCPCS,Outpatient,,,1146.05,573.03,,859.54,75,,,percent of total billed charges,75% of total billed charges,859.54,75,,,percent of total billed charges,75% of total billed charges,366.74,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,160.45,14,,,percent of total billed charges,14% of total billed charges,160.45,859.54,
"36200-PF Introduction of catheter, aorta",4271168,CDM,960,RC,36200,HCPCS,Outpatient,,,1146.05,573.03,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
36215- Selec place/art 1st ord/thor/brach,3430701,CDM,510,RC,36215,HCPCS,Outpatient,,,2594.36,1297.18,,1945.77,75,,,percent of total billed charges,75% of total billed charges,1945.77,75,,,percent of total billed charges,75% of total billed charges,830.2,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,363.21,14,,,percent of total billed charges,14% of total billed charges,363.21,1945.77,
"36215-Catheter placement, arterial system; first order thoracic or brachiocephalic branch",4271254,CDM,481,RC,36215,HCPCS,Outpatient,,,1980.31,990.16,,1485.23,75,,,percent of total billed charges,75% of total billed charges,1485.23,75,,,percent of total billed charges,75% of total billed charges,633.7,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,277.24,14,,,percent of total billed charges,14% of total billed charges,277.24,1485.23,
"36215-PF Catheter placement, arterial system; first order thoracic or brachiocephalic branch",4271255,CDM,960,RC,36215,HCPCS,Outpatient,,,1980.31,990.16,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
36216- Selec place/art 2nd ord/thor/brach,3430702,CDM,510,RC,36216,HCPCS,Outpatient,,,2692.61,1346.31,,2019.46,75,,,percent of total billed charges,75% of total billed charges,2019.46,75,,,percent of total billed charges,75% of total billed charges,861.64,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,376.97,14,,,percent of total billed charges,14% of total billed charges,376.97,2019.46,
"36216-Catheter placement, arterial system; initial second order thoracic or brachiocephalic branch",4271225,CDM,481,RC,36216,HCPCS,Outpatient,,,2692.61,1346.31,,2019.46,75,,,percent of total billed charges,75% of total billed charges,2019.46,75,,,percent of total billed charges,75% of total billed charges,861.64,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,376.97,14,,,percent of total billed charges,14% of total billed charges,376.97,2019.46,
"36216-PF Catheter placement, arterial system; initial second order thoracic or brachiocephalic branc",4271226,CDM,960,RC,36216,HCPCS,Outpatient,,,2692.61,1346.31,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
"36217- Selective catheter placement, arterial system; initial third order or more selective thoracic",3569386,CDM,510,RC,36217,HCPCS,Outpatient,,,4416.32,2208.16,,3312.24,75,,,percent of total billed charges,75% of total billed charges,3312.24,75,,,percent of total billed charges,75% of total billed charges,1413.22,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,618.28,14,,,percent of total billed charges,14% of total billed charges,618.28,3312.24,
"36217-Catheter placement, arterial system; initial third order or more selective thoracic or brachio",4271227,CDM,481,RC,36217,HCPCS,Outpatient,,,4416.32,2208.16,,3312.24,75,,,percent of total billed charges,75% of total billed charges,3312.24,75,,,percent of total billed charges,75% of total billed charges,1413.22,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,618.28,14,,,percent of total billed charges,14% of total billed charges,618.28,3312.24,
"36217-PF Catheter placement, arterial system; initial third order or more selective thoracic or brac",4271228,CDM,960,RC,36217,HCPCS,Outpatient,,,4416.32,2208.16,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
"36218-Cath placement, art system; additional second order, third order, and beyond, thoracic or brac",4271229,CDM,481,RC,36218,HCPCS,Outpatient,,,401.23,200.62,,300.92,75,,,percent of total billed charges,75% of total billed charges,300.92,75,,,percent of total billed charges,75% of total billed charges,128.39,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.17,14,,,percent of total billed charges,14% of total billed charges,56.17,300.92,
"36218-PF Cath placement, art system; additional second order, third order, and beyond, thoracic or b",4271230,CDM,960,RC,36218,HCPCS,Outpatient,,,401.23,200.62,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
36221- Non-select cath/thoracic aorta,3430703,CDM,510,RC,36221,HCPCS,Outpatient,,,2503.18,1251.59,,1877.39,75,,,percent of total billed charges,75% of total billed charges,1877.39,75,,,percent of total billed charges,75% of total billed charges,2800.72,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,4621.2,165,,,Fee Schedule,165% of CMS OPPS Rate,2902.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8044.7,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11032.67,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13819.54,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,2800.72,100,,,Fee Schedule,100% of CMS OPPS Rate,2902.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,350.45,14,,,percent of total billed charges,14% of total billed charges,350.45,13819.54,
36221-PF Thoracic Angiogram,3580880,CDM,960,RC,36221,HCPCS,Outpatient,,,2503.18,1251.59,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
36221-Thoracic Angiogram,3560673,CDM,481,RC,36221,HCPCS,Outpatient,,,2503.18,1251.59,,1877.39,75,,,percent of total billed charges,75% of total billed charges,1877.39,75,,,percent of total billed charges,75% of total billed charges,2800.72,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,4621.2,165,,,Fee Schedule,165% of CMS OPPS Rate,2902.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8044.7,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11032.67,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13819.54,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,2800.72,100,,,Fee Schedule,100% of CMS OPPS Rate,2902.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,350.45,14,,,percent of total billed charges,14% of total billed charges,350.45,13819.54,
Arch Study (Cardiology),,,761,RC,36221,HCPCS,Outpatient,,,2375.94,1187.97,,1781.96,75,,,percent of total billed charges,75% of total billed charges,1781.96,75,,,percent of total billed charges,75% of total billed charges,2800.72,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,4621.2,165,,,Fee Schedule,165% of CMS OPPS Rate,2902.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8044.7,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11032.67,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13819.54,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,2800.72,100,,,Fee Schedule,100% of CMS OPPS Rate,2902.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,332.63,14,,,percent of total billed charges,14% of total billed charges,332.63,13819.54,
36222- Cath place/com carotid/innom art,3430704,CDM,510,RC,36222,HCPCS,Outpatient,,,3034.72,1517.36,,2276.04,75,,,percent of total billed charges,75% of total billed charges,2276.04,75,,,percent of total billed charges,75% of total billed charges,2800.72,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,4621.2,165,,,Fee Schedule,165% of CMS OPPS Rate,2902.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8044.7,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11032.67,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13819.54,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,2800.72,100,,,Fee Schedule,100% of CMS OPPS Rate,2902.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,424.86,14,,,percent of total billed charges,14% of total billed charges,424.86,13819.54,
36222-Carotid Angiography Selective,3431836,CDM,481,RC,36222,HCPCS,Outpatient,,,3034.72,1517.36,,2276.04,75,,,percent of total billed charges,75% of total billed charges,2276.04,75,,,percent of total billed charges,75% of total billed charges,2800.72,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,4621.2,165,,,Fee Schedule,165% of CMS OPPS Rate,2902.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8044.7,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11032.67,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13819.54,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,2800.72,100,,,Fee Schedule,100% of CMS OPPS Rate,2902.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,424.86,14,,,percent of total billed charges,14% of total billed charges,424.86,13819.54,
36222-Carotid Angiography Selective BILAT,3431835,CDM,320,RC,36222,HCPCS,Outpatient,,,3034.72,1517.36,,2276.04,75,,,percent of total billed charges,75% of total billed charges,2276.04,75,,,percent of total billed charges,75% of total billed charges,2800.72,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,4621.2,165,,,Fee Schedule,165% of CMS OPPS Rate,2902.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8044.7,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11032.67,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13819.54,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,2800.72,100,,,Fee Schedule,100% of CMS OPPS Rate,2902.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,424.86,14,,,percent of total billed charges,14% of total billed charges,424.86,13819.54,
36222-Carotid Angiography Selective RT,3431837,CDM,320,RC,36222,HCPCS,Outpatient,,,3034.72,1517.36,,2276.04,75,,,percent of total billed charges,75% of total billed charges,2276.04,75,,,percent of total billed charges,75% of total billed charges,2800.72,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,4621.2,165,,,Fee Schedule,165% of CMS OPPS Rate,2902.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8044.7,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11032.67,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13819.54,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,2800.72,100,,,Fee Schedule,100% of CMS OPPS Rate,2902.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,424.86,14,,,percent of total billed charges,14% of total billed charges,424.86,13819.54,
Carotid Angio BILAT,,,761,RC,36222,HCPCS,Outpatient,,,2937.37,1468.69,,2203.03,75,,,percent of total billed charges,75% of total billed charges,2203.03,75,,,percent of total billed charges,75% of total billed charges,2800.72,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,4621.2,165,,,Fee Schedule,165% of CMS OPPS Rate,2902.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8044.7,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11032.67,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13819.54,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,2800.72,100,,,Fee Schedule,100% of CMS OPPS Rate,2902.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,411.23,14,,,percent of total billed charges,14% of total billed charges,411.23,13819.54,
Carotid Angio LT,,,761,RC,36222,HCPCS,Outpatient,,,2937.37,1468.69,,2203.03,75,,,percent of total billed charges,75% of total billed charges,2203.03,75,,,percent of total billed charges,75% of total billed charges,2800.72,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,4621.2,165,,,Fee Schedule,165% of CMS OPPS Rate,2902.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8044.7,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11032.67,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13819.54,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,2800.72,100,,,Fee Schedule,100% of CMS OPPS Rate,2902.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,411.23,14,,,percent of total billed charges,14% of total billed charges,411.23,13819.54,
Carotid Angio RT,,,761,RC,36222,HCPCS,Outpatient,,,2937.37,1468.69,,2203.03,75,,,percent of total billed charges,75% of total billed charges,2203.03,75,,,percent of total billed charges,75% of total billed charges,2800.72,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,4621.2,165,,,Fee Schedule,165% of CMS OPPS Rate,2902.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8044.7,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11032.67,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13819.54,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,2800.72,100,,,Fee Schedule,100% of CMS OPPS Rate,2902.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,411.23,14,,,percent of total billed charges,14% of total billed charges,411.23,13819.54,
36223- Cath place/com carotid/innom art,3430705,CDM,510,RC,36223,HCPCS,Outpatient,,,3993.24,1996.62,,2994.93,75,,,percent of total billed charges,75% of total billed charges,2994.93,75,,,percent of total billed charges,75% of total billed charges,4832.22,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,7973.18,165,,,Fee Schedule,165% of CMS OPPS Rate,5008.19,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,13879.91,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,19035.19,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,23843.51,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,4832.22,100,,,Fee Schedule,100% of CMS OPPS Rate,5008.19,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,559.05,14,,,percent of total billed charges,14% of total billed charges,559.05,23843.51,
36224-Carotid Angio,3431838,CDM,481,RC,36224,HCPCS,Outpatient,,,4993.5,2496.75,,3745.13,75,,,percent of total billed charges,75% of total billed charges,3745.13,75,,,percent of total billed charges,75% of total billed charges,4832.22,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,7973.18,165,,,Fee Schedule,165% of CMS OPPS Rate,5008.19,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,13879.91,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,19035.19,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,23843.51,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,4832.22,100,,,Fee Schedule,100% of CMS OPPS Rate,5008.19,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,699.09,14,,,percent of total billed charges,14% of total billed charges,699.09,23843.51,
36224-Carotid Angiography Selective BILAT,3533611,CDM,360,RC,36224,HCPCS,Outpatient,,,4993.5,2496.75,,3745.13,75,,,percent of total billed charges,75% of total billed charges,3745.13,75,,,percent of total billed charges,75% of total billed charges,4832.22,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,7973.18,165,,,Fee Schedule,165% of CMS OPPS Rate,5008.19,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,13879.91,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,19035.19,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,23843.51,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,4832.22,100,,,Fee Schedule,100% of CMS OPPS Rate,5008.19,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,699.09,14,,,percent of total billed charges,14% of total billed charges,699.09,23843.51,
36224-Carotid Angiography Selective LT,3533612,CDM,320,RC,36224,HCPCS,Outpatient,,,4993.5,2496.75,,3745.13,75,,,percent of total billed charges,75% of total billed charges,3745.13,75,,,percent of total billed charges,75% of total billed charges,4832.22,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,7973.18,165,,,Fee Schedule,165% of CMS OPPS Rate,5008.19,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,13879.91,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,19035.19,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,23843.51,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,4832.22,100,,,Fee Schedule,100% of CMS OPPS Rate,5008.19,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,699.09,14,,,percent of total billed charges,14% of total billed charges,699.09,23843.51,
36224-Carotid Angiography Selective RT,3533613,CDM,320,RC,36224,HCPCS,Outpatient,,,4993.5,2496.75,,3745.13,75,,,percent of total billed charges,75% of total billed charges,3745.13,75,,,percent of total billed charges,75% of total billed charges,4832.22,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,7973.18,165,,,Fee Schedule,165% of CMS OPPS Rate,5008.19,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,13879.91,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,19035.19,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,23843.51,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,4832.22,100,,,Fee Schedule,100% of CMS OPPS Rate,5008.19,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,699.09,14,,,percent of total billed charges,14% of total billed charges,699.09,23843.51,
36224-PF Carotid Angio,3580881,CDM,960,RC,36224,HCPCS,Outpatient,,,4993.5,2496.75,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
36224-PF Carotid Angiography Selective BILAT,3580882,CDM,960,RC,36224,HCPCS,Outpatient,,,4993.5,2496.75,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
36224-PF Carotid Angiography Selective LT,3580883,CDM,960,RC,36224,HCPCS,Outpatient,,,4993.5,2496.75,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
36224-PF Carotid Angiography Selective RT,3580884,CDM,960,RC,36224,HCPCS,Outpatient,,,4993.5,2496.75,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
36225- Cath place/subclavian artery,3430706,CDM,320,RC,36225,HCPCS,Outpatient,,,3797.57,1898.79,,2848.18,75,,,percent of total billed charges,75% of total billed charges,2848.18,75,,,percent of total billed charges,75% of total billed charges,2800.72,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,4621.2,165,,,Fee Schedule,165% of CMS OPPS Rate,2902.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8044.7,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11032.67,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13819.54,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,2800.72,100,,,Fee Schedule,100% of CMS OPPS Rate,2902.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,531.66,14,,,percent of total billed charges,14% of total billed charges,531.66,13819.54,
36225-Subclavian Angiography,3431839,CDM,481,RC,36225,HCPCS,Outpatient,,,3797.57,1898.79,,2848.18,75,,,percent of total billed charges,75% of total billed charges,2848.18,75,,,percent of total billed charges,75% of total billed charges,2800.72,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,4621.2,165,,,Fee Schedule,165% of CMS OPPS Rate,2902.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8044.7,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11032.67,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13819.54,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,2800.72,100,,,Fee Schedule,100% of CMS OPPS Rate,2902.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,531.66,14,,,percent of total billed charges,14% of total billed charges,531.66,13819.54,
Subclavian Angiography,3427226,CDM,960,RC,36225,HCPCS,Outpatient,,,3726.91,1863.46,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
36226- Cath place/vertebral artery,3430707,CDM,510,RC,36226,HCPCS,Outpatient,,,4819.17,2409.59,,3614.38,75,,,percent of total billed charges,75% of total billed charges,3614.38,75,,,percent of total billed charges,75% of total billed charges,4832.22,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,7973.18,165,,,Fee Schedule,165% of CMS OPPS Rate,5008.19,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,13879.91,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,19035.19,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,23843.51,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,4832.22,100,,,Fee Schedule,100% of CMS OPPS Rate,5008.19,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,674.68,14,,,percent of total billed charges,14% of total billed charges,674.68,23843.51,
36245- Selec place/art 1st ord/abd/pel/LE,3430708,CDM,481,RC,36245,HCPCS,Outpatient,,,3121.54,1560.77,,2341.16,75,,,percent of total billed charges,75% of total billed charges,2341.16,75,,,percent of total billed charges,75% of total billed charges,998.89,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,437.02,14,,,percent of total billed charges,14% of total billed charges,437.02,2341.16,
"36245-Lower extremity cath, first order",4271169,CDM,481,RC,36245,HCPCS,Outpatient,,,2381.42,1190.71,,1786.07,75,,,percent of total billed charges,75% of total billed charges,1786.07,75,,,percent of total billed charges,75% of total billed charges,762.05,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,333.4,14,,,percent of total billed charges,14% of total billed charges,333.4,1786.07,
"36245-PF Lower extremity cath, first order",4271170,CDM,960,RC,36245,HCPCS,Outpatient,,,2381.42,1190.71,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
IR Sel Cath Placement Abdominal,603468,CDM,481,RC,36245,HCPCS,Outpatient,,,2976.78,1488.39,,2232.59,75,,,percent of total billed charges,75% of total billed charges,2232.59,75,,,percent of total billed charges,75% of total billed charges,952.57,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,416.75,14,,,percent of total billed charges,14% of total billed charges,416.75,2232.59,
36246- Selec place/art 2nd ord/abd/pel/LE,3430709,CDM,510,RC,36246,HCPCS,Outpatient,,,2132.83,1066.42,,1599.62,75,,,percent of total billed charges,75% of total billed charges,1599.62,75,,,percent of total billed charges,75% of total billed charges,682.51,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,298.6,14,,,percent of total billed charges,14% of total billed charges,298.6,1599.62,
"36246-Lower extremity cath, second order",4271171,CDM,481,RC,36246,HCPCS,Outpatient,,,1626.74,813.37,,1220.06,75,,,percent of total billed charges,75% of total billed charges,1220.06,75,,,percent of total billed charges,75% of total billed charges,520.56,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,227.74,14,,,percent of total billed charges,14% of total billed charges,227.74,1220.06,
"36246-PF Lower extremity cath, second order",4271172,CDM,960,RC,36246,HCPCS,Outpatient,,,1626.74,813.37,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
36247- Selec place/art 3rd ord/abd/pel/LE,3430710,CDM,510,RC,36247,HCPCS,Outpatient,,,3592.24,1796.12,,2694.18,75,,,percent of total billed charges,75% of total billed charges,2694.18,75,,,percent of total billed charges,75% of total billed charges,1149.52,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,502.91,14,,,percent of total billed charges,14% of total billed charges,502.91,2694.18,
"36247-Lower extremity cath, third order",4271173,CDM,481,RC,36247,HCPCS,Outpatient,,,2732.96,1366.48,,2049.72,75,,,percent of total billed charges,75% of total billed charges,2049.72,75,,,percent of total billed charges,75% of total billed charges,874.55,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,382.61,14,,,percent of total billed charges,14% of total billed charges,382.61,2049.72,
"36247-PF Lower extremity cath, third order",4271174,CDM,960,RC,36247,HCPCS,Outpatient,,,2732.96,1366.48,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
"36248 - (PF) Selective catheter placement, arterial system; additional second order, third order,",3634905,CDM,510,RC,36248,HCPCS,Outpatient,,,296.97,148.49,,222.73,75,,,percent of total billed charges,75% of total billed charges,222.73,75,,,percent of total billed charges,75% of total billed charges,95.03,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.58,14,,,percent of total billed charges,14% of total billed charges,41.58,222.73,
"36248-Lower extremity cath, each additional order",4271175,CDM,481,RC,36248,HCPCS,Outpatient,,,230.51,115.26,,172.88,75,,,percent of total billed charges,75% of total billed charges,172.88,75,,,percent of total billed charges,75% of total billed charges,73.76,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.27,14,,,percent of total billed charges,14% of total billed charges,32.27,172.88,
"36248-PF Lower extremity cath, each additional order",4271176,CDM,960,RC,36248,HCPCS,Outpatient,,,230.51,115.26,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
36251-Renal Angio Ulilateral (Right),3560672,CDM,481,RC,36251,HCPCS,Outpatient,,,3242.68,1621.34,,2432.01,75,,,percent of total billed charges,75% of total billed charges,2432.01,75,,,percent of total billed charges,75% of total billed charges,2800.72,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,4621.2,165,,,Fee Schedule,165% of CMS OPPS Rate,2902.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8044.7,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11032.67,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13819.54,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,2800.72,100,,,Fee Schedule,100% of CMS OPPS Rate,2902.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,453.98,14,,,percent of total billed charges,14% of total billed charges,453.98,13819.54,
36251-Renal Angiography LT,3431840,CDM,481,RC,36251,HCPCS,Outpatient,,,3242.68,1621.34,,2432.01,75,,,percent of total billed charges,75% of total billed charges,2432.01,75,,,percent of total billed charges,75% of total billed charges,2800.72,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,4621.2,165,,,Fee Schedule,165% of CMS OPPS Rate,2902.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8044.7,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11032.67,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13819.54,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,2800.72,100,,,Fee Schedule,100% of CMS OPPS Rate,2902.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,453.98,14,,,percent of total billed charges,14% of total billed charges,453.98,13819.54,
36251-Renal Angiography RT,3431841,CDM,481,RC,36251,HCPCS,Outpatient,,,3242.68,1621.34,,2432.01,75,,,percent of total billed charges,75% of total billed charges,2432.01,75,,,percent of total billed charges,75% of total billed charges,2800.72,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,4621.2,165,,,Fee Schedule,165% of CMS OPPS Rate,2902.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8044.7,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11032.67,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13819.54,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,2800.72,100,,,Fee Schedule,100% of CMS OPPS Rate,2902.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,453.98,14,,,percent of total billed charges,14% of total billed charges,453.98,13819.54,
36251-SELECT/FLUSH RENAL ANGIO UNILAT LT,3431842,CDM,481,RC,36251,HCPCS,Outpatient,,,3242.68,1621.34,,2432.01,75,,,percent of total billed charges,75% of total billed charges,2432.01,75,,,percent of total billed charges,75% of total billed charges,2800.72,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,4621.2,165,,,Fee Schedule,165% of CMS OPPS Rate,2902.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8044.7,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11032.67,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13819.54,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,2800.72,100,,,Fee Schedule,100% of CMS OPPS Rate,2902.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,453.98,14,,,percent of total billed charges,14% of total billed charges,453.98,13819.54,
36251-SELECT/FLUSH RENAL ANGIO UNILAT RT,3431843,CDM,481,RC,36251,HCPCS,Outpatient,,,3242.68,1621.34,,2432.01,75,,,percent of total billed charges,75% of total billed charges,2432.01,75,,,percent of total billed charges,75% of total billed charges,2800.72,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,4621.2,165,,,Fee Schedule,165% of CMS OPPS Rate,2902.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8044.7,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11032.67,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13819.54,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,2800.72,100,,,Fee Schedule,100% of CMS OPPS Rate,2902.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,453.98,14,,,percent of total billed charges,14% of total billed charges,453.98,13819.54,
Renal Angiography LT,3427235,CDM,960,RC,36251,HCPCS,Outpatient,,,3091.1,1545.55,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
Renal Angiography RT,3427236,CDM,960,RC,36251,HCPCS,Outpatient,,,3091.1,1545.55,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
36252- Sel cath place/renal/1st ord/bilat,3430902,CDM,481,RC,36252,HCPCS,Outpatient,,,3528.14,1764.07,,2646.11,75,,,percent of total billed charges,75% of total billed charges,2646.11,75,,,percent of total billed charges,75% of total billed charges,2800.72,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,4621.2,165,,,Fee Schedule,165% of CMS OPPS Rate,2902.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8044.7,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11032.67,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13819.54,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,2800.72,100,,,Fee Schedule,100% of CMS OPPS Rate,2902.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,493.94,14,,,percent of total billed charges,14% of total billed charges,493.94,13819.54,
36252-Renal Angio Bilateral,3560641,CDM,481,RC,36252,HCPCS,Outpatient,,,3528.14,1764.07,,2646.11,75,,,percent of total billed charges,75% of total billed charges,2646.11,75,,,percent of total billed charges,75% of total billed charges,2800.72,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,4621.2,165,,,Fee Schedule,165% of CMS OPPS Rate,2902.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8044.7,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11032.67,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13819.54,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,2800.72,100,,,Fee Schedule,100% of CMS OPPS Rate,2902.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,493.94,14,,,percent of total billed charges,14% of total billed charges,493.94,13819.54,
36252-Renal Angiography BILAT,3431844,CDM,481,RC,36252,HCPCS,Outpatient,,,3528.14,1764.07,,2646.11,75,,,percent of total billed charges,75% of total billed charges,2646.11,75,,,percent of total billed charges,75% of total billed charges,2800.72,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,4621.2,165,,,Fee Schedule,165% of CMS OPPS Rate,2902.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8044.7,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11032.67,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13819.54,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,2800.72,100,,,Fee Schedule,100% of CMS OPPS Rate,2902.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,493.94,14,,,percent of total billed charges,14% of total billed charges,493.94,13819.54,
36252-SELECT/FLUSH ANGIO RENAL BILATERAL,3431845,CDM,481,RC,36252,HCPCS,Outpatient,,,3528.14,1764.07,,2646.11,75,,,percent of total billed charges,75% of total billed charges,2646.11,75,,,percent of total billed charges,75% of total billed charges,2800.72,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,4621.2,165,,,Fee Schedule,165% of CMS OPPS Rate,2902.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8044.7,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11032.67,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13819.54,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,2800.72,100,,,Fee Schedule,100% of CMS OPPS Rate,2902.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,493.94,14,,,percent of total billed charges,14% of total billed charges,493.94,13819.54,
Read,630458,CDM,972,RC,36252,HCPCS,Outpatient,,,1344.14,672.07,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
Renal Angiography BILAT,,,761,RC,36252,HCPCS,Outpatient,,,3360.36,1680.18,,2520.27,75,,,percent of total billed charges,75% of total billed charges,2520.27,75,,,percent of total billed charges,75% of total billed charges,2800.72,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,4621.2,165,,,Fee Schedule,165% of CMS OPPS Rate,2902.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8044.7,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11032.67,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13819.54,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,2800.72,100,,,Fee Schedule,100% of CMS OPPS Rate,2902.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,470.45,14,,,percent of total billed charges,14% of total billed charges,470.45,13819.54,
36253 - Supslctv Cath 3nd+Ord Renal & Accessory Artery/S&I,3899034,CDM,975,RC,36253,HCPCS,Outpatient,,,5042.06,2521.03,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
36253-Renal Angiography Supraselect  LT,3431846,CDM,481,RC,36253,HCPCS,Outpatient,,,5042.06,2521.03,,3781.55,75,,,percent of total billed charges,75% of total billed charges,3781.55,75,,,percent of total billed charges,75% of total billed charges,4832.22,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,7973.18,165,,,Fee Schedule,165% of CMS OPPS Rate,5008.19,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,13879.91,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,19035.19,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,23843.51,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,4832.22,100,,,Fee Schedule,100% of CMS OPPS Rate,5008.19,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,705.89,14,,,percent of total billed charges,14% of total billed charges,705.89,23843.51,
36253-Renal Angiography Supraselect RT,3431847,CDM,481,RC,36253,HCPCS,Outpatient,,,5042.06,2521.03,,3781.55,75,,,percent of total billed charges,75% of total billed charges,3781.55,75,,,percent of total billed charges,75% of total billed charges,4832.22,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,7973.18,165,,,Fee Schedule,165% of CMS OPPS Rate,5008.19,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,13879.91,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,19035.19,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,23843.51,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,4832.22,100,,,Fee Schedule,100% of CMS OPPS Rate,5008.19,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,705.89,14,,,percent of total billed charges,14% of total billed charges,705.89,23843.51,
Renal Angiography Supraselect  LT,,,761,RC,36253,HCPCS,Outpatient,,,4804.75,2402.38,,3603.56,75,,,percent of total billed charges,75% of total billed charges,3603.56,75,,,percent of total billed charges,75% of total billed charges,4832.22,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,7973.18,165,,,Fee Schedule,165% of CMS OPPS Rate,5008.19,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,13879.91,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,19035.19,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,23843.51,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,4832.22,100,,,Fee Schedule,100% of CMS OPPS Rate,5008.19,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,672.67,14,,,percent of total billed charges,14% of total billed charges,672.67,23843.51,
Renal Angiography Supraselect RT,,,761,RC,36253,HCPCS,Outpatient,,,4804.75,2402.38,,3603.56,75,,,percent of total billed charges,75% of total billed charges,3603.56,75,,,percent of total billed charges,75% of total billed charges,4832.22,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,7973.18,165,,,Fee Schedule,165% of CMS OPPS Rate,5008.19,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,13879.91,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,19035.19,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,23843.51,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,4832.22,100,,,Fee Schedule,100% of CMS OPPS Rate,5008.19,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,672.67,14,,,percent of total billed charges,14% of total billed charges,672.67,23843.51,
36254-Renal Angiography Supraselect BILAT,3431848,CDM,481,RC,36254,HCPCS,Outpatient,,,5020.79,2510.4,,3765.59,75,,,percent of total billed charges,75% of total billed charges,3765.59,75,,,percent of total billed charges,75% of total billed charges,2800.72,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,4621.2,165,,,Fee Schedule,165% of CMS OPPS Rate,2902.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8044.7,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11032.67,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13819.54,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,2800.72,100,,,Fee Schedule,100% of CMS OPPS Rate,2902.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,702.91,14,,,percent of total billed charges,14% of total billed charges,702.91,13819.54,
Renal Angiography Supraselect BILAT,,,761,RC,36254,HCPCS,Outpatient,,,4760.78,2380.39,,3570.59,75,,,percent of total billed charges,75% of total billed charges,3570.59,75,,,percent of total billed charges,75% of total billed charges,2800.72,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,4621.2,165,,,Fee Schedule,165% of CMS OPPS Rate,2902.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8044.7,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11032.67,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13819.54,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,2800.72,100,,,Fee Schedule,100% of CMS OPPS Rate,2902.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,666.51,14,,,percent of total billed charges,14% of total billed charges,666.51,13819.54,
36406- Venipunc/<3yrs/MD/PA/APRN/oth vein,3430712,CDM,510,RC,36406,HCPCS,Outpatient,,,42.95,21.48,,32.21,75,,,percent of total billed charges,75% of total billed charges,32.21,75,,,percent of total billed charges,75% of total billed charges,13.74,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.01,14,,,percent of total billed charges,14% of total billed charges,6.01,32.21,
36410 - PF Non-Routine BL Draw 3/ > Yrs,4311494,CDM,960,RC,36410,HCPCS,Outpatient,,,18.53,9.27,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
36410-PF NON-ROUTINE BL DRAW 3/> YRS,4321424,CDM,981,RC,36410,HCPCS,Outpatient,,,18.53,9.27,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
Midline Insertion,605007,CDM,940,RC,36410,HCPCS,Outpatient,,,18.53,9.27,,13.9,75,,,percent of total billed charges,75% of total billed charges,13.9,75,,,percent of total billed charges,75% of total billed charges,5.93,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,14,,,percent of total billed charges,14% of total billed charges,2.59,13.9,
Venipuncture,3549915,CDM,960,RC,36415,HCPCS,Outpatient,,,14.63,7.32,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
36425-PF VENIPUNCTURE CUTDOWN AGE 1 YR/>,4321426,CDM,981,RC,36425,HCPCS,Outpatient,,,78.16,39.08,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
36430-PF  TRANSFUSION BLOOD/BLOOD COMPONENTS,4321667,CDM,981,RC,36430,HCPCS,Outpatient,,,68.74,34.37,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
36471- Inj sclero solu/mult vein/same leg,3430715,CDM,960,RC,36471,HCPCS,Outpatient,,,157.62,78.81,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
36475- Endo abl/incom vein/ext/rad fre/#1,3430716,CDM,761,RC,36475,HCPCS,Outpatient,,,576.05,288.03,,432.04,75,,,percent of total billed charges,75% of total billed charges,432.04,75,,,percent of total billed charges,75% of total billed charges,2800.71,100,,,Fee Schedule,100% of CMS OPPS Rate,1102.62,102,,,Fee Schedule,102% of WV Medicaid Rate,4621.18,165,,,Fee Schedule,165% of CMS OPPS Rate,2902.7,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8044.7,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11032.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13819.53,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1081,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2800.71,100,,,Fee Schedule,100% of CMS OPPS Rate,2902.7,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,80.65,14,,,percent of total billed charges,14% of total billed charges,80.65,13819.53,
36475 Endovenous rf 1st vein,3428319,CDM,510,RC,36475,HCPCS,Outpatient,,,576.05,288.03,,432.04,75,,,percent of total billed charges,75% of total billed charges,432.04,75,,,percent of total billed charges,75% of total billed charges,2800.71,100,,,Fee Schedule,100% of CMS OPPS Rate,1102.62,102,,,Fee Schedule,102% of WV Medicaid Rate,4621.18,165,,,Fee Schedule,165% of CMS OPPS Rate,2902.7,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8044.7,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11032.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13819.53,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1081,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2800.71,100,,,Fee Schedule,100% of CMS OPPS Rate,2902.7,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,80.65,14,,,percent of total billed charges,14% of total billed charges,80.65,13819.53,
36476- RF abla/sec & subs vein/single ext,3430903,CDM,761,RC,36476,HCPCS,Outpatient,,,738.63,369.32,,553.97,75,,,percent of total billed charges,75% of total billed charges,553.97,75,,,percent of total billed charges,75% of total billed charges,236.36,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,103.41,14,,,percent of total billed charges,14% of total billed charges,103.41,553.97,
36513- Apheresis/platelets,3430717,CDM,510,RC,36513,HCPCS,Outpatient,,,278.27,139.14,,208.7,75,,,percent of total billed charges,75% of total billed charges,208.7,75,,,percent of total billed charges,75% of total billed charges,383.34,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,632.52,165,,,Fee Schedule,165% of CMS OPPS Rate,397.31,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1101.11,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1510.1,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1891.56,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,383.34,100,,,Fee Schedule,100% of CMS OPPS Rate,397.31,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,38.96,14,,,percent of total billed charges,14% of total billed charges,38.96,1891.56,
36513-PF THERAPEUTIC APHERESIS PLATELETS,4321666,CDM,981,RC,36513,HCPCS,Outpatient,,,206.06,103.03,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
36514- Apheresis/plasma pheresis,3430718,CDM,510,RC,36514,HCPCS,Outpatient,,,1383,691.5,,1037.25,75,,,percent of total billed charges,75% of total billed charges,1037.25,75,,,percent of total billed charges,75% of total billed charges,1278.47,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,2109.46,165,,,Fee Schedule,165% of CMS OPPS Rate,1325.02,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,3672.24,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5036.18,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6308.34,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,1278.47,100,,,Fee Schedule,100% of CMS OPPS Rate,1325.02,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,193.62,14,,,percent of total billed charges,14% of total billed charges,193.62,6308.34,
36555- Insert central venous cath/<5yrs,3430719,CDM,510,RC,36555,HCPCS,Outpatient,,,483.78,241.89,,362.84,75,,,percent of total billed charges,75% of total billed charges,362.84,75,,,percent of total billed charges,75% of total billed charges,2800.71,100,,,Fee Schedule,100% of CMS OPPS Rate,1102.62,102,,,Fee Schedule,102% of WV Medicaid Rate,4621.18,165,,,Fee Schedule,165% of CMS OPPS Rate,2902.7,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8044.7,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11032.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13819.53,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1081,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2800.71,100,,,Fee Schedule,100% of CMS OPPS Rate,2902.7,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,67.73,14,,,percent of total billed charges,14% of total billed charges,67.73,13819.53,
36555-PF INSJ NON-TUNNELED CENTRAL VENOUS CATH AGE < 5 Y,4321665,CDM,981,RC,36555,HCPCS,Outpatient,,,168.12,84.06,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
36556 - PF Ins Non-Tunneled CV Cath Age 5 yr/ >,4311495,CDM,960,RC,36556,HCPCS,Outpatient,,,198.5,99.25,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
36556- Insert CVC 5 yrs or >,3430720,CDM,510,RC,36556,HCPCS,Outpatient,,,543.02,271.51,,407.27,75,,,percent of total billed charges,75% of total billed charges,407.27,75,,,percent of total billed charges,75% of total billed charges,2800.71,100,,,Fee Schedule,100% of CMS OPPS Rate,1102.62,102,,,Fee Schedule,102% of WV Medicaid Rate,4621.18,165,,,Fee Schedule,165% of CMS OPPS Rate,2902.7,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8044.7,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11032.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13819.53,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1081,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2800.71,100,,,Fee Schedule,100% of CMS OPPS Rate,2902.7,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,76.02,14,,,percent of total billed charges,14% of total billed charges,76.02,13819.53,
36556-Insert non-tunnel CV catheter AGE 5 YR/>,4271231,CDM,481,RC,36556,HCPCS,Outpatient,,,542.99,271.5,,407.24,75,,,percent of total billed charges,75% of total billed charges,407.24,75,,,percent of total billed charges,75% of total billed charges,2800.71,100,,,Fee Schedule,100% of CMS OPPS Rate,1102.62,102,,,Fee Schedule,102% of WV Medicaid Rate,4621.18,165,,,Fee Schedule,165% of CMS OPPS Rate,2902.7,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8044.7,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11032.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13819.53,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1081,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2800.71,100,,,Fee Schedule,100% of CMS OPPS Rate,2902.7,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,76.02,14,,,percent of total billed charges,14% of total billed charges,76.02,13819.53,
36556-PF Insert non-tunnel CV catheter AGE 5 YR/>,4271232,CDM,960,RC,36556,HCPCS,Outpatient,,,542.99,271.5,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
36556-PF INSJ NON-TUNNELED CENTRAL VENOUS CATH AGE 5 YR/>,4321664,CDM,981,RC,36556,HCPCS,Outpatient,,,167.2,83.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
Insert non-tunnel CV catheter AGE 5 YR/>,4271233,CDM,761,RC,36556,HCPCS,Outpatient,,,542.99,271.5,,407.24,75,,,percent of total billed charges,75% of total billed charges,407.24,75,,,percent of total billed charges,75% of total billed charges,2800.71,100,,,Fee Schedule,100% of CMS OPPS Rate,1102.62,102,,,Fee Schedule,102% of WV Medicaid Rate,4621.18,165,,,Fee Schedule,165% of CMS OPPS Rate,2902.7,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8044.7,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11032.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13819.53,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1081,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2800.71,100,,,Fee Schedule,100% of CMS OPPS Rate,2902.7,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,76.02,14,,,percent of total billed charges,14% of total billed charges,76.02,13819.53,
"36557- Insertion of tunneled  venous cath, upto 5 yrs",3569417,CDM,510,RC,36557,HCPCS,Outpatient,,,2971.37,1485.69,,2228.53,75,,,percent of total billed charges,75% of total billed charges,2228.53,75,,,percent of total billed charges,75% of total billed charges,4832.22,100,,,Fee Schedule,100% of CMS OPPS Rate,2493.94,102,,,Fee Schedule,102% of WV Medicaid Rate,7973.16,165,,,Fee Schedule,165% of CMS OPPS Rate,5008.18,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,13879.91,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,19035.18,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,23843.51,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,2445.04,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,4832.22,100,,,Fee Schedule,100% of CMS OPPS Rate,5008.18,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,415.99,14,,,percent of total billed charges,14% of total billed charges,415.99,23843.51,
36558 - PF In Tunneled CV Cath w/ o Subq Port/ Pmp Age 5 yr/ >,4311496,CDM,960,RC,36558,HCPCS,Outpatient,,,602.29,301.15,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
36558- Insert tunn CVC w/o sub-q port 5yr,3430721,CDM,510,RC,36558,HCPCS,Outpatient,,,2117.84,1058.92,,1588.38,75,,,percent of total billed charges,75% of total billed charges,1588.38,75,,,percent of total billed charges,75% of total billed charges,2800.71,100,,,Fee Schedule,100% of CMS OPPS Rate,1102.62,102,,,Fee Schedule,102% of WV Medicaid Rate,4621.18,165,,,Fee Schedule,165% of CMS OPPS Rate,2902.7,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8044.7,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11032.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13819.53,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1081,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2800.71,100,,,Fee Schedule,100% of CMS OPPS Rate,2902.7,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,296.5,14,,,percent of total billed charges,14% of total billed charges,296.5,13819.53,
"36558-Insertion of tunneled centrally inserted central venous catheter, without subcutaneous port or",3554657,CDM,481,RC,36558,HCPCS,Outpatient,,,2117.84,1058.92,,1588.38,75,,,percent of total billed charges,75% of total billed charges,1588.38,75,,,percent of total billed charges,75% of total billed charges,2800.71,100,,,Fee Schedule,100% of CMS OPPS Rate,1102.62,102,,,Fee Schedule,102% of WV Medicaid Rate,4621.18,165,,,Fee Schedule,165% of CMS OPPS Rate,2902.7,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8044.7,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11032.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13819.53,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1081,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2800.71,100,,,Fee Schedule,100% of CMS OPPS Rate,2902.7,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,296.5,14,,,percent of total billed charges,14% of total billed charges,296.5,13819.53,
36558-PF INSJ TUNNELED CVC W/O SUBQ PORT/PMP AGE 5 YR/>,4321663,CDM,981,RC,36558,HCPCS,Outpatient,,,507.32,253.66,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
36558-TCC Placement,3431849,CDM,481,RC,36558,HCPCS,Outpatient,,,2117.84,1058.92,,1588.38,75,,,percent of total billed charges,75% of total billed charges,1588.38,75,,,percent of total billed charges,75% of total billed charges,2800.71,100,,,Fee Schedule,100% of CMS OPPS Rate,1102.62,102,,,Fee Schedule,102% of WV Medicaid Rate,4621.18,165,,,Fee Schedule,165% of CMS OPPS Rate,2902.7,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8044.7,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11032.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13819.53,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1081,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2800.71,100,,,Fee Schedule,100% of CMS OPPS Rate,2902.7,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,296.5,14,,,percent of total billed charges,14% of total billed charges,296.5,13819.53,
Hickman Placement,,,761,RC,36558,HCPCS,Outpatient,,,2016.76,1008.38,,1512.57,75,,,percent of total billed charges,75% of total billed charges,1512.57,75,,,percent of total billed charges,75% of total billed charges,2800.71,100,,,Fee Schedule,100% of CMS OPPS Rate,1102.62,102,,,Fee Schedule,102% of WV Medicaid Rate,4621.18,165,,,Fee Schedule,165% of CMS OPPS Rate,2902.7,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8044.7,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11032.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13819.53,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1081,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2800.71,100,,,Fee Schedule,100% of CMS OPPS Rate,2902.7,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,282.35,14,,,percent of total billed charges,14% of total billed charges,282.35,13819.53,
TCC Placement,3427243,CDM,960,RC,36558,HCPCS,Outpatient,,,2016.76,1008.38,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
36561 - PF Ins Tunneled CV Cath VAD w/ Subq Port Age 5 yr/ >,4311497,CDM,960,RC,36561,HCPCS,Outpatient,,,774.74,387.37,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
36561- Insert tunn CVC w/sub-q port 5yr>,3430722,CDM,510,RC,36561,HCPCS,Outpatient,,,2525.55,1262.78,,1894.16,75,,,percent of total billed charges,75% of total billed charges,1894.16,75,,,percent of total billed charges,75% of total billed charges,2800.71,100,,,Fee Schedule,100% of CMS OPPS Rate,1102.62,102,,,Fee Schedule,102% of WV Medicaid Rate,4621.18,165,,,Fee Schedule,165% of CMS OPPS Rate,2902.7,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8044.7,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11032.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13819.53,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1081,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2800.71,100,,,Fee Schedule,100% of CMS OPPS Rate,2902.7,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,353.58,14,,,percent of total billed charges,14% of total billed charges,353.58,13819.53,
"36561-Insertion of tunneled centrally inserted central venous access device, with subcut port,age 5",3554656,CDM,481,RC,36561,HCPCS,Outpatient,,,2525.55,1262.78,,1894.16,75,,,percent of total billed charges,75% of total billed charges,1894.16,75,,,percent of total billed charges,75% of total billed charges,2800.71,100,,,Fee Schedule,100% of CMS OPPS Rate,1102.62,102,,,Fee Schedule,102% of WV Medicaid Rate,4621.18,165,,,Fee Schedule,165% of CMS OPPS Rate,2902.7,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8044.7,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11032.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13819.53,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1081,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2800.71,100,,,Fee Schedule,100% of CMS OPPS Rate,2902.7,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,353.58,14,,,percent of total billed charges,14% of total billed charges,353.58,13819.53,
36561-PF INSJ TUNNELED CTR VAD W/SUBQ PORT AGE 5 YR/>,4321435,CDM,981,RC,36561,HCPCS,Outpatient,,,652.58,326.29,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
36563-Insertion of tunneled centrally inserted central venous access device w/ subcutanoues pump,3554655,CDM,481,RC,36563,HCPCS,Outpatient,,,2877.05,1438.53,,2157.79,75,,,percent of total billed charges,75% of total billed charges,2157.79,75,,,percent of total billed charges,75% of total billed charges,4832.22,100,,,Fee Schedule,100% of CMS OPPS Rate,3399.02,102,,,Fee Schedule,102% of WV Medicaid Rate,7973.16,165,,,Fee Schedule,165% of CMS OPPS Rate,5008.18,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,13879.91,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,19035.18,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,23843.51,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,3332.37,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,4832.22,100,,,Fee Schedule,100% of CMS OPPS Rate,5008.18,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,402.79,14,,,percent of total billed charges,14% of total billed charges,402.79,23843.51,
36563-PF Insertion of tunneled centrally inserted central venous access device w/ subcutanoues pump,3580885,CDM,960,RC,36563,HCPCS,Outpatient,,,2877.05,1438.53,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
"36565 - Insertion of tunneled centrally inserted central venous access device, requiring 2 catheters",3783246,CDM,510,RC,36565,HCPCS,Outpatient,,,2131.3,1065.65,,1598.48,75,,,percent of total billed charges,75% of total billed charges,1598.48,75,,,percent of total billed charges,75% of total billed charges,2800.71,100,,,Fee Schedule,100% of CMS OPPS Rate,1102.62,102,,,Fee Schedule,102% of WV Medicaid Rate,4621.18,165,,,Fee Schedule,165% of CMS OPPS Rate,2902.7,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8044.7,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11032.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13819.53,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1081,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2800.71,100,,,Fee Schedule,100% of CMS OPPS Rate,2902.7,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,298.38,14,,,percent of total billed charges,14% of total billed charges,298.38,13819.53,
36566-INSERT TUNNELED CV CATH,3430904,CDM,510,RC,36566,HCPCS,Outpatient,,,10675.26,5337.63,,8006.45,75,,,percent of total billed charges,75% of total billed charges,8006.45,75,,,percent of total billed charges,75% of total billed charges,4832.22,100,,,Fee Schedule,100% of CMS OPPS Rate,1912.09,102,,,Fee Schedule,102% of WV Medicaid Rate,7973.16,165,,,Fee Schedule,165% of CMS OPPS Rate,5008.18,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,13879.91,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,19035.18,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,23843.51,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1874.6,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,4832.22,100,,,Fee Schedule,100% of CMS OPPS Rate,5008.18,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1494.54,14,,,percent of total billed charges,14% of total billed charges,1494.54,23843.51,
36568-PF INSERTION PICC W/O IMG GDN < 5 YR,4321436,CDM,981,RC,36568,HCPCS,Outpatient,,,184.86,92.43,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
36569 PF Insertion PICC w/o Img Gdn 5 yrs/>,4279417,CDM,960,RC,36569,HCPCS,Outpatient,,,220.18,110.09,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
36569-PF INSERTION PICC W/O IMG GDN 5 YR/>,4321662,CDM,981,RC,36569,HCPCS,Outpatient,,,220.18,110.09,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
PICC Insertion with ECG Confirmation,3310602,CDM,940,RC,36569,HCPCS,Outpatient,,,220.18,110.09,,165.14,75,,,percent of total billed charges,75% of total billed charges,165.14,75,,,percent of total billed charges,75% of total billed charges,1398.82,100,,,Fee Schedule,100% of CMS OPPS Rate,440.05,102,,,Fee Schedule,102% of WV Medicaid Rate,2308.05,165,,,Fee Schedule,165% of CMS OPPS Rate,1449.76,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4017.93,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5510.28,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6902.18,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,431.42,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1398.82,100,,,Fee Schedule,100% of CMS OPPS Rate,1449.76,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,30.83,14,,,percent of total billed charges,14% of total billed charges,30.83,6902.18,
36570-PF INSJ PRPH CTR VAD W/SUBQ PORT UNDER 5 YR,4321661,CDM,981,RC,36570,HCPCS,Outpatient,,,660.16,330.08,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
RI INF Ins Non-Tunnel CVC -> Insert Non-Tunnel CVC <5 Yrs,3438251,CDM,360,RC,36570,HCPCS,Outpatient,,,3512.84,1756.42,,2634.63,75,,,percent of total billed charges,75% of total billed charges,2634.63,75,,,percent of total billed charges,75% of total billed charges,2800.71,100,,,Fee Schedule,100% of CMS OPPS Rate,1102.62,102,,,Fee Schedule,102% of WV Medicaid Rate,4621.18,165,,,Fee Schedule,165% of CMS OPPS Rate,2902.7,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8044.7,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11032.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13819.53,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1081,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2800.71,100,,,Fee Schedule,100% of CMS OPPS Rate,2902.7,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,491.8,14,,,percent of total billed charges,14% of total billed charges,491.8,13819.53,
"36571 - (50)  Insertion of peripherally inserted central venous access device, with subcutaneous por",3699142,CDM,510,RC,36571,HCPCS,Outpatient,,,3244.72,1622.36,,2433.54,75,,,percent of total billed charges,75% of total billed charges,2433.54,75,,,percent of total billed charges,75% of total billed charges,2800.71,100,,,Fee Schedule,100% of CMS OPPS Rate,1102.62,102,,,Fee Schedule,102% of WV Medicaid Rate,4621.18,165,,,Fee Schedule,165% of CMS OPPS Rate,2902.7,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8044.7,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11032.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13819.53,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1081,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2800.71,100,,,Fee Schedule,100% of CMS OPPS Rate,2902.7,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,454.26,14,,,percent of total billed charges,14% of total billed charges,454.26,13819.53,
"36571 - (PF) Insertion of peripherally inserted central venous access device, with subcutaneous port",3634907,CDM,510,RC,36571,HCPCS,Outpatient,,,3244.72,1622.36,,2433.54,75,,,percent of total billed charges,75% of total billed charges,2433.54,75,,,percent of total billed charges,75% of total billed charges,2800.71,100,,,Fee Schedule,100% of CMS OPPS Rate,1102.62,102,,,Fee Schedule,102% of WV Medicaid Rate,4621.18,165,,,Fee Schedule,165% of CMS OPPS Rate,2902.7,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8044.7,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11032.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13819.53,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1081,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2800.71,100,,,Fee Schedule,100% of CMS OPPS Rate,2902.7,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,454.26,14,,,percent of total billed charges,14% of total billed charges,454.26,13819.53,
36571 - PF Ins Prph Ctr Vad w/ Subq Port Age 5 yr/ >,4311498,CDM,960,RC,36571,HCPCS,Outpatient,,,730.03,365.02,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
RI INF Ins Non-Tunnel CVC -> Insert Non-Tunnel CVC >=5 yrs,3438250,CDM,360,RC,36571,HCPCS,Outpatient,,,3042.07,1521.04,,2281.55,75,,,percent of total billed charges,75% of total billed charges,2281.55,75,,,percent of total billed charges,75% of total billed charges,2800.71,100,,,Fee Schedule,100% of CMS OPPS Rate,1102.62,102,,,Fee Schedule,102% of WV Medicaid Rate,4621.18,165,,,Fee Schedule,165% of CMS OPPS Rate,2902.7,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8044.7,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11032.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13819.53,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1081,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2800.71,100,,,Fee Schedule,100% of CMS OPPS Rate,2902.7,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,425.89,14,,,percent of total billed charges,14% of total billed charges,425.89,13819.53,
36573-PF INSERTION PICC W/RS&I 5 YR/>,4321437,CDM,981,RC,36573,HCPCS,Outpatient,,,165.04,82.52,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
"36575 - (PF) Repair of tunneled or non-tunneled central venous access catheter, without subcutaneous",3634908,CDM,510,RC,36575,HCPCS,Outpatient,,,370.52,185.26,,277.89,75,,,percent of total billed charges,75% of total billed charges,277.89,75,,,percent of total billed charges,75% of total billed charges,543.88,100,,,Fee Schedule,100% of CMS OPPS Rate,220.64,102,,,Fee Schedule,102% of WV Medicaid Rate,897.4,165,,,Fee Schedule,165% of CMS OPPS Rate,563.67,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1562.23,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2142.48,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,2683.68,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,216.31,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,543.88,100,,,Fee Schedule,100% of CMS OPPS Rate,563.67,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,51.87,14,,,percent of total billed charges,14% of total billed charges,51.87,2683.68,
36575-PF RPR TUN/NON-TUN CTR VAD CATH W/O SUBQ PORT/PMP,4321442,CDM,981,RC,36575,HCPCS,Outpatient,,,65.4,32.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
RI INF Repair CVAD w/o Port/Pump,3402965,CDM,360,RC,36575,HCPCS,Outpatient,,,346.92,173.46,,260.19,75,,,percent of total billed charges,75% of total billed charges,260.19,75,,,percent of total billed charges,75% of total billed charges,543.88,100,,,Fee Schedule,100% of CMS OPPS Rate,220.64,102,,,Fee Schedule,102% of WV Medicaid Rate,897.4,165,,,Fee Schedule,165% of CMS OPPS Rate,563.67,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1562.23,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2142.48,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,2683.68,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,216.31,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,543.88,100,,,Fee Schedule,100% of CMS OPPS Rate,563.67,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,48.57,14,,,percent of total billed charges,14% of total billed charges,48.57,2683.68,
36576- Rpr cent ven access dev/port/pump,3430905,CDM,510,RC,36576,HCPCS,Outpatient,,,895.48,447.74,,671.61,75,,,percent of total billed charges,75% of total billed charges,671.61,75,,,percent of total billed charges,75% of total billed charges,1398.82,100,,,Fee Schedule,100% of CMS OPPS Rate,440.05,102,,,Fee Schedule,102% of WV Medicaid Rate,2308.05,165,,,Fee Schedule,165% of CMS OPPS Rate,1449.76,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4017.93,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5510.28,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6902.18,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,431.42,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1398.82,100,,,Fee Schedule,100% of CMS OPPS Rate,1449.76,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,125.37,14,,,percent of total billed charges,14% of total billed charges,125.37,6902.18,
36578- Rep cath only/cen ven acc/por/pump,3430906,CDM,510,RC,36578,HCPCS,Outpatient,,,1121.72,560.86,,841.29,75,,,percent of total billed charges,75% of total billed charges,841.29,75,,,percent of total billed charges,75% of total billed charges,2800.71,100,,,Fee Schedule,100% of CMS OPPS Rate,1480.13,102,,,Fee Schedule,102% of WV Medicaid Rate,4621.18,165,,,Fee Schedule,165% of CMS OPPS Rate,2902.7,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8044.7,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11032.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13819.53,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1451.11,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2800.71,100,,,Fee Schedule,100% of CMS OPPS Rate,2902.7,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,157.04,14,,,percent of total billed charges,14% of total billed charges,157.04,13819.53,
36580-PF RPLCMT COMPL NON-TUN CVC W/O SUBQ PORT/PMP,4321660,CDM,981,RC,36580,HCPCS,Outpatient,,,129.88,64.94,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
36581-TCC Replacement,3431850,CDM,481,RC,36581,HCPCS,Outpatient,,,1971.9,985.95,,1478.93,75,,,percent of total billed charges,75% of total billed charges,1478.93,75,,,percent of total billed charges,75% of total billed charges,2800.71,100,,,Fee Schedule,100% of CMS OPPS Rate,1457.15,102,,,Fee Schedule,102% of WV Medicaid Rate,4621.18,165,,,Fee Schedule,165% of CMS OPPS Rate,2902.7,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8044.7,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11032.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13819.53,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1428.58,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2800.71,100,,,Fee Schedule,100% of CMS OPPS Rate,2902.7,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,276.07,14,,,percent of total billed charges,14% of total billed charges,276.07,13819.53,
TCC Replacement,3427244,CDM,960,RC,36581,HCPCS,Outpatient,,,1867.35,933.68,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
"36582 - (PF) Replacement, complete, of a tunneled centrally inserted central venous access device,",3634909,CDM,510,RC,36582,HCPCS,Outpatient,,,2260.41,1130.21,,1695.31,75,,,percent of total billed charges,75% of total billed charges,1695.31,75,,,percent of total billed charges,75% of total billed charges,2800.71,100,,,Fee Schedule,100% of CMS OPPS Rate,1102.62,102,,,Fee Schedule,102% of WV Medicaid Rate,4621.18,165,,,Fee Schedule,165% of CMS OPPS Rate,2902.7,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8044.7,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11032.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13819.53,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1081,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2800.71,100,,,Fee Schedule,100% of CMS OPPS Rate,2902.7,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,316.46,14,,,percent of total billed charges,14% of total billed charges,316.46,13819.53,
36584-PF COMPLETE REPLACEMENT PICC RS&I,4321659,CDM,981,RC,36584,HCPCS,Outpatient,,,114.94,57.47,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
36585- Replace PICC/same venous access,3430907,CDM,510,RC,36585,HCPCS,Outpatient,,,2947.04,1473.52,,2210.28,75,,,percent of total billed charges,75% of total billed charges,2210.28,75,,,percent of total billed charges,75% of total billed charges,2800.71,100,,,Fee Schedule,100% of CMS OPPS Rate,1102.62,102,,,Fee Schedule,102% of WV Medicaid Rate,4621.18,165,,,Fee Schedule,165% of CMS OPPS Rate,2902.7,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8044.7,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11032.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13819.53,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1081,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2800.71,100,,,Fee Schedule,100% of CMS OPPS Rate,2902.7,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,412.59,14,,,percent of total billed charges,14% of total billed charges,412.59,13819.53,
36589 - PF Rmvl Tun CVC w/ o Subq Port/ Pmp,4311499,CDM,960,RC,36589,HCPCS,Outpatient,,,316.35,158.18,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
36589- Rmv tunnel cent ven access cath,3430724,CDM,361,RC,36589,HCPCS,Outpatient,,,430.96,215.48,,323.22,75,,,percent of total billed charges,75% of total billed charges,323.22,75,,,percent of total billed charges,75% of total billed charges,543.88,100,,,Fee Schedule,100% of CMS OPPS Rate,220.64,102,,,Fee Schedule,102% of WV Medicaid Rate,897.41,165,,,Fee Schedule,165% of CMS OPPS Rate,563.69,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1562.23,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2142.48,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,2683.68,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,216.31,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,543.88,100,,,Fee Schedule,100% of CMS OPPS Rate,563.69,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,60.33,14,,,percent of total billed charges,14% of total billed charges,60.33,2683.68,
36589-TCC Removal,3431851,CDM,481,RC,36589,HCPCS,Outpatient,,,430.96,215.48,,323.22,75,,,percent of total billed charges,75% of total billed charges,323.22,75,,,percent of total billed charges,75% of total billed charges,543.88,100,,,Fee Schedule,100% of CMS OPPS Rate,220.64,102,,,Fee Schedule,102% of WV Medicaid Rate,897.41,165,,,Fee Schedule,165% of CMS OPPS Rate,563.69,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1562.23,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2142.48,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,2683.68,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,216.31,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,543.88,100,,,Fee Schedule,100% of CMS OPPS Rate,563.69,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,60.33,14,,,percent of total billed charges,14% of total billed charges,60.33,2683.68,
TCC Removal,,,761,RC,36589,HCPCS,Outpatient,,,421.81,210.91,,316.36,75,,,percent of total billed charges,75% of total billed charges,316.36,75,,,percent of total billed charges,75% of total billed charges,543.88,100,,,Fee Schedule,100% of CMS OPPS Rate,220.64,102,,,Fee Schedule,102% of WV Medicaid Rate,897.41,165,,,Fee Schedule,165% of CMS OPPS Rate,563.69,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1562.23,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2142.48,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,2683.68,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,216.31,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,543.88,100,,,Fee Schedule,100% of CMS OPPS Rate,563.69,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,59.05,14,,,percent of total billed charges,14% of total billed charges,59.05,2683.68,
36590 - PF Rmvl Tun Ctr Vad W/ Subq Port/ Pmp Ctr/ Prph Ins,4311500,CDM,960,RC,36590,HCPCS,Outpatient,,,441.45,220.73,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
36590- Rmv tun cen ven acces cath/SQ port,3430725,CDM,361,RC,36590,HCPCS,Outpatient,,,587.56,293.78,,440.67,75,,,percent of total billed charges,75% of total billed charges,440.67,75,,,percent of total billed charges,75% of total billed charges,1398.82,100,,,Fee Schedule,100% of CMS OPPS Rate,440.05,102,,,Fee Schedule,102% of WV Medicaid Rate,2308.06,165,,,Fee Schedule,165% of CMS OPPS Rate,1449.76,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4017.93,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5510.28,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6902.18,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,431.42,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1398.82,100,,,Fee Schedule,100% of CMS OPPS Rate,1449.76,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,82.26,14,,,percent of total billed charges,14% of total billed charges,82.26,6902.18,
36590-PF Removal of Tunneled CV Access Device,3872931,CDM,960,RC,36590,HCPCS,Outpatient,,,587.56,293.78,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
36590-PF RMVL TUN CTR VAD W/SUBQ PORT/PMP CTR/PRPH INSJ,4321443,CDM,981,RC,36590,HCPCS,Outpatient,,,371.84,185.92,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
36590-Removal of Tunneled CV Access Device,3872929,CDM,481,RC,36590,HCPCS,Outpatient,,,587.56,293.78,,440.67,75,,,percent of total billed charges,75% of total billed charges,440.67,75,,,percent of total billed charges,75% of total billed charges,1398.82,100,,,Fee Schedule,100% of CMS OPPS Rate,440.05,102,,,Fee Schedule,102% of WV Medicaid Rate,2308.06,165,,,Fee Schedule,165% of CMS OPPS Rate,1449.76,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4017.93,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5510.28,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6902.18,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,431.42,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1398.82,100,,,Fee Schedule,100% of CMS OPPS Rate,1449.76,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,82.26,14,,,percent of total billed charges,14% of total billed charges,82.26,6902.18,
Removal of Tunneled CV Access Device,,,761,RC,36590,HCPCS,Outpatient,,,573.78,286.89,,430.34,75,,,percent of total billed charges,75% of total billed charges,430.34,75,,,percent of total billed charges,75% of total billed charges,1398.82,100,,,Fee Schedule,100% of CMS OPPS Rate,440.05,102,,,Fee Schedule,102% of WV Medicaid Rate,2308.06,165,,,Fee Schedule,165% of CMS OPPS Rate,1449.76,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4017.93,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5510.28,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6902.18,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,431.42,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1398.82,100,,,Fee Schedule,100% of CMS OPPS Rate,1449.76,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,80.33,14,,,percent of total billed charges,14% of total billed charges,80.33,6902.18,
36591-PF COLLECT BLOOD FROM IMPLANT VENOUS ACCESS DEVICE,4321658,CDM,981,RC,36591,HCPCS,Outpatient,,,46.9,23.45,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
"36595 Mechanical removal of pericatheter obstructive material (eg, fibrin sheath) from central venou",3621453,CDM,510,RC,36595,HCPCS,Outpatient,,,1510.73,755.37,,1133.05,75,,,percent of total billed charges,75% of total billed charges,1133.05,75,,,percent of total billed charges,75% of total billed charges,2800.71,100,,,Fee Schedule,100% of CMS OPPS Rate,1432.13,102,,,Fee Schedule,102% of WV Medicaid Rate,4621.18,165,,,Fee Schedule,165% of CMS OPPS Rate,2902.7,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8044.7,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11032.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13819.53,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1404.05,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2800.71,100,,,Fee Schedule,100% of CMS OPPS Rate,2902.7,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,211.5,14,,,percent of total billed charges,14% of total billed charges,211.5,13819.53,
36597-TCC Reposition,3431852,CDM,481,RC,36597,HCPCS,Outpatient,,,281.74,140.87,,211.31,75,,,percent of total billed charges,75% of total billed charges,211.31,75,,,percent of total billed charges,75% of total billed charges,1398.82,100,,,Fee Schedule,100% of CMS OPPS Rate,440.05,102,,,Fee Schedule,102% of WV Medicaid Rate,2308.05,165,,,Fee Schedule,165% of CMS OPPS Rate,1449.76,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4017.93,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5510.28,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6902.18,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,431.42,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1398.82,100,,,Fee Schedule,100% of CMS OPPS Rate,1449.76,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,39.44,14,,,percent of total billed charges,14% of total billed charges,39.44,6902.18,
TCC Reposition,,,761,RC,36597,HCPCS,Outpatient,,,280.14,140.07,,210.11,75,,,percent of total billed charges,75% of total billed charges,210.11,75,,,percent of total billed charges,75% of total billed charges,1398.82,100,,,Fee Schedule,100% of CMS OPPS Rate,440.05,102,,,Fee Schedule,102% of WV Medicaid Rate,2308.05,165,,,Fee Schedule,165% of CMS OPPS Rate,1449.76,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4017.93,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5510.28,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6902.18,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,431.42,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1398.82,100,,,Fee Schedule,100% of CMS OPPS Rate,1449.76,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,39.22,14,,,percent of total billed charges,14% of total billed charges,39.22,6902.18,
DR Existing Central Venous Injection,659958,CDM,320,RC,36598,HCPCS,Outpatient,,,292.19,146.1,,219.14,75,,,percent of total billed charges,75% of total billed charges,219.14,75,,,percent of total billed charges,75% of total billed charges,194.2,100,,,Fee Schedule,100% of CMS OPPS Rate,78.36,102,,,Fee Schedule,102% of WV Medicaid Rate,320.44,165,,,Fee Schedule,165% of CMS OPPS Rate,201.28,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,557.84,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,765.02,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,958.27,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,76.82,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,194.2,100,,,Fee Schedule,100% of CMS OPPS Rate,201.28,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,40.91,14,,,percent of total billed charges,14% of total billed charges,40.91,958.27,
Read,3348400,CDM,972,RC,36598,HCPCS,Outpatient,,,116.88,58.44,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
36600 - PF Arterial Puncture Withdrawal Blood Dx,4311501,CDM,960,RC,36600,HCPCS,Outpatient,,,34.72,17.36,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
36600-PF ARTERIAL PUNCTURE WITHDRAWAL BLOOD DX,4321444,CDM,981,RC,36600,HCPCS,Outpatient,,,29.24,14.62,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
36620 - PF Artl Cath/ Cannul Mntr/ Transfusion Spx Prq,4311502,CDM,960,RC,36620,HCPCS,Outpatient,,,105.18,52.59,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
36620- Arterial Blood Draw/Perc,3430728,CDM,510,RC,36620,HCPCS,Outpatient,,,117.76,58.88,,88.32,75,,,percent of total billed charges,75% of total billed charges,88.32,75,,,percent of total billed charges,75% of total billed charges,37.68,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.49,14,,,percent of total billed charges,14% of total billed charges,16.49,88.32,
"36620-Arterial cannulation for sampling, monitoring or transfusion",4271177,CDM,481,RC,36620,HCPCS,Outpatient,,,93.92,46.96,,70.44,75,,,percent of total billed charges,75% of total billed charges,70.44,75,,,percent of total billed charges,75% of total billed charges,30.05,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.15,14,,,percent of total billed charges,14% of total billed charges,13.15,70.44,
"36620-PF Arterial cannulation for sampling, monitoring or transfusion",4271178,CDM,960,RC,36620,HCPCS,Outpatient,,,93.92,46.96,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
36620-PF ARTL CATHJ/CANNULJ MNTR/TRANSFUSION SPX PRQ,4321445,CDM,981,RC,36620,HCPCS,Outpatient,,,88.6,44.3,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
36680-PF PLACEMENT NEEDLE INTRAOSSEOUS INFUSION,4321657,CDM,981,RC,36680,HCPCS,Outpatient,,,120.02,60.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
36800- Insert hemodial cannula/vein/vein,3430730,CDM,510,RC,36800,HCPCS,Outpatient,,,322.71,161.36,,242.03,75,,,percent of total billed charges,75% of total billed charges,242.03,75,,,percent of total billed charges,75% of total billed charges,4832.22,100,,,Fee Schedule,100% of CMS OPPS Rate,1912.09,102,,,Fee Schedule,102% of WV Medicaid Rate,7973.16,165,,,Fee Schedule,165% of CMS OPPS Rate,5008.18,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,13879.91,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,19035.18,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,23843.51,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1874.6,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,4832.22,100,,,Fee Schedule,100% of CMS OPPS Rate,5008.18,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,45.18,14,,,percent of total billed charges,14% of total billed charges,45.18,23843.51,
"36818- Arteriovenous anastomosis, open; by upper arm cephalic vein transposition",3566783,CDM,510,RC,36818,HCPCS,Outpatient,,,1856.79,928.4,,1392.59,75,,,percent of total billed charges,75% of total billed charges,1392.59,75,,,percent of total billed charges,75% of total billed charges,4832.22,100,,,Fee Schedule,100% of CMS OPPS Rate,1912.09,102,,,Fee Schedule,102% of WV Medicaid Rate,7973.16,165,,,Fee Schedule,165% of CMS OPPS Rate,5008.18,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,13879.91,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,19035.18,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,23843.51,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1874.6,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,4832.22,100,,,Fee Schedule,100% of CMS OPPS Rate,5008.18,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,259.95,14,,,percent of total billed charges,14% of total billed charges,259.95,23843.51,
"36821- Arteriovenous anastomosis, open; direct, any site (eg, Cimino type) (separate procedure",3566784,CDM,510,RC,36821,HCPCS,Outpatient,,,1784.88,892.44,,1338.66,75,,,percent of total billed charges,75% of total billed charges,1338.66,75,,,percent of total billed charges,75% of total billed charges,2800.71,100,,,Fee Schedule,100% of CMS OPPS Rate,1102.62,102,,,Fee Schedule,102% of WV Medicaid Rate,4621.18,165,,,Fee Schedule,165% of CMS OPPS Rate,2902.7,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8044.7,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11032.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13819.53,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1081,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2800.71,100,,,Fee Schedule,100% of CMS OPPS Rate,2902.7,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,249.88,14,,,percent of total billed charges,14% of total billed charges,249.88,13819.53,
36825 - Creation of arteriovenous fistula by other than direct arteriovenous anastomosis (separate p,3783259,CDM,510,RC,36825,HCPCS,Outpatient,,,2138.57,1069.29,,1603.93,75,,,percent of total billed charges,75% of total billed charges,1603.93,75,,,percent of total billed charges,75% of total billed charges,4832.22,100,,,Fee Schedule,100% of CMS OPPS Rate,1912.09,102,,,Fee Schedule,102% of WV Medicaid Rate,7973.16,165,,,Fee Schedule,165% of CMS OPPS Rate,5008.18,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,13879.91,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,19035.18,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,23843.51,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1874.6,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,4832.22,100,,,Fee Schedule,100% of CMS OPPS Rate,5008.18,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,299.4,14,,,percent of total billed charges,14% of total billed charges,299.4,23843.51,
36830 - Creation of arteriovenous fistula by other than direct arteriovenous anastomosis (separate p,3572801,CDM,960,RC,36830,HCPCS,Outpatient,,,1797.79,898.9,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
36830-Hero Graft Placement,4233157,CDM,481,RC,36830,HCPCS,Outpatient,,,1410.67,705.34,,1058,75,,,percent of total billed charges,75% of total billed charges,1058,75,,,percent of total billed charges,75% of total billed charges,4832.22,100,,,Fee Schedule,100% of CMS OPPS Rate,1912.09,102,,,Fee Schedule,102% of WV Medicaid Rate,7973.16,165,,,Fee Schedule,165% of CMS OPPS Rate,5008.18,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,13879.91,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,19035.18,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,23843.51,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1874.6,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,4832.22,100,,,Fee Schedule,100% of CMS OPPS Rate,5008.18,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,197.49,14,,,percent of total billed charges,14% of total billed charges,197.49,23843.51,
36830-PF Hero Graft Placement,4233158,CDM,960,RC,36830,HCPCS,Outpatient,,,1410.67,705.34,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
Hero Graft Placement,,,761,RC,36830,HCPCS,Outpatient,,,1410.67,705.34,,1058,75,,,percent of total billed charges,75% of total billed charges,1058,75,,,percent of total billed charges,75% of total billed charges,4832.22,100,,,Fee Schedule,100% of CMS OPPS Rate,1912.09,102,,,Fee Schedule,102% of WV Medicaid Rate,7973.16,165,,,Fee Schedule,165% of CMS OPPS Rate,5008.18,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,13879.91,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,19035.18,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,23843.51,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1874.6,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,4832.22,100,,,Fee Schedule,100% of CMS OPPS Rate,5008.18,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,197.49,14,,,percent of total billed charges,14% of total billed charges,197.49,23843.51,
36831- Open Thrombectomy of AV Fistula w/o Revision,3430908,CDM,510,RC,36831,HCPCS,Outpatient,,,1656.18,828.09,,1242.14,75,,,percent of total billed charges,75% of total billed charges,1242.14,75,,,percent of total billed charges,75% of total billed charges,4832.22,100,,,Fee Schedule,100% of CMS OPPS Rate,1912.09,102,,,Fee Schedule,102% of WV Medicaid Rate,7973.16,165,,,Fee Schedule,165% of CMS OPPS Rate,5008.18,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,13879.91,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,19035.18,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,23843.51,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1874.6,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,4832.22,100,,,Fee Schedule,100% of CMS OPPS Rate,5008.18,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,231.87,14,,,percent of total billed charges,14% of total billed charges,231.87,23843.51,
36832- Revise/open/AV fist w/o thrombect,3430731,CDM,510,RC,36832,HCPCS,Outpatient,,,2035.14,1017.57,,1526.36,75,,,percent of total billed charges,75% of total billed charges,1526.36,75,,,percent of total billed charges,75% of total billed charges,4832.22,100,,,Fee Schedule,100% of CMS OPPS Rate,1912.09,102,,,Fee Schedule,102% of WV Medicaid Rate,7973.16,165,,,Fee Schedule,165% of CMS OPPS Rate,5008.18,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,13879.91,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,19035.18,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,23843.51,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1874.6,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,4832.22,100,,,Fee Schedule,100% of CMS OPPS Rate,5008.18,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,284.92,14,,,percent of total billed charges,14% of total billed charges,284.92,23843.51,
36833- AV fis revis/open throm/dial gft,3430909,CDM,510,RC,36833,HCPCS,Outpatient,,,2178.25,1089.13,,1633.69,75,,,percent of total billed charges,75% of total billed charges,1633.69,75,,,percent of total billed charges,75% of total billed charges,4832.22,100,,,Fee Schedule,100% of CMS OPPS Rate,1912.09,102,,,Fee Schedule,102% of WV Medicaid Rate,7973.16,165,,,Fee Schedule,165% of CMS OPPS Rate,5008.18,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,13879.91,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,19035.18,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,23843.51,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1874.6,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,4832.22,100,,,Fee Schedule,100% of CMS OPPS Rate,5008.18,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,304.96,14,,,percent of total billed charges,14% of total billed charges,304.96,23843.51,
36861-Insert balloon catheter for declot from dialysis cannula,4271234,CDM,481,RC,36861,HCPCS,Outpatient,,,298.24,149.12,,223.68,75,,,percent of total billed charges,75% of total billed charges,223.68,75,,,percent of total billed charges,75% of total billed charges,4832.22,100,,,Fee Schedule,100% of CMS OPPS Rate,2687.03,102,,,Fee Schedule,102% of WV Medicaid Rate,7973.16,165,,,Fee Schedule,165% of CMS OPPS Rate,5008.18,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,13879.91,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,19035.18,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,23843.51,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,2634.34,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,4832.22,100,,,Fee Schedule,100% of CMS OPPS Rate,5008.18,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,41.75,14,,,percent of total billed charges,14% of total billed charges,41.75,23843.51,
36861-PF Insert balloon catheter for declot from dialysis cannula,4271235,CDM,960,RC,36861,HCPCS,Outpatient,,,298.24,149.12,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
"36901 - PF - Introduction of needle(s) and/or catheter(s), dialysis circuit, with diagnostic angiogr",3640895,CDM,510,RC,36901,HCPCS,Outpatient,,,1778.53,889.27,,1333.9,75,,,percent of total billed charges,75% of total billed charges,1333.9,75,,,percent of total billed charges,75% of total billed charges,1398.82,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,2308.05,165,,,Fee Schedule,165% of CMS OPPS Rate,1449.76,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4017.93,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5510.28,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6902.18,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,1398.82,100,,,Fee Schedule,100% of CMS OPPS Rate,1449.76,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,248.99,14,,,percent of total billed charges,14% of total billed charges,248.99,6902.18,
36901-Fistulogram Angiography,3431853,CDM,360,RC,36901,HCPCS,Outpatient,,,1778.53,889.27,,1333.9,75,,,percent of total billed charges,75% of total billed charges,1333.9,75,,,percent of total billed charges,75% of total billed charges,1398.82,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,2308.05,165,,,Fee Schedule,165% of CMS OPPS Rate,1449.76,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4017.93,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5510.28,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6902.18,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,1398.82,100,,,Fee Schedule,100% of CMS OPPS Rate,1449.76,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,248.99,14,,,percent of total billed charges,14% of total billed charges,248.99,6902.18,
36901-Fistulogram- Angiography,3560663,CDM,481,RC,36901,HCPCS,Outpatient,,,1778.53,889.27,,1333.9,75,,,percent of total billed charges,75% of total billed charges,1333.9,75,,,percent of total billed charges,75% of total billed charges,1398.82,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,2308.05,165,,,Fee Schedule,165% of CMS OPPS Rate,1449.76,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4017.93,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5510.28,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6902.18,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,1398.82,100,,,Fee Schedule,100% of CMS OPPS Rate,1449.76,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,248.99,14,,,percent of total billed charges,14% of total billed charges,248.99,6902.18,
36901-Fistulogram LT,3431854,CDM,481,RC,36901,HCPCS,Outpatient,,,1778.53,889.27,,1333.9,75,,,percent of total billed charges,75% of total billed charges,1333.9,75,,,percent of total billed charges,75% of total billed charges,1398.82,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,2308.05,165,,,Fee Schedule,165% of CMS OPPS Rate,1449.76,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4017.93,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5510.28,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6902.18,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,1398.82,100,,,Fee Schedule,100% of CMS OPPS Rate,1449.76,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,248.99,14,,,percent of total billed charges,14% of total billed charges,248.99,6902.18,
36901-Fistulogram RT,3431855,CDM,360,RC,36901,HCPCS,Outpatient,,,1778.53,889.27,,1333.9,75,,,percent of total billed charges,75% of total billed charges,1333.9,75,,,percent of total billed charges,75% of total billed charges,1398.82,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,2308.05,165,,,Fee Schedule,165% of CMS OPPS Rate,1449.76,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4017.93,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5510.28,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6902.18,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,1398.82,100,,,Fee Schedule,100% of CMS OPPS Rate,1449.76,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,248.99,14,,,percent of total billed charges,14% of total billed charges,248.99,6902.18,
Fistulogram LT,,,761,RC,36901,HCPCS,Outpatient,,,1699.64,849.82,,1274.73,75,,,percent of total billed charges,75% of total billed charges,1274.73,75,,,percent of total billed charges,75% of total billed charges,1398.82,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,2308.05,165,,,Fee Schedule,165% of CMS OPPS Rate,1449.76,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4017.93,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5510.28,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6902.18,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,1398.82,100,,,Fee Schedule,100% of CMS OPPS Rate,1449.76,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,237.95,14,,,percent of total billed charges,14% of total billed charges,237.95,6902.18,
Fistulogram RT,,,761,RC,36901,HCPCS,Outpatient,,,1699.64,849.82,,1274.73,75,,,percent of total billed charges,75% of total billed charges,1274.73,75,,,percent of total billed charges,75% of total billed charges,1398.82,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,2308.05,165,,,Fee Schedule,165% of CMS OPPS Rate,1449.76,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4017.93,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5510.28,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6902.18,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,1398.82,100,,,Fee Schedule,100% of CMS OPPS Rate,1449.76,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,237.95,14,,,percent of total billed charges,14% of total billed charges,237.95,6902.18,
"36902 - PF - Introduction of needle(s) and/or catheter(s), dialysis circuit, with diagnostic angiogr",3640896,CDM,510,RC,36902,HCPCS,Outpatient,,,3038.33,1519.17,,2278.75,75,,,percent of total billed charges,75% of total billed charges,2278.75,75,,,percent of total billed charges,75% of total billed charges,4903.32,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,8090.5,165,,,Fee Schedule,165% of CMS OPPS Rate,5081.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,14084.18,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,19315.33,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,24194.41,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,4903.32,100,,,Fee Schedule,100% of CMS OPPS Rate,5081.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,425.37,14,,,percent of total billed charges,14% of total billed charges,425.37,24194.41,
36902-Fistulogram PTA,3431856,CDM,481,RC,36902,HCPCS,Outpatient,,,3038.33,1519.17,,2278.75,75,,,percent of total billed charges,75% of total billed charges,2278.75,75,,,percent of total billed charges,75% of total billed charges,4903.32,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,8090.5,165,,,Fee Schedule,165% of CMS OPPS Rate,5081.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,14084.18,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,19315.33,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,24194.41,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,4903.32,100,,,Fee Schedule,100% of CMS OPPS Rate,5081.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,425.37,14,,,percent of total billed charges,14% of total billed charges,425.37,24194.41,
Fistulogram PTA,,,761,RC,36902,HCPCS,Outpatient,,,2890.83,1445.42,,2168.12,75,,,percent of total billed charges,75% of total billed charges,2168.12,75,,,percent of total billed charges,75% of total billed charges,4903.32,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,8090.5,165,,,Fee Schedule,165% of CMS OPPS Rate,5081.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,14084.18,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,19315.33,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,24194.41,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,4903.32,100,,,Fee Schedule,100% of CMS OPPS Rate,5081.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,404.72,14,,,percent of total billed charges,14% of total billed charges,404.72,24194.41,
"36903 - PF - Introduction of needle(s) and/or catheter(s), dialysis circuit, with diagnostic angiogr",3640897,CDM,510,RC,36903,HCPCS,Outpatient,,,10748.95,5374.48,,8061.71,75,,,percent of total billed charges,75% of total billed charges,8061.71,75,,,percent of total billed charges,75% of total billed charges,9980.15,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,16467.25,165,,,Fee Schedule,165% of CMS OPPS Rate,10343.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,28666.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,39314,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,49244.77,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,9980.15,100,,,Fee Schedule,100% of CMS OPPS Rate,10343.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1504.85,14,,,percent of total billed charges,14% of total billed charges,1504.85,49244.77,
36903-Fistulogram Stent w PTA,3431857,CDM,481,RC,36903,HCPCS,Outpatient,,,10748.95,5374.48,,8061.71,75,,,percent of total billed charges,75% of total billed charges,8061.71,75,,,percent of total billed charges,75% of total billed charges,9980.15,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,16467.25,165,,,Fee Schedule,165% of CMS OPPS Rate,10343.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,28666.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,39314,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,49244.77,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,9980.15,100,,,Fee Schedule,100% of CMS OPPS Rate,10343.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1504.85,14,,,percent of total billed charges,14% of total billed charges,1504.85,49244.77,
36903-Tib/Peroneal PTA Unilateral,3560661,CDM,481,RC,36903,HCPCS,Outpatient,,,10748.95,5374.48,,8061.71,75,,,percent of total billed charges,75% of total billed charges,8061.71,75,,,percent of total billed charges,75% of total billed charges,9980.15,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,16467.25,165,,,Fee Schedule,165% of CMS OPPS Rate,10343.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,28666.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,39314,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,49244.77,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,9980.15,100,,,Fee Schedule,100% of CMS OPPS Rate,10343.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1504.85,14,,,percent of total billed charges,14% of total billed charges,1504.85,49244.77,
Fistulogram Stent w PTA,,,761,RC,36903,HCPCS,Outpatient,,,10078.59,5039.3,,7558.94,75,,,percent of total billed charges,75% of total billed charges,7558.94,75,,,percent of total billed charges,75% of total billed charges,9980.15,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,16467.25,165,,,Fee Schedule,165% of CMS OPPS Rate,10343.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,28666.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,39314,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,49244.77,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,9980.15,100,,,Fee Schedule,100% of CMS OPPS Rate,10343.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1411,14,,,percent of total billed charges,14% of total billed charges,1411,49244.77,
36904 - PERQ THRMBC/NFS DIALYSIS CIRCUIT IMG DX ANGRPH,4037512,CDM,983,RC,36904,HCPCS,Outpatient,,,4541.32,2270.66,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
36904-Fistulogram Thrombectomy,3431858,CDM,481,RC,36904,HCPCS,Outpatient,,,4541.32,2270.66,,3405.99,75,,,percent of total billed charges,75% of total billed charges,3405.99,75,,,percent of total billed charges,75% of total billed charges,4903.32,100,,,Fee Schedule,100% of CMS OPPS Rate,2329.81,102,,,Fee Schedule,102% of WV Medicaid Rate,8090.5,165,,,Fee Schedule,165% of CMS OPPS Rate,5081.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,14084.18,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,19315.33,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,24194.41,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,2284.13,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,4903.32,100,,,Fee Schedule,100% of CMS OPPS Rate,5081.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,635.78,14,,,percent of total billed charges,14% of total billed charges,635.78,24194.41,
Fistulogram Thrombectomy,,,761,RC,36904,HCPCS,Outpatient,,,4342.64,2171.32,,3256.98,75,,,percent of total billed charges,75% of total billed charges,3256.98,75,,,percent of total billed charges,75% of total billed charges,4903.32,100,,,Fee Schedule,100% of CMS OPPS Rate,2329.81,102,,,Fee Schedule,102% of WV Medicaid Rate,8090.5,165,,,Fee Schedule,165% of CMS OPPS Rate,5081.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,14084.18,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,19315.33,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,24194.41,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,2284.13,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,4903.32,100,,,Fee Schedule,100% of CMS OPPS Rate,5081.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,607.97,14,,,percent of total billed charges,14% of total billed charges,607.97,24194.41,
"36905 - PF - Percutaneous transluminal mechanical thrombectomy and/or infusion for thrombolysis, dia",3640914,CDM,510,RC,36905,HCPCS,Outpatient,,,5747.99,2874,,4310.99,75,,,percent of total billed charges,75% of total billed charges,4310.99,75,,,percent of total billed charges,75% of total billed charges,9980.15,100,,,Fee Schedule,100% of CMS OPPS Rate,4471.74,102,,,Fee Schedule,102% of WV Medicaid Rate,16467.25,165,,,Fee Schedule,165% of CMS OPPS Rate,10343.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,28666.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,39314,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,49244.77,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,4384.06,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,9980.15,100,,,Fee Schedule,100% of CMS OPPS Rate,10343.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,804.72,14,,,percent of total billed charges,14% of total billed charges,804.72,49244.77,
36905-Fistulogram with Balloon PTA,3431859,CDM,481,RC,36905,HCPCS,Outpatient,,,5747.99,2874,,4310.99,75,,,percent of total billed charges,75% of total billed charges,4310.99,75,,,percent of total billed charges,75% of total billed charges,9980.15,100,,,Fee Schedule,100% of CMS OPPS Rate,4471.74,102,,,Fee Schedule,102% of WV Medicaid Rate,16467.25,165,,,Fee Schedule,165% of CMS OPPS Rate,10343.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,28666.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,39314,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,49244.77,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,4384.06,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,9980.15,100,,,Fee Schedule,100% of CMS OPPS Rate,10343.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,804.72,14,,,percent of total billed charges,14% of total billed charges,804.72,49244.77,
Fistulogram with Balloon PTA,,,761,RC,36905,HCPCS,Outpatient,,,5457.49,2728.75,,4093.12,75,,,percent of total billed charges,75% of total billed charges,4093.12,75,,,percent of total billed charges,75% of total billed charges,9980.15,100,,,Fee Schedule,100% of CMS OPPS Rate,4471.74,102,,,Fee Schedule,102% of WV Medicaid Rate,16467.25,165,,,Fee Schedule,165% of CMS OPPS Rate,10343.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,28666.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,39314,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,49244.77,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,4384.06,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,9980.15,100,,,Fee Schedule,100% of CMS OPPS Rate,10343.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,764.05,14,,,percent of total billed charges,14% of total billed charges,764.05,49244.77,
36906 - PERQ THRMBC/NFS DIAL CIRCUIT TCAT PLMT IV STENT,4037522,CDM,983,RC,36906,HCPCS,Outpatient,,,13628.47,6814.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
36906-Fistulogram with Intravascular Stent,3431860,CDM,481,RC,36906,HCPCS,Outpatient,,,13628.47,6814.24,,10221.35,75,,,percent of total billed charges,75% of total billed charges,10221.35,75,,,percent of total billed charges,75% of total billed charges,16149.79,100,,,Fee Schedule,100% of CMS OPPS Rate,8598.04,102,,,Fee Schedule,102% of WV Medicaid Rate,26647.16,165,,,Fee Schedule,165% of CMS OPPS Rate,16737.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,46388.09,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,63617.56,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,79687.45,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,8429.45,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,16149.79,100,,,Fee Schedule,100% of CMS OPPS Rate,16737.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1907.99,14,,,percent of total billed charges,14% of total billed charges,1907.99,79687.45,
Fistulogram with Intravascular Stent,,,761,RC,36906,HCPCS,Outpatient,,,12816.51,6408.26,,9612.38,75,,,percent of total billed charges,75% of total billed charges,9612.38,75,,,percent of total billed charges,75% of total billed charges,16149.79,100,,,Fee Schedule,100% of CMS OPPS Rate,8598.04,102,,,Fee Schedule,102% of WV Medicaid Rate,26647.16,165,,,Fee Schedule,165% of CMS OPPS Rate,16737.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,46388.09,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,63617.56,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,79687.45,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,8429.45,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,16149.79,100,,,Fee Schedule,100% of CMS OPPS Rate,16737.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1794.31,14,,,percent of total billed charges,14% of total billed charges,1794.31,79687.45,
36907-Add On Code: Dialysis Circuit PTA In Central Segment,4271179,CDM,481,RC,36907,HCPCS,Outpatient,,,1140.28,570.14,,855.21,75,,,percent of total billed charges,75% of total billed charges,855.21,75,,,percent of total billed charges,75% of total billed charges,364.89,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,159.64,14,,,percent of total billed charges,14% of total billed charges,159.64,855.21,
36907-PF Add On Code: Dialysis Circuit PTA In Central Segment,4271180,CDM,960,RC,36907,HCPCS,Outpatient,,,1140.28,570.14,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
"z36907- TBA, central dialysis seg, perf thru dialysis circ",3569473,CDM,510,RC,36907,HCPCS,Outpatient,,,1493.4,746.7,,1120.05,75,,,percent of total billed charges,75% of total billed charges,1120.05,75,,,percent of total billed charges,75% of total billed charges,477.89,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,209.08,14,,,percent of total billed charges,14% of total billed charges,209.08,1120.05,
"36908 - (PF) Transcatheter placement of intravascular stent(s), central dialysis segment, performed",3634910,CDM,510,RC,36908,HCPCS,Outpatient,,,3568.15,1784.08,,2676.11,75,,,percent of total billed charges,75% of total billed charges,2676.11,75,,,percent of total billed charges,75% of total billed charges,1141.81,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,499.54,14,,,percent of total billed charges,14% of total billed charges,499.54,2676.11,
36908-Add On Code: Dialysis Circuit Stent In Central Segment,4271181,CDM,481,RC,36908,HCPCS,Outpatient,,,2698.57,1349.29,,2023.93,75,,,percent of total billed charges,75% of total billed charges,2023.93,75,,,percent of total billed charges,75% of total billed charges,863.54,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,377.8,14,,,percent of total billed charges,14% of total billed charges,377.8,2023.93,
36908-PF Add On Code: Dialysis Circuit Stent In Central Segment,4271182,CDM,960,RC,36908,HCPCS,Outpatient,,,2698.57,1349.29,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
36909-Dialysis Circuit- Embolization,4217147,CDM,481,RC,36909,HCPCS,Outpatient,,,3623.44,1811.72,,2717.58,75,,,percent of total billed charges,75% of total billed charges,2717.58,75,,,percent of total billed charges,75% of total billed charges,1159.5,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,507.28,14,,,percent of total billed charges,14% of total billed charges,507.28,2717.58,
36909-PF Dialysis Circuit- Embolization,4217148,CDM,960,RC,36909,HCPCS,Outpatient,,,3623.44,1811.72,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
Dialysis Circuit- Embolization,4217149,CDM,960,RC,36909,HCPCS,Outpatient,,,3623.44,1811.72,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
37184- Thromb/perc/translu/thromb inj/ini,3430910,CDM,510,RC,37184,HCPCS,Outpatient,,,4369.83,2184.92,,3277.37,75,,,percent of total billed charges,75% of total billed charges,3277.37,75,,,percent of total billed charges,75% of total billed charges,9980.15,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,16467.25,165,,,Fee Schedule,165% of CMS OPPS Rate,10343.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,28666.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,39314,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,49244.77,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,9980.15,100,,,Fee Schedule,100% of CMS OPPS Rate,10343.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,611.78,14,,,percent of total billed charges,14% of total billed charges,611.78,49244.77,
37184-Peripheral Thrombectomy,3560669,CDM,481,RC,37184,HCPCS,Outpatient,,,4369.83,2184.92,,3277.37,75,,,percent of total billed charges,75% of total billed charges,3277.37,75,,,percent of total billed charges,75% of total billed charges,9980.15,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,16467.25,165,,,Fee Schedule,165% of CMS OPPS Rate,10343.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,28666.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,39314,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,49244.77,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,9980.15,100,,,Fee Schedule,100% of CMS OPPS Rate,10343.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,611.78,14,,,percent of total billed charges,14% of total billed charges,611.78,49244.77,
37184-Peripheral Thrombectomy Arterial,3431861,CDM,360,RC,37184,HCPCS,Outpatient,,,4369.83,2184.92,,3277.37,75,,,percent of total billed charges,75% of total billed charges,3277.37,75,,,percent of total billed charges,75% of total billed charges,9980.15,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,16467.25,165,,,Fee Schedule,165% of CMS OPPS Rate,10343.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,28666.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,39314,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,49244.77,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,9980.15,100,,,Fee Schedule,100% of CMS OPPS Rate,10343.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,611.78,14,,,percent of total billed charges,14% of total billed charges,611.78,49244.77,
Peripheral Thrombectomy Arterial,,,761,RC,37184,HCPCS,Outpatient,,,4141,2070.5,,3105.75,75,,,percent of total billed charges,75% of total billed charges,3105.75,75,,,percent of total billed charges,75% of total billed charges,9980.15,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,16467.25,165,,,Fee Schedule,165% of CMS OPPS Rate,10343.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,28666.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,39314,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,49244.77,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,9980.15,100,,,Fee Schedule,100% of CMS OPPS Rate,10343.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,579.74,14,,,percent of total billed charges,14% of total billed charges,579.74,49244.77,
"37185 - Primary percutaneous transluminal mechanical thrombectomy, noncoronary, non-intracranial, ar",3800923,CDM,983,RC,37185,HCPCS,Outpatient,,,1213.19,606.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
37185-Periph Thrombectomy Art same add vessel,3431862,CDM,481,RC,37185,HCPCS,Outpatient,,,1213.19,606.6,,909.89,75,,,percent of total billed charges,75% of total billed charges,909.89,75,,,percent of total billed charges,75% of total billed charges,388.22,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,169.85,14,,,percent of total billed charges,14% of total billed charges,169.85,909.89,
Periph Thrombectomy Art same add vessel,3427279,CDM,960,RC,37185,HCPCS,Outpatient,,,1160.81,580.41,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
37186-Periph Thrombectomy Art second vessel,3431863,CDM,481,RC,37186,HCPCS,Outpatient,,,3014.93,1507.47,,2261.2,75,,,percent of total billed charges,75% of total billed charges,2261.2,75,,,percent of total billed charges,75% of total billed charges,964.78,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,422.09,14,,,percent of total billed charges,14% of total billed charges,422.09,2261.2,
37186-PF Periph Thrombectomy Art second vessel,3580886,CDM,960,RC,37186,HCPCS,Outpatient,,,3014.93,1507.47,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
37187- Thrombectomy/mechanical/venous,3430911,CDM,360,RC,37187,HCPCS,Outpatient,,,4355.74,2177.87,,3266.81,75,,,percent of total billed charges,75% of total billed charges,3266.81,75,,,percent of total billed charges,75% of total billed charges,9980.15,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,16467.25,165,,,Fee Schedule,165% of CMS OPPS Rate,10343.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,28666.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,39314,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,49244.77,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,9980.15,100,,,Fee Schedule,100% of CMS OPPS Rate,10343.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,609.8,14,,,percent of total billed charges,14% of total billed charges,609.8,49244.77,
37187-Thrombectomy Venous,3431864,CDM,481,RC,37187,HCPCS,Outpatient,,,4355.74,2177.87,,3266.81,75,,,percent of total billed charges,75% of total billed charges,3266.81,75,,,percent of total billed charges,75% of total billed charges,9980.15,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,16467.25,165,,,Fee Schedule,165% of CMS OPPS Rate,10343.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,28666.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,39314,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,49244.77,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,9980.15,100,,,Fee Schedule,100% of CMS OPPS Rate,10343.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,609.8,14,,,percent of total billed charges,14% of total billed charges,609.8,49244.77,
Thrombectomy Venous,,,761,RC,37187,HCPCS,Outpatient,,,4104.53,2052.27,,3078.4,75,,,percent of total billed charges,75% of total billed charges,3078.4,75,,,percent of total billed charges,75% of total billed charges,9980.15,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,16467.25,165,,,Fee Schedule,165% of CMS OPPS Rate,10343.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,28666.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,39314,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,49244.77,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,9980.15,100,,,Fee Schedule,100% of CMS OPPS Rate,10343.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,574.63,14,,,percent of total billed charges,14% of total billed charges,574.63,49244.77,
37188-Thombectomy Venous repeat tx,3431865,CDM,481,RC,37188,HCPCS,Outpatient,,,3700.78,1850.39,,2775.59,75,,,percent of total billed charges,75% of total billed charges,2775.59,75,,,percent of total billed charges,75% of total billed charges,2800.71,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,4621.18,165,,,Fee Schedule,165% of CMS OPPS Rate,2902.7,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8044.7,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11032.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13819.53,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,2800.71,100,,,Fee Schedule,100% of CMS OPPS Rate,2902.7,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,518.11,14,,,percent of total billed charges,14% of total billed charges,518.11,13819.53,
Thombectomy Venous repeat tx,,,761,RC,37188,HCPCS,Outpatient,,,3523.84,1761.92,,2642.88,75,,,percent of total billed charges,75% of total billed charges,2642.88,75,,,percent of total billed charges,75% of total billed charges,2800.71,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,4621.18,165,,,Fee Schedule,165% of CMS OPPS Rate,2902.7,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8044.7,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11032.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13819.53,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,2800.71,100,,,Fee Schedule,100% of CMS OPPS Rate,2902.7,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,493.34,14,,,percent of total billed charges,14% of total billed charges,493.34,13819.53,
"37191- Insert IVC filter, endovascular",3430732,CDM,481,RC,37191,HCPCS,Outpatient,,,5095.36,2547.68,,3821.52,75,,,percent of total billed charges,75% of total billed charges,3821.52,75,,,percent of total billed charges,75% of total billed charges,4832.22,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,7973.16,165,,,Fee Schedule,165% of CMS OPPS Rate,5008.18,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,13879.91,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,19035.18,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,23843.51,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,4832.22,100,,,Fee Schedule,100% of CMS OPPS Rate,5008.18,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,713.35,14,,,percent of total billed charges,14% of total billed charges,713.35,23843.51,
37191-IVC Filter Insertion,3431866,CDM,481,RC,37191,HCPCS,Outpatient,,,5095.36,2547.68,,3821.52,75,,,percent of total billed charges,75% of total billed charges,3821.52,75,,,percent of total billed charges,75% of total billed charges,4832.22,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,7973.16,165,,,Fee Schedule,165% of CMS OPPS Rate,5008.18,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,13879.91,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,19035.18,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,23843.51,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,4832.22,100,,,Fee Schedule,100% of CMS OPPS Rate,5008.18,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,713.35,14,,,percent of total billed charges,14% of total billed charges,713.35,23843.51,
37191-IVC Filter with S&I,3560667,CDM,481,RC,37191,HCPCS,Outpatient,,,5095.36,2547.68,,3821.52,75,,,percent of total billed charges,75% of total billed charges,3821.52,75,,,percent of total billed charges,75% of total billed charges,4832.22,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,7973.16,165,,,Fee Schedule,165% of CMS OPPS Rate,5008.18,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,13879.91,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,19035.18,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,23843.51,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,4832.22,100,,,Fee Schedule,100% of CMS OPPS Rate,5008.18,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,713.35,14,,,percent of total billed charges,14% of total billed charges,713.35,23843.51,
37191-IVC insertion,3431867,CDM,481,RC,37191,HCPCS,Outpatient,,,5095.36,2547.68,,3821.52,75,,,percent of total billed charges,75% of total billed charges,3821.52,75,,,percent of total billed charges,75% of total billed charges,4832.22,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,7973.16,165,,,Fee Schedule,165% of CMS OPPS Rate,5008.18,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,13879.91,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,19035.18,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,23843.51,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,4832.22,100,,,Fee Schedule,100% of CMS OPPS Rate,5008.18,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,713.35,14,,,percent of total billed charges,14% of total billed charges,713.35,23843.51,
IVC Filter Insertion,,,761,RC,37191,HCPCS,Outpatient,,,4818.95,2409.48,,3614.21,75,,,percent of total billed charges,75% of total billed charges,3614.21,75,,,percent of total billed charges,75% of total billed charges,4832.22,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,7973.16,165,,,Fee Schedule,165% of CMS OPPS Rate,5008.18,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,13879.91,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,19035.18,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,23843.51,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,4832.22,100,,,Fee Schedule,100% of CMS OPPS Rate,5008.18,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,674.65,14,,,percent of total billed charges,14% of total billed charges,674.65,23843.51,
Read,597013,CDM,972,RC,37191,HCPCS,Outpatient,,,1927.58,963.79,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
37192-IVC Filter Reposition,3431868,CDM,481,RC,37192,HCPCS,Outpatient,,,3269.03,1634.52,,2451.77,75,,,percent of total billed charges,75% of total billed charges,2451.77,75,,,percent of total billed charges,75% of total billed charges,2800.71,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,4621.18,165,,,Fee Schedule,165% of CMS OPPS Rate,2902.7,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8044.7,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11032.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13819.53,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,2800.71,100,,,Fee Schedule,100% of CMS OPPS Rate,2902.7,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,457.66,14,,,percent of total billed charges,14% of total billed charges,457.66,13819.53,
37192-IVC reposition,3431869,CDM,481,RC,37192,HCPCS,Outpatient,,,3269.03,1634.52,,2451.77,75,,,percent of total billed charges,75% of total billed charges,2451.77,75,,,percent of total billed charges,75% of total billed charges,2800.71,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,4621.18,165,,,Fee Schedule,165% of CMS OPPS Rate,2902.7,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8044.7,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11032.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13819.53,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,2800.71,100,,,Fee Schedule,100% of CMS OPPS Rate,2902.7,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,457.66,14,,,percent of total billed charges,14% of total billed charges,457.66,13819.53,
IVC Filter Reposition,,,761,RC,37192,HCPCS,Outpatient,,,3120.64,1560.32,,2340.48,75,,,percent of total billed charges,75% of total billed charges,2340.48,75,,,percent of total billed charges,75% of total billed charges,2800.71,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,4621.18,165,,,Fee Schedule,165% of CMS OPPS Rate,2902.7,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8044.7,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11032.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13819.53,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,2800.71,100,,,Fee Schedule,100% of CMS OPPS Rate,2902.7,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,436.89,14,,,percent of total billed charges,14% of total billed charges,436.89,13819.53,
37193- Remove IVC filter,3430912,CDM,481,RC,37193,HCPCS,Outpatient,,,3776.5,1888.25,,2832.38,75,,,percent of total billed charges,75% of total billed charges,2832.38,75,,,percent of total billed charges,75% of total billed charges,2800.71,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,4621.18,165,,,Fee Schedule,165% of CMS OPPS Rate,2902.7,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8044.7,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11032.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13819.53,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,2800.71,100,,,Fee Schedule,100% of CMS OPPS Rate,2902.7,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,528.71,14,,,percent of total billed charges,14% of total billed charges,528.71,13819.53,
37193-IVC Filter Removal,3431870,CDM,481,RC,37193,HCPCS,Outpatient,,,3776.5,1888.25,,2832.38,75,,,percent of total billed charges,75% of total billed charges,2832.38,75,,,percent of total billed charges,75% of total billed charges,2800.71,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,4621.18,165,,,Fee Schedule,165% of CMS OPPS Rate,2902.7,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8044.7,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11032.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13819.53,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,2800.71,100,,,Fee Schedule,100% of CMS OPPS Rate,2902.7,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,528.71,14,,,percent of total billed charges,14% of total billed charges,528.71,13819.53,
37193-IVC removal,3431871,CDM,481,RC,37193,HCPCS,Outpatient,,,3776.5,1888.25,,2832.38,75,,,percent of total billed charges,75% of total billed charges,2832.38,75,,,percent of total billed charges,75% of total billed charges,2800.71,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,4621.18,165,,,Fee Schedule,165% of CMS OPPS Rate,2902.7,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8044.7,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11032.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13819.53,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,2800.71,100,,,Fee Schedule,100% of CMS OPPS Rate,2902.7,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,528.71,14,,,percent of total billed charges,14% of total billed charges,528.71,13819.53,
IVC Filter Removal,,,761,RC,37193,HCPCS,Outpatient,,,3613.38,1806.69,,2710.04,75,,,percent of total billed charges,75% of total billed charges,2710.04,75,,,percent of total billed charges,75% of total billed charges,2800.71,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,4621.18,165,,,Fee Schedule,165% of CMS OPPS Rate,2902.7,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8044.7,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11032.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13819.53,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,2800.71,100,,,Fee Schedule,100% of CMS OPPS Rate,2902.7,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,505.87,14,,,percent of total billed charges,14% of total billed charges,505.87,13819.53,
"37195 - Thrombolysis, cerebral, by intravenous infusion",3999137,CDM,960,RC,37195,HCPCS,Outpatient,,,865.98,432.99,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
37195-PF THROMBOLYSIS CEREBRAL IV INFUSION,4321446,CDM,981,RC,37195,HCPCS,Outpatient,,,1045,522.5,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
37197-Foreign Body Removal,3431872,CDM,481,RC,37197,HCPCS,Outpatient,,,3929.59,1964.8,,2947.19,75,,,percent of total billed charges,75% of total billed charges,2947.19,75,,,percent of total billed charges,75% of total billed charges,2800.71,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,4621.18,165,,,Fee Schedule,165% of CMS OPPS Rate,2902.7,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8044.7,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11032.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13819.53,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,2800.71,100,,,Fee Schedule,100% of CMS OPPS Rate,2902.7,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,550.14,14,,,percent of total billed charges,14% of total billed charges,550.14,13819.53,
37197-PF Foreign Body Removal,3580887,CDM,960,RC,37197,HCPCS,Outpatient,,,3929.59,1964.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
37211- Thrombolysis/artery/S&I/initial tx,3430734,CDM,510,RC,37211,HCPCS,Outpatient,,,1033.38,516.69,,775.04,75,,,percent of total billed charges,75% of total billed charges,775.04,75,,,percent of total billed charges,75% of total billed charges,4832.22,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,7973.16,165,,,Fee Schedule,165% of CMS OPPS Rate,5008.18,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,13879.91,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,19035.18,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,23843.51,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,4832.22,100,,,Fee Schedule,100% of CMS OPPS Rate,5008.18,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,144.67,14,,,percent of total billed charges,14% of total billed charges,144.67,23843.51,
37211-Periph Thrombolysis Insertion Artery,3431873,CDM,481,RC,37211,HCPCS,Outpatient,,,1033.38,516.69,,775.04,75,,,percent of total billed charges,75% of total billed charges,775.04,75,,,percent of total billed charges,75% of total billed charges,4832.22,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,7973.16,165,,,Fee Schedule,165% of CMS OPPS Rate,5008.18,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,13879.91,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,19035.18,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,23843.51,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,4832.22,100,,,Fee Schedule,100% of CMS OPPS Rate,5008.18,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,144.67,14,,,percent of total billed charges,14% of total billed charges,144.67,23843.51,
Periph Thrombolysis Insertion Artery,,,761,RC,37211,HCPCS,Outpatient,,,1016.17,508.09,,762.13,75,,,percent of total billed charges,75% of total billed charges,762.13,75,,,percent of total billed charges,75% of total billed charges,4832.22,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,7973.16,165,,,Fee Schedule,165% of CMS OPPS Rate,5008.18,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,13879.91,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,19035.18,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,23843.51,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,4832.22,100,,,Fee Schedule,100% of CMS OPPS Rate,5008.18,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,142.26,14,,,percent of total billed charges,14% of total billed charges,142.26,23843.51,
37212- Thrombolysis/venous/S&I/initial tx,3430735,CDM,320,RC,37212,HCPCS,Outpatient,,,898.34,449.17,,673.76,75,,,percent of total billed charges,75% of total billed charges,673.76,75,,,percent of total billed charges,75% of total billed charges,2800.71,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,4621.18,165,,,Fee Schedule,165% of CMS OPPS Rate,2902.7,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8044.7,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11032.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13819.53,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,2800.71,100,,,Fee Schedule,100% of CMS OPPS Rate,2902.7,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,125.77,14,,,percent of total billed charges,14% of total billed charges,125.77,13819.53,
37212-Periph Thromobolysis Insertion Venous,3431874,CDM,481,RC,37212,HCPCS,Outpatient,,,898.34,449.17,,673.76,75,,,percent of total billed charges,75% of total billed charges,673.76,75,,,percent of total billed charges,75% of total billed charges,2800.71,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,4621.18,165,,,Fee Schedule,165% of CMS OPPS Rate,2902.7,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8044.7,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11032.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13819.53,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,2800.71,100,,,Fee Schedule,100% of CMS OPPS Rate,2902.7,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,125.77,14,,,percent of total billed charges,14% of total billed charges,125.77,13819.53,
37212-PF THROMBOLYSIS VENOUS INFUSION W/IMAGING INIT TX,4321656,CDM,981,RC,37212,HCPCS,Outpatient,,,668.66,334.33,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
Periph Thromobolysis Insertion Venous,,,761,RC,37212,HCPCS,Outpatient,,,885.98,442.99,,664.49,75,,,percent of total billed charges,75% of total billed charges,664.49,75,,,percent of total billed charges,75% of total billed charges,2800.71,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,4621.18,165,,,Fee Schedule,165% of CMS OPPS Rate,2902.7,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8044.7,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11032.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13819.53,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,2800.71,100,,,Fee Schedule,100% of CMS OPPS Rate,2902.7,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,124.04,14,,,percent of total billed charges,14% of total billed charges,124.04,13819.53,
37213- Thrombolysis/art/ven/S&I/subs tx,3430736,CDM,320,RC,37213,HCPCS,Outpatient,,,619.46,309.73,,464.6,75,,,percent of total billed charges,75% of total billed charges,464.6,75,,,percent of total billed charges,75% of total billed charges,2800.71,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,4621.18,165,,,Fee Schedule,165% of CMS OPPS Rate,2902.7,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8044.7,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11032.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13819.53,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,2800.71,100,,,Fee Schedule,100% of CMS OPPS Rate,2902.7,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,86.72,14,,,percent of total billed charges,14% of total billed charges,86.72,13819.53,
37213-Periph Thromboysis Cath Relook,3431875,CDM,481,RC,37213,HCPCS,Outpatient,,,619.46,309.73,,464.6,75,,,percent of total billed charges,75% of total billed charges,464.6,75,,,percent of total billed charges,75% of total billed charges,2800.71,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,4621.18,165,,,Fee Schedule,165% of CMS OPPS Rate,2902.7,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8044.7,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11032.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13819.53,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,2800.71,100,,,Fee Schedule,100% of CMS OPPS Rate,2902.7,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,86.72,14,,,percent of total billed charges,14% of total billed charges,86.72,13819.53,
37213-Peripheral Thrombolysis Relook,3431876,CDM,320,RC,37213,HCPCS,Outpatient,,,619.46,309.73,,464.6,75,,,percent of total billed charges,75% of total billed charges,464.6,75,,,percent of total billed charges,75% of total billed charges,2800.71,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,4621.18,165,,,Fee Schedule,165% of CMS OPPS Rate,2902.7,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8044.7,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11032.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13819.53,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,2800.71,100,,,Fee Schedule,100% of CMS OPPS Rate,2902.7,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,86.72,14,,,percent of total billed charges,14% of total billed charges,86.72,13819.53,
Periph Thromboysis Cath Relook,,,761,RC,37213,HCPCS,Outpatient,,,607.49,303.75,,455.62,75,,,percent of total billed charges,75% of total billed charges,455.62,75,,,percent of total billed charges,75% of total billed charges,2800.71,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,4621.18,165,,,Fee Schedule,165% of CMS OPPS Rate,2902.7,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8044.7,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11032.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13819.53,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,2800.71,100,,,Fee Schedule,100% of CMS OPPS Rate,2902.7,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,85.05,14,,,percent of total billed charges,14% of total billed charges,85.05,13819.53,
Peripheral Thrombolysis Relook,,,761,RC,37213,HCPCS,Outpatient,,,607.49,303.75,,455.62,75,,,percent of total billed charges,75% of total billed charges,455.62,75,,,percent of total billed charges,75% of total billed charges,2800.71,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,4621.18,165,,,Fee Schedule,165% of CMS OPPS Rate,2902.7,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8044.7,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11032.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13819.53,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,2800.71,100,,,Fee Schedule,100% of CMS OPPS Rate,2902.7,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,85.05,14,,,percent of total billed charges,14% of total billed charges,85.05,13819.53,
37214- Trans cath cessation/thrombolysis,3430737,CDM,320,RC,37214,HCPCS,Outpatient,,,324.89,162.45,,243.67,75,,,percent of total billed charges,75% of total billed charges,243.67,75,,,percent of total billed charges,75% of total billed charges,2800.71,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,4621.18,165,,,Fee Schedule,165% of CMS OPPS Rate,2902.7,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8044.7,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11032.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13819.53,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,2800.71,100,,,Fee Schedule,100% of CMS OPPS Rate,2902.7,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,45.48,14,,,percent of total billed charges,14% of total billed charges,45.48,13819.53,
37214-Periph Thrombolysis Cath Removal,3431877,CDM,481,RC,37214,HCPCS,Outpatient,,,324.89,162.45,,243.67,75,,,percent of total billed charges,75% of total billed charges,243.67,75,,,percent of total billed charges,75% of total billed charges,2800.71,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,4621.18,165,,,Fee Schedule,165% of CMS OPPS Rate,2902.7,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8044.7,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11032.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13819.53,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,2800.71,100,,,Fee Schedule,100% of CMS OPPS Rate,2902.7,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,45.48,14,,,percent of total billed charges,14% of total billed charges,45.48,13819.53,
37214-Peripheral Thrombolysis Reposition,3431878,CDM,320,RC,37214,HCPCS,Outpatient,,,324.89,162.45,,243.67,75,,,percent of total billed charges,75% of total billed charges,243.67,75,,,percent of total billed charges,75% of total billed charges,2800.71,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,4621.18,165,,,Fee Schedule,165% of CMS OPPS Rate,2902.7,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8044.7,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11032.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13819.53,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,2800.71,100,,,Fee Schedule,100% of CMS OPPS Rate,2902.7,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,45.48,14,,,percent of total billed charges,14% of total billed charges,45.48,13819.53,
Periph Thrombolysis Cath Removal,,,761,RC,37214,HCPCS,Outpatient,,,321.92,160.96,,241.44,75,,,percent of total billed charges,75% of total billed charges,241.44,75,,,percent of total billed charges,75% of total billed charges,2800.71,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,4621.18,165,,,Fee Schedule,165% of CMS OPPS Rate,2902.7,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8044.7,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11032.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13819.53,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,2800.71,100,,,Fee Schedule,100% of CMS OPPS Rate,2902.7,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,45.07,14,,,percent of total billed charges,14% of total billed charges,45.07,13819.53,
Peripheral Thrombolysis Reposition,,,761,RC,37214,HCPCS,Outpatient,,,321.92,160.96,,241.44,75,,,percent of total billed charges,75% of total billed charges,241.44,75,,,percent of total billed charges,75% of total billed charges,2800.71,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,4621.18,165,,,Fee Schedule,165% of CMS OPPS Rate,2902.7,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8044.7,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11032.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13819.53,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,2800.71,100,,,Fee Schedule,100% of CMS OPPS Rate,2902.7,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,45.07,14,,,percent of total billed charges,14% of total billed charges,45.07,13819.53,
37215- Transca stent/cerv carot/emb prot,3430738,CDM,360,RC,37215,HCPCS,Outpatient,,,2672.28,1336.14,,2004.21,75,,,percent of total billed charges,75% of total billed charges,2004.21,75,,,percent of total billed charges,75% of total billed charges,2672.28,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,2672.28,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2672.28,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2672.28,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2672.28,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2672.28,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,2672.28,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2672.28,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,374.12,14,,,percent of total billed charges,14% of total billed charges,374.12,2672.28,
37215-Carotid Stent w embolic protection,3431879,CDM,481,RC,37215,HCPCS,Outpatient,,,2672.28,1336.14,,2004.21,75,,,percent of total billed charges,75% of total billed charges,2004.21,75,,,percent of total billed charges,75% of total billed charges,2672.28,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,2672.28,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2672.28,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2672.28,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2672.28,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2672.28,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,2672.28,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2672.28,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,374.12,14,,,percent of total billed charges,14% of total billed charges,374.12,2672.28,
Carotid Stent w embolic protection,,,761,RC,37215,HCPCS,Outpatient,,,2625.09,1312.55,,1968.82,75,,,percent of total billed charges,75% of total billed charges,1968.82,75,,,percent of total billed charges,75% of total billed charges,2625.09,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,2625.09,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2625.09,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2625.09,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2625.09,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2625.09,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,2625.09,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2625.09,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,367.51,14,,,percent of total billed charges,14% of total billed charges,367.51,2625.09,
37216-Carotid stent wo embolic protection,3431880,CDM,481,RC,37216,HCPCS,Outpatient,,,3063,1531.5,,2297.25,75,,,percent of total billed charges,75% of total billed charges,2297.25,75,,,percent of total billed charges,75% of total billed charges,980.16,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,428.82,14,,,percent of total billed charges,14% of total billed charges,428.82,2297.25,
"37217 - PF - Transcatheter placement of intravascular stent(s), intrathoracic common carotid artery",3640915,CDM,510,RC,37217,HCPCS,Outpatient,,,2922.56,1461.28,,2191.92,75,,,percent of total billed charges,75% of total billed charges,2191.92,75,,,percent of total billed charges,75% of total billed charges,2922.56,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,2922.56,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2922.56,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2922.56,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2922.56,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2922.56,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,2922.56,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2922.56,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,409.16,14,,,percent of total billed charges,14% of total billed charges,409.16,2922.56,
"37217-Carotid Stenting, common or innominate, retrograde open",4331297,CDM,481,RC,37217,HCPCS,Outpatient,,,2922.56,1461.28,,2191.92,75,,,percent of total billed charges,75% of total billed charges,2191.92,75,,,percent of total billed charges,75% of total billed charges,2922.56,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,2922.56,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2922.56,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2922.56,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2922.56,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2922.56,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,2922.56,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2922.56,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,409.16,14,,,percent of total billed charges,14% of total billed charges,409.16,2922.56,
"37217-PF Carotid Stenting, common or innominate, retrograde open",4331298,CDM,960,RC,37217,HCPCS,Outpatient,,,2922.56,1461.28,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
Carotid Stent LT,,,761,RC,37217,HCPCS,Outpatient,,,2878.67,1439.34,,2159,75,,,percent of total billed charges,75% of total billed charges,2159,75,,,percent of total billed charges,75% of total billed charges,2878.67,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,2878.67,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2878.67,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2878.67,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2878.67,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2878.67,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,2878.67,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2878.67,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,403.01,14,,,percent of total billed charges,14% of total billed charges,403.01,2878.67,
Carotid Stent RT,,,761,RC,37217,HCPCS,Outpatient,,,2878.67,1439.34,,2159,75,,,percent of total billed charges,75% of total billed charges,2159,75,,,percent of total billed charges,75% of total billed charges,2878.67,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,2878.67,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2878.67,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2878.67,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2878.67,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2878.67,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,2878.67,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2878.67,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,403.01,14,,,percent of total billed charges,14% of total billed charges,403.01,2878.67,
"Carotid Stenting, common or innominate, retrograde open",,,761,RC,37217,HCPCS,Outpatient,,,2922.56,1461.28,,2191.92,75,,,percent of total billed charges,75% of total billed charges,2191.92,75,,,percent of total billed charges,75% of total billed charges,2922.56,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,2922.56,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2922.56,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2922.56,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2922.56,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2922.56,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,2922.56,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2922.56,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,409.16,14,,,percent of total billed charges,14% of total billed charges,409.16,2922.56,
37218-Common Carotid or Innominate Artery Stent via antegrade approach,4271236,CDM,481,RC,37218,HCPCS,Outpatient,,,1739.52,869.76,,1304.64,75,,,percent of total billed charges,75% of total billed charges,1304.64,75,,,percent of total billed charges,75% of total billed charges,1739.52,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,1739.52,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1739.52,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1739.52,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1739.52,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1739.52,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,1739.52,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1739.52,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,243.53,14,,,percent of total billed charges,14% of total billed charges,243.53,1739.52,
37218-PF Common Carotid or Innominate Artery Stent via antegrade approach,4271237,CDM,960,RC,37218,HCPCS,Outpatient,,,1739.52,869.76,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
Common Carotid or Innominate Artery Stent via antegrade approach,4271238,CDM,761,RC,37218,HCPCS,Outpatient,,,1739.52,869.76,,1304.64,75,,,percent of total billed charges,75% of total billed charges,1304.64,75,,,percent of total billed charges,75% of total billed charges,1739.52,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,1739.52,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1739.52,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1739.52,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1739.52,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1739.52,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,1739.52,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1739.52,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,243.53,14,,,percent of total billed charges,14% of total billed charges,243.53,1739.52,
37220- Angioplasty/iliac/init ves/unilat,3430739,CDM,481,RC,37220,HCPCS,Outpatient,,,6339.22,3169.61,,4754.42,75,,,percent of total billed charges,75% of total billed charges,4754.42,75,,,percent of total billed charges,75% of total billed charges,4903.32,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,8090.5,165,,,Fee Schedule,165% of CMS OPPS Rate,5081.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,14084.18,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,19315.33,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,24194.41,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,4903.32,100,,,Fee Schedule,100% of CMS OPPS Rate,5081.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,887.49,14,,,percent of total billed charges,14% of total billed charges,887.49,24194.41,
37220-ILIAC ANGIOPLASTY UNILATERAL,3431883,CDM,481,RC,37220,HCPCS,Outpatient,,,6339.22,3169.61,,4754.42,75,,,percent of total billed charges,75% of total billed charges,4754.42,75,,,percent of total billed charges,75% of total billed charges,4903.32,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,8090.5,165,,,Fee Schedule,165% of CMS OPPS Rate,5081.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,14084.18,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,19315.33,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,24194.41,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,4903.32,100,,,Fee Schedule,100% of CMS OPPS Rate,5081.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,887.49,14,,,percent of total billed charges,14% of total billed charges,887.49,24194.41,
37220-Peripheral Angio Iliac w PTA,3431884,CDM,481,RC,37220,HCPCS,Outpatient,,,6339.22,3169.61,,4754.42,75,,,percent of total billed charges,75% of total billed charges,4754.42,75,,,percent of total billed charges,75% of total billed charges,4903.32,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,8090.5,165,,,Fee Schedule,165% of CMS OPPS Rate,5081.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,14084.18,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,19315.33,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,24194.41,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,4903.32,100,,,Fee Schedule,100% of CMS OPPS Rate,5081.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,887.49,14,,,percent of total billed charges,14% of total billed charges,887.49,24194.41,
37220-Peripheral Angio Iliac w PTA RT,3431885,CDM,481,RC,37220,HCPCS,Outpatient,,,6339.22,3169.61,,4754.42,75,,,percent of total billed charges,75% of total billed charges,4754.42,75,,,percent of total billed charges,75% of total billed charges,4903.32,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,8090.5,165,,,Fee Schedule,165% of CMS OPPS Rate,5081.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,14084.18,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,19315.33,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,24194.41,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,4903.32,100,,,Fee Schedule,100% of CMS OPPS Rate,5081.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,887.49,14,,,percent of total billed charges,14% of total billed charges,887.49,24194.41,
Peripheral Angio Iliac w PTA LT,,,761,RC,37220,HCPCS,Outpatient,,,5995.89,2997.95,,4496.92,75,,,percent of total billed charges,75% of total billed charges,4496.92,75,,,percent of total billed charges,75% of total billed charges,4903.32,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,8090.5,165,,,Fee Schedule,165% of CMS OPPS Rate,5081.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,14084.18,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,19315.33,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,24194.41,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,4903.32,100,,,Fee Schedule,100% of CMS OPPS Rate,5081.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,839.42,14,,,percent of total billed charges,14% of total billed charges,839.42,24194.41,
Peripheral Angio Iliac w PTA RT,3427184,CDM,960,RC,37220,HCPCS,Outpatient,,,5995.89,2997.95,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
37221- Stent iliac/open or perc/uni/init,3430740,CDM,481,RC,37221,HCPCS,Outpatient,,,7822.3,3911.15,,5866.73,75,,,percent of total billed charges,75% of total billed charges,5866.73,75,,,percent of total billed charges,75% of total billed charges,9980.15,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,16467.25,165,,,Fee Schedule,165% of CMS OPPS Rate,10343.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,28666.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,39314,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,49244.77,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,9980.15,100,,,Fee Schedule,100% of CMS OPPS Rate,10343.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1095.12,14,,,percent of total billed charges,14% of total billed charges,1095.12,49244.77,
37221-ILIAC STENT W/WO ANGIOPLASTY UNILAT,3431886,CDM,481,RC,37221,HCPCS,Outpatient,,,7822.3,3911.15,,5866.73,75,,,percent of total billed charges,75% of total billed charges,5866.73,75,,,percent of total billed charges,75% of total billed charges,9980.15,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,16467.25,165,,,Fee Schedule,165% of CMS OPPS Rate,10343.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,28666.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,39314,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,49244.77,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,9980.15,100,,,Fee Schedule,100% of CMS OPPS Rate,10343.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1095.12,14,,,percent of total billed charges,14% of total billed charges,1095.12,49244.77,
37221-Peripheral Angio Iliac Stent,3431887,CDM,481,RC,37221,HCPCS,Outpatient,,,7822.3,3911.15,,5866.73,75,,,percent of total billed charges,75% of total billed charges,5866.73,75,,,percent of total billed charges,75% of total billed charges,9980.15,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,16467.25,165,,,Fee Schedule,165% of CMS OPPS Rate,10343.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,28666.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,39314,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,49244.77,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,9980.15,100,,,Fee Schedule,100% of CMS OPPS Rate,10343.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1095.12,14,,,percent of total billed charges,14% of total billed charges,1095.12,49244.77,
37221-Peripheral Angio Iliac Stent RT,3431888,CDM,481,RC,37221,HCPCS,Outpatient,,,7822.3,3911.15,,5866.73,75,,,percent of total billed charges,75% of total billed charges,5866.73,75,,,percent of total billed charges,75% of total billed charges,9980.15,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,16467.25,165,,,Fee Schedule,165% of CMS OPPS Rate,10343.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,28666.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,39314,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,49244.77,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,9980.15,100,,,Fee Schedule,100% of CMS OPPS Rate,10343.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1095.12,14,,,percent of total billed charges,14% of total billed charges,1095.12,49244.77,
37221-Peripheral Intervention Iliac,3431889,CDM,481,RC,37221,HCPCS,Outpatient,,,7822.3,3911.15,,5866.73,75,,,percent of total billed charges,75% of total billed charges,5866.73,75,,,percent of total billed charges,75% of total billed charges,9980.15,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,16467.25,165,,,Fee Schedule,165% of CMS OPPS Rate,10343.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,28666.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,39314,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,49244.77,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,9980.15,100,,,Fee Schedule,100% of CMS OPPS Rate,10343.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1095.12,14,,,percent of total billed charges,14% of total billed charges,1095.12,49244.77,
Peripheral Angio Iliac Stent LT,3427185,CDM,960,RC,37221,HCPCS,Outpatient,,,7379.4,3689.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
Peripheral Angio Iliac Stent RT,3427186,CDM,960,RC,37221,HCPCS,Outpatient,,,7379.4,3689.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
Peripheral Intervention Iliac,3427216,CDM,960,RC,37221,HCPCS,Outpatient,,,7379.4,3689.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
"37222 - PF - Revascularization, endovascular, open or percutaneous, iliac artery, each additional ip",3640916,CDM,510,RC,37222,HCPCS,Outpatient,,,1569.3,784.65,,1176.98,75,,,percent of total billed charges,75% of total billed charges,1176.98,75,,,percent of total billed charges,75% of total billed charges,502.18,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,219.7,14,,,percent of total billed charges,14% of total billed charges,219.7,1176.98,
37222-Peripheral Angio Iliac PTA add,3431890,CDM,481,RC,37222,HCPCS,Outpatient,,,1569.3,784.65,,1176.98,75,,,percent of total billed charges,75% of total billed charges,1176.98,75,,,percent of total billed charges,75% of total billed charges,502.18,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,219.7,14,,,percent of total billed charges,14% of total billed charges,219.7,1176.98,
Peripheral Angio Iliac PTA add,3427187,CDM,960,RC,37222,HCPCS,Outpatient,,,1503.24,751.62,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
37223- Stent iliac/open/perc/ea ad/ipsila,3430741,CDM,481,RC,37223,HCPCS,Outpatient,,,3237.54,1618.77,,2428.16,75,,,percent of total billed charges,75% of total billed charges,2428.16,75,,,percent of total billed charges,75% of total billed charges,1036.01,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,453.26,14,,,percent of total billed charges,14% of total billed charges,453.26,2428.16,
37223-Iliac Stent Additional,3560665,CDM,481,RC,37223,HCPCS,Outpatient,,,3237.54,1618.77,,2428.16,75,,,percent of total billed charges,75% of total billed charges,2428.16,75,,,percent of total billed charges,75% of total billed charges,1036.01,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,453.26,14,,,percent of total billed charges,14% of total billed charges,453.26,2428.16,
37223-Peripheral Angio Iliac stent add,3431891,CDM,481,RC,37223,HCPCS,Outpatient,,,3237.54,1618.77,,2428.16,75,,,percent of total billed charges,75% of total billed charges,2428.16,75,,,percent of total billed charges,75% of total billed charges,1036.01,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,453.26,14,,,percent of total billed charges,14% of total billed charges,453.26,2428.16,
Peripheral Angio Iliac stent add,3427188,CDM,960,RC,37223,HCPCS,Outpatient,,,3053.65,1526.83,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
37224- Angioplasty fem/pop unilat,3430742,CDM,481,RC,37224,HCPCS,Outpatient,,,7405.83,3702.92,,5554.37,75,,,percent of total billed charges,75% of total billed charges,5554.37,75,,,percent of total billed charges,75% of total billed charges,4903.32,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,8090.5,165,,,Fee Schedule,165% of CMS OPPS Rate,5081.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,14084.18,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,19315.33,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,24194.41,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,4903.32,100,,,Fee Schedule,100% of CMS OPPS Rate,5081.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1036.82,14,,,percent of total billed charges,14% of total billed charges,1036.82,24194.41,
37224-FEM POPLITEAL TERRITORY PTA UNILAT,3431892,CDM,481,RC,37224,HCPCS,Outpatient,,,7405.83,3702.92,,5554.37,75,,,percent of total billed charges,75% of total billed charges,5554.37,75,,,percent of total billed charges,75% of total billed charges,4903.32,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,8090.5,165,,,Fee Schedule,165% of CMS OPPS Rate,5081.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,14084.18,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,19315.33,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,24194.41,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,4903.32,100,,,Fee Schedule,100% of CMS OPPS Rate,5081.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1036.82,14,,,percent of total billed charges,14% of total billed charges,1036.82,24194.41,
37224-Peripheral Angio PTA,3431893,CDM,481,RC,37224,HCPCS,Outpatient,,,7405.83,3702.92,,5554.37,75,,,percent of total billed charges,75% of total billed charges,5554.37,75,,,percent of total billed charges,75% of total billed charges,4903.32,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,8090.5,165,,,Fee Schedule,165% of CMS OPPS Rate,5081.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,14084.18,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,19315.33,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,24194.41,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,4903.32,100,,,Fee Schedule,100% of CMS OPPS Rate,5081.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1036.82,14,,,percent of total billed charges,14% of total billed charges,1036.82,24194.41,
37224-Peripheral Angio PTA RT,3431894,CDM,481,RC,37224,HCPCS,Outpatient,,,7405.83,3702.92,,5554.37,75,,,percent of total billed charges,75% of total billed charges,5554.37,75,,,percent of total billed charges,75% of total billed charges,4903.32,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,8090.5,165,,,Fee Schedule,165% of CMS OPPS Rate,5081.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,14084.18,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,19315.33,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,24194.41,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,4903.32,100,,,Fee Schedule,100% of CMS OPPS Rate,5081.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1036.82,14,,,percent of total billed charges,14% of total billed charges,1036.82,24194.41,
Peripheral Angio PTA LT,,,761,RC,37224,HCPCS,Outpatient,,,6987.34,3493.67,,5240.51,75,,,percent of total billed charges,75% of total billed charges,5240.51,75,,,percent of total billed charges,75% of total billed charges,4903.32,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,8090.5,165,,,Fee Schedule,165% of CMS OPPS Rate,5081.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,14084.18,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,19315.33,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,24194.41,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,4903.32,100,,,Fee Schedule,100% of CMS OPPS Rate,5081.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,978.23,14,,,percent of total billed charges,14% of total billed charges,978.23,24194.41,
Peripheral Angio PTA RT,,,761,RC,37224,HCPCS,Outpatient,,,6987.34,3493.67,,5240.51,75,,,percent of total billed charges,75% of total billed charges,5240.51,75,,,percent of total billed charges,75% of total billed charges,4903.32,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,8090.5,165,,,Fee Schedule,165% of CMS OPPS Rate,5081.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,14084.18,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,19315.33,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,24194.41,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,4903.32,100,,,Fee Schedule,100% of CMS OPPS Rate,5081.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,978.23,14,,,percent of total billed charges,14% of total billed charges,978.23,24194.41,
37225- Athrectomy fem/pop/unilateral,3430913,CDM,481,RC,37225,HCPCS,Outpatient,,,22029.29,11014.65,,16521.97,75,,,percent of total billed charges,75% of total billed charges,16521.97,75,,,percent of total billed charges,75% of total billed charges,9980.15,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,16467.25,165,,,Fee Schedule,165% of CMS OPPS Rate,10343.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,28666.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,39314,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,49244.77,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,9980.15,100,,,Fee Schedule,100% of CMS OPPS Rate,10343.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,3084.1,14,,,percent of total billed charges,14% of total billed charges,3084.1,49244.77,
37225-Periph Angio Athrectomy PTA Femoral Pop,3431895,CDM,481,RC,37225,HCPCS,Outpatient,,,22029.29,11014.65,,16521.97,75,,,percent of total billed charges,75% of total billed charges,16521.97,75,,,percent of total billed charges,75% of total billed charges,9980.15,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,16467.25,165,,,Fee Schedule,165% of CMS OPPS Rate,10343.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,28666.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,39314,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,49244.77,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,9980.15,100,,,Fee Schedule,100% of CMS OPPS Rate,10343.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,3084.1,14,,,percent of total billed charges,14% of total billed charges,3084.1,49244.77,
Periph Angio Athrectomy PTA Femoral Pop,,,761,RC,37225,HCPCS,Outpatient,,,20652.06,10326.03,,15489.05,75,,,percent of total billed charges,75% of total billed charges,15489.05,75,,,percent of total billed charges,75% of total billed charges,9980.15,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,16467.25,165,,,Fee Schedule,165% of CMS OPPS Rate,10343.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,28666.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,39314,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,49244.77,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,9980.15,100,,,Fee Schedule,100% of CMS OPPS Rate,10343.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,2891.29,14,,,percent of total billed charges,14% of total billed charges,2891.29,49244.77,
"37226 - (50)  Revascularization, endovascular, open or percutaneous, femoral, popliteal artery(s), u",3699317,CDM,960,RC,37226,HCPCS,Outpatient,,,1652.71,826.36,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
37226 - REVSC OPN/PRQ FEM/POP W/STNT/ANGIOP SM VSL,4037523,CDM,481,RC,37226,HCPCS,Outpatient,,,1101.81,550.91,,826.36,75,,,percent of total billed charges,75% of total billed charges,826.36,75,,,percent of total billed charges,75% of total billed charges,9980.15,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,16467.25,165,,,Fee Schedule,165% of CMS OPPS Rate,10343.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,28666.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,39314,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,49244.77,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,9980.15,100,,,Fee Schedule,100% of CMS OPPS Rate,10343.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,154.25,14,,,percent of total billed charges,14% of total billed charges,154.25,49244.77,
37226- Stent fem/pop/open or perc/unilat,3430743,CDM,960,RC,37226,HCPCS,Outpatient,,,1101.81,550.91,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
37226-FEM POP TERRITORY STENT W/WO PTA UN,3431896,CDM,481,RC,37226,HCPCS,Outpatient,,,1101.81,550.91,,826.36,75,,,percent of total billed charges,75% of total billed charges,826.36,75,,,percent of total billed charges,75% of total billed charges,9980.15,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,16467.25,165,,,Fee Schedule,165% of CMS OPPS Rate,10343.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,28666.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,39314,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,49244.77,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,9980.15,100,,,Fee Schedule,100% of CMS OPPS Rate,10343.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,154.25,14,,,percent of total billed charges,14% of total billed charges,154.25,49244.77,
37226-Periph Angio Femoral Pop Stent wwo PTA,3431897,CDM,481,RC,37226,HCPCS,Outpatient,,,1101.81,550.91,,826.36,75,,,percent of total billed charges,75% of total billed charges,826.36,75,,,percent of total billed charges,75% of total billed charges,9980.15,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,16467.25,165,,,Fee Schedule,165% of CMS OPPS Rate,10343.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,28666.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,39314,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,49244.77,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,9980.15,100,,,Fee Schedule,100% of CMS OPPS Rate,10343.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,154.25,14,,,percent of total billed charges,14% of total billed charges,154.25,49244.77,
Periph Angio Femoral Pop Stent wwo PTA,3427181,CDM,481,RC,37226,HCPCS,Outpatient,,,1101.81,550.91,,826.36,75,,,percent of total billed charges,75% of total billed charges,826.36,75,,,percent of total billed charges,75% of total billed charges,9980.15,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,16467.25,165,,,Fee Schedule,165% of CMS OPPS Rate,10343.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,28666.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,39314,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,49244.77,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,9980.15,100,,,Fee Schedule,100% of CMS OPPS Rate,10343.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,154.25,14,,,percent of total billed charges,14% of total billed charges,154.25,49244.77,
37227- Stent/athrectomy/fem/pop/unilat,3430914,CDM,960,RC,37227,HCPCS,Outpatient,,,1519.59,759.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
37227-Fem/ Pop w/Ather/Stent/W or w/o PTA,3560656,CDM,481,RC,37227,HCPCS,Outpatient,,,1519.59,759.8,,1139.69,75,,,percent of total billed charges,75% of total billed charges,1139.69,75,,,percent of total billed charges,75% of total billed charges,16149.79,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,26647.16,165,,,Fee Schedule,165% of CMS OPPS Rate,16737.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,46388.09,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,63617.56,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,79687.45,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,16149.79,100,,,Fee Schedule,100% of CMS OPPS Rate,16737.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,212.74,14,,,percent of total billed charges,14% of total billed charges,212.74,79687.45,
37227-Periph Angio Fem Pop Stent w ath wwo PTA,3431898,CDM,481,RC,37227,HCPCS,Outpatient,,,1519.59,759.8,,1139.69,75,,,percent of total billed charges,75% of total billed charges,1139.69,75,,,percent of total billed charges,75% of total billed charges,16149.79,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,26647.16,165,,,Fee Schedule,165% of CMS OPPS Rate,16737.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,46388.09,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,63617.56,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,79687.45,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,16149.79,100,,,Fee Schedule,100% of CMS OPPS Rate,16737.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,212.74,14,,,percent of total billed charges,14% of total billed charges,212.74,79687.45,
Periph Angio Fem Pop Stent w ath wwo PTA,,,481,RC,37227,HCPCS,Outpatient,,,1519.59,759.8,,1139.69,75,,,percent of total billed charges,75% of total billed charges,1139.69,75,,,percent of total billed charges,75% of total billed charges,16149.79,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,26647.16,165,,,Fee Schedule,165% of CMS OPPS Rate,16737.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,46388.09,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,63617.56,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,79687.45,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,16149.79,100,,,Fee Schedule,100% of CMS OPPS Rate,16737.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,212.74,14,,,percent of total billed charges,14% of total billed charges,212.74,79687.45,
37228- Angio tib/peroneal/init ves/unila,3430744,CDM,481,RC,37228,HCPCS,Outpatient,,,10496.63,5248.32,,7872.47,75,,,percent of total billed charges,75% of total billed charges,7872.47,75,,,percent of total billed charges,75% of total billed charges,9980.15,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,16467.25,165,,,Fee Schedule,165% of CMS OPPS Rate,10343.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,28666.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,39314,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,49244.77,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,9980.15,100,,,Fee Schedule,100% of CMS OPPS Rate,10343.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1469.53,14,,,percent of total billed charges,14% of total billed charges,1469.53,49244.77,
37228-Peripheral Angio Tibial Peroneal PTA LT,3431899,CDM,481,RC,37228,HCPCS,Outpatient,,,10496.63,5248.32,,7872.47,75,,,percent of total billed charges,75% of total billed charges,7872.47,75,,,percent of total billed charges,75% of total billed charges,9980.15,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,16467.25,165,,,Fee Schedule,165% of CMS OPPS Rate,10343.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,28666.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,39314,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,49244.77,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,9980.15,100,,,Fee Schedule,100% of CMS OPPS Rate,10343.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1469.53,14,,,percent of total billed charges,14% of total billed charges,1469.53,49244.77,
37228-Peripheral Angio Tibial Peroneal PTA RT,3431900,CDM,481,RC,37228,HCPCS,Outpatient,,,10496.63,5248.32,,7872.47,75,,,percent of total billed charges,75% of total billed charges,7872.47,75,,,percent of total billed charges,75% of total billed charges,9980.15,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,16467.25,165,,,Fee Schedule,165% of CMS OPPS Rate,10343.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,28666.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,39314,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,49244.77,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,9980.15,100,,,Fee Schedule,100% of CMS OPPS Rate,10343.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1469.53,14,,,percent of total billed charges,14% of total billed charges,1469.53,49244.77,
37228-TIB PERONEAL TERRITORY PTA UNILA,3431901,CDM,481,RC,37228,HCPCS,Outpatient,,,10496.63,5248.32,,7872.47,75,,,percent of total billed charges,75% of total billed charges,7872.47,75,,,percent of total billed charges,75% of total billed charges,9980.15,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,16467.25,165,,,Fee Schedule,165% of CMS OPPS Rate,10343.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,28666.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,39314,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,49244.77,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,9980.15,100,,,Fee Schedule,100% of CMS OPPS Rate,10343.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1469.53,14,,,percent of total billed charges,14% of total billed charges,1469.53,49244.77,
Peripheral Angio Tibial Peroneal PTA LT,3427193,CDM,960,RC,37228,HCPCS,Outpatient,,,9885.3,4942.65,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
Peripheral Angio Tibial Peroneal PTA RT,3427194,CDM,960,RC,37228,HCPCS,Outpatient,,,9885.3,4942.65,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
37229- Athrectomy tib/pero/unilat/ini ves,3430915,CDM,960,RC,37229,HCPCS,Outpatient,,,1465.47,732.74,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
37229-Peripheral Angio Tibial Per Ath w PTA,3431902,CDM,481,RC,37229,HCPCS,Outpatient,,,1465.47,732.74,,1099.1,75,,,percent of total billed charges,75% of total billed charges,1099.1,75,,,percent of total billed charges,75% of total billed charges,16149.79,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,26647.16,165,,,Fee Schedule,165% of CMS OPPS Rate,16737.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,46388.09,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,63617.56,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,79687.45,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,16149.79,100,,,Fee Schedule,100% of CMS OPPS Rate,16737.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,205.17,14,,,percent of total billed charges,14% of total billed charges,205.17,79687.45,
Peripheral Angio Tibial Per Ath w PTA,3427195,CDM,481,RC,37229,HCPCS,Outpatient,,,1465.47,732.74,,1099.1,75,,,percent of total billed charges,75% of total billed charges,1099.1,75,,,percent of total billed charges,75% of total billed charges,16149.79,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,26647.16,165,,,Fee Schedule,165% of CMS OPPS Rate,16737.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,46388.09,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,63617.56,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,79687.45,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,16149.79,100,,,Fee Schedule,100% of CMS OPPS Rate,16737.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,205.17,14,,,percent of total billed charges,14% of total billed charges,205.17,79687.45,
"37230 - PF - Revascularization, endovascular, open or percutaneous, tibial, peroneal artery, unilate",3640898,CDM,510,RC,37230,HCPCS,Outpatient,,,22472.43,11236.22,,16854.32,75,,,percent of total billed charges,75% of total billed charges,16854.32,75,,,percent of total billed charges,75% of total billed charges,16149.79,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,26647.16,165,,,Fee Schedule,165% of CMS OPPS Rate,16737.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,46388.09,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,63617.56,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,79687.45,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,16149.79,100,,,Fee Schedule,100% of CMS OPPS Rate,16737.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,3146.14,14,,,percent of total billed charges,14% of total billed charges,3146.14,79687.45,
37230-Peripheral Angio Tibial Peroneal Stent,3431903,CDM,481,RC,37230,HCPCS,Outpatient,,,22472.43,11236.22,,16854.32,75,,,percent of total billed charges,75% of total billed charges,16854.32,75,,,percent of total billed charges,75% of total billed charges,16149.79,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,26647.16,165,,,Fee Schedule,165% of CMS OPPS Rate,16737.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,46388.09,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,63617.56,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,79687.45,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,16149.79,100,,,Fee Schedule,100% of CMS OPPS Rate,16737.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,3146.14,14,,,percent of total billed charges,14% of total billed charges,3146.14,79687.45,
37230-Peripheral Intervention Tibal Peroneal,3431904,CDM,481,RC,37230,HCPCS,Outpatient,,,22472.43,11236.22,,16854.32,75,,,percent of total billed charges,75% of total billed charges,16854.32,75,,,percent of total billed charges,75% of total billed charges,16149.79,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,26647.16,165,,,Fee Schedule,165% of CMS OPPS Rate,16737.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,46388.09,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,63617.56,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,79687.45,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,16149.79,100,,,Fee Schedule,100% of CMS OPPS Rate,16737.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,3146.14,14,,,percent of total billed charges,14% of total billed charges,3146.14,79687.45,
Peripheral Angio Tibial Peroneal Stent,,,761,RC,37230,HCPCS,Outpatient,,,21051.05,10525.53,,15788.29,75,,,percent of total billed charges,75% of total billed charges,15788.29,75,,,percent of total billed charges,75% of total billed charges,16149.79,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,26647.16,165,,,Fee Schedule,165% of CMS OPPS Rate,16737.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,46388.09,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,63617.56,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,79687.45,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,16149.79,100,,,Fee Schedule,100% of CMS OPPS Rate,16737.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,2947.15,14,,,percent of total billed charges,14% of total billed charges,2947.15,79687.45,
Peripheral Intervention Tibal Peroneal,,,761,RC,37230,HCPCS,Outpatient,,,21051.05,10525.53,,15788.29,75,,,percent of total billed charges,75% of total billed charges,15788.29,75,,,percent of total billed charges,75% of total billed charges,16149.79,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,26647.16,165,,,Fee Schedule,165% of CMS OPPS Rate,16737.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,46388.09,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,63617.56,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,79687.45,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,16149.79,100,,,Fee Schedule,100% of CMS OPPS Rate,16737.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,2947.15,14,,,percent of total billed charges,14% of total billed charges,2947.15,79687.45,
37231 - REVSC OPN/PRQ TIB/PERO W/STNT/ATHR/ANGIOP SM VSL,4037542,CDM,481,RC,37231,HCPCS,Outpatient,,,1543.81,771.91,,1157.86,75,,,percent of total billed charges,75% of total billed charges,1157.86,75,,,percent of total billed charges,75% of total billed charges,16149.79,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,26647.16,165,,,Fee Schedule,165% of CMS OPPS Rate,16737.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,46388.09,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,63617.56,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,79687.45,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,16149.79,100,,,Fee Schedule,100% of CMS OPPS Rate,16737.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,216.13,14,,,percent of total billed charges,14% of total billed charges,216.13,79687.45,
37231-Periph Angio Tib Per Stent w Ath w PTA,3431905,CDM,481,RC,37231,HCPCS,Outpatient,,,1543.81,771.91,,1157.86,75,,,percent of total billed charges,75% of total billed charges,1157.86,75,,,percent of total billed charges,75% of total billed charges,16149.79,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,26647.16,165,,,Fee Schedule,165% of CMS OPPS Rate,16737.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,46388.09,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,63617.56,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,79687.45,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,16149.79,100,,,Fee Schedule,100% of CMS OPPS Rate,16737.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,216.13,14,,,percent of total billed charges,14% of total billed charges,216.13,79687.45,
"37231-Tib/Peroneal Stent, Ather, PTA",3560674,CDM,481,RC,37231,HCPCS,Outpatient,,,1543.81,771.91,,1157.86,75,,,percent of total billed charges,75% of total billed charges,1157.86,75,,,percent of total billed charges,75% of total billed charges,16149.79,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,26647.16,165,,,Fee Schedule,165% of CMS OPPS Rate,16737.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,46388.09,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,63617.56,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,79687.45,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,16149.79,100,,,Fee Schedule,100% of CMS OPPS Rate,16737.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,216.13,14,,,percent of total billed charges,14% of total billed charges,216.13,79687.45,
Periph Angio Tib Per Stent w Ath w PTA,,,481,RC,37231,HCPCS,Outpatient,,,1543.81,771.91,,1157.86,75,,,percent of total billed charges,75% of total billed charges,1157.86,75,,,percent of total billed charges,75% of total billed charges,16149.79,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,26647.16,165,,,Fee Schedule,165% of CMS OPPS Rate,16737.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,46388.09,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,63617.56,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,79687.45,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,16149.79,100,,,Fee Schedule,100% of CMS OPPS Rate,16737.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,216.13,14,,,percent of total billed charges,14% of total billed charges,216.13,79687.45,
37232- Angioplasty tib/pero/unilat/ea add,3430916,CDM,510,RC,37232,HCPCS,Outpatient,,,2082.6,1041.3,,1561.95,75,,,percent of total billed charges,75% of total billed charges,1561.95,75,,,percent of total billed charges,75% of total billed charges,666.43,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,291.56,14,,,percent of total billed charges,14% of total billed charges,291.56,1561.95,
37232-Peripheral Angio Tibial Peroneal PTA add,3431906,CDM,481,RC,37232,HCPCS,Outpatient,,,2082.6,1041.3,,1561.95,75,,,percent of total billed charges,75% of total billed charges,1561.95,75,,,percent of total billed charges,75% of total billed charges,666.43,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,291.56,14,,,percent of total billed charges,14% of total billed charges,291.56,1561.95,
Peripheral Angio Tibial Peroneal PTA add,,,761,RC,37232,HCPCS,Outpatient,,,1985.09,992.55,,1488.82,75,,,percent of total billed charges,75% of total billed charges,1488.82,75,,,percent of total billed charges,75% of total billed charges,635.23,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,277.91,14,,,percent of total billed charges,14% of total billed charges,277.91,1488.82,
37233-Periph Angio Tibial Peroneal Ath add,3431907,CDM,481,RC,37233,HCPCS,Outpatient,,,2639.9,1319.95,,1979.93,75,,,percent of total billed charges,75% of total billed charges,1979.93,75,,,percent of total billed charges,75% of total billed charges,844.77,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,369.59,14,,,percent of total billed charges,14% of total billed charges,369.59,1979.93,
Periph Angio Tibial Peroneal Ath add,,,761,RC,37233,HCPCS,Outpatient,,,2547.29,1273.65,,1910.47,75,,,percent of total billed charges,75% of total billed charges,1910.47,75,,,percent of total billed charges,75% of total billed charges,815.13,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,356.62,14,,,percent of total billed charges,14% of total billed charges,356.62,1910.47,
37234- Stent/tib/peroneal/unilat/ea add,3430917,CDM,510,RC,37234,HCPCS,Outpatient,,,9054.14,4527.07,,6790.61,75,,,percent of total billed charges,75% of total billed charges,6790.61,75,,,percent of total billed charges,75% of total billed charges,2897.32,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1267.58,14,,,percent of total billed charges,14% of total billed charges,1267.58,6790.61,
37234-Periph Angio Tibial Peroneal Stent add,3431908,CDM,481,RC,37234,HCPCS,Outpatient,,,9054.14,4527.07,,6790.61,75,,,percent of total billed charges,75% of total billed charges,6790.61,75,,,percent of total billed charges,75% of total billed charges,2897.32,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1267.58,14,,,percent of total billed charges,14% of total billed charges,1267.58,6790.61,
Periph Angio Tibial Peroneal Stent add,,,761,RC,37234,HCPCS,Outpatient,,,8569.23,4284.62,,6426.92,75,,,percent of total billed charges,75% of total billed charges,6426.92,75,,,percent of total billed charges,75% of total billed charges,2742.15,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1199.69,14,,,percent of total billed charges,14% of total billed charges,1199.69,6426.92,
37235-Periph Angio Tib Per Stent w Ath ea add,3431909,CDM,481,RC,37235,HCPCS,Outpatient,,,9714.6,4857.3,,7285.95,75,,,percent of total billed charges,75% of total billed charges,7285.95,75,,,percent of total billed charges,75% of total billed charges,3108.67,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1360.04,14,,,percent of total billed charges,14% of total billed charges,1360.04,7285.95,
Periph Angio Tib Per Stent w Ath ea add,,,761,RC,37235,HCPCS,Outpatient,,,9360.94,4680.47,,7020.71,75,,,percent of total billed charges,75% of total billed charges,7020.71,75,,,percent of total billed charges,75% of total billed charges,2995.5,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1310.53,14,,,percent of total billed charges,14% of total billed charges,1310.53,7020.71,
37236-Insertion of Aortic Stent,3581331,CDM,481,RC,37236,HCPCS,Outpatient,,,6949.3,3474.65,,5211.98,75,,,percent of total billed charges,75% of total billed charges,5211.98,75,,,percent of total billed charges,75% of total billed charges,9980.15,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,16467.25,165,,,Fee Schedule,165% of CMS OPPS Rate,10343.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,28666.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,39314,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,49244.77,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,9980.15,100,,,Fee Schedule,100% of CMS OPPS Rate,10343.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,972.9,14,,,percent of total billed charges,14% of total billed charges,972.9,49244.77,
37236-Peripheral Angio Stent w PTA,3431910,CDM,481,RC,37236,HCPCS,Outpatient,,,6949.3,3474.65,,5211.98,75,,,percent of total billed charges,75% of total billed charges,5211.98,75,,,percent of total billed charges,75% of total billed charges,9980.15,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,16467.25,165,,,Fee Schedule,165% of CMS OPPS Rate,10343.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,28666.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,39314,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,49244.77,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,9980.15,100,,,Fee Schedule,100% of CMS OPPS Rate,10343.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,972.9,14,,,percent of total billed charges,14% of total billed charges,972.9,49244.77,
37236-Peripheral Intervention Celiac,3431911,CDM,360,RC,37236,HCPCS,Outpatient,,,6949.3,3474.65,,5211.98,75,,,percent of total billed charges,75% of total billed charges,5211.98,75,,,percent of total billed charges,75% of total billed charges,9980.15,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,16467.25,165,,,Fee Schedule,165% of CMS OPPS Rate,10343.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,28666.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,39314,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,49244.77,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,9980.15,100,,,Fee Schedule,100% of CMS OPPS Rate,10343.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,972.9,14,,,percent of total billed charges,14% of total billed charges,972.9,49244.77,
37236-Peripheral Intervention Mesenteric,3431912,CDM,481,RC,37236,HCPCS,Outpatient,,,6949.3,3474.65,,5211.98,75,,,percent of total billed charges,75% of total billed charges,5211.98,75,,,percent of total billed charges,75% of total billed charges,9980.15,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,16467.25,165,,,Fee Schedule,165% of CMS OPPS Rate,10343.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,28666.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,39314,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,49244.77,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,9980.15,100,,,Fee Schedule,100% of CMS OPPS Rate,10343.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,972.9,14,,,percent of total billed charges,14% of total billed charges,972.9,49244.77,
37236-Peripheral Intervention Splenic,3431913,CDM,481,RC,37236,HCPCS,Outpatient,,,6949.3,3474.65,,5211.98,75,,,percent of total billed charges,75% of total billed charges,5211.98,75,,,percent of total billed charges,75% of total billed charges,9980.15,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,16467.25,165,,,Fee Schedule,165% of CMS OPPS Rate,10343.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,28666.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,39314,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,49244.77,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,9980.15,100,,,Fee Schedule,100% of CMS OPPS Rate,10343.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,972.9,14,,,percent of total billed charges,14% of total billed charges,972.9,49244.77,
37236-PF Insertion of Aortic Stent,3581339,CDM,960,RC,37236,HCPCS,Outpatient,,,6949.3,3474.65,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
37236-Renal Angiography stent w PTA,3431914,CDM,360,RC,37236,HCPCS,Outpatient,,,6949.3,3474.65,,5211.98,75,,,percent of total billed charges,75% of total billed charges,5211.98,75,,,percent of total billed charges,75% of total billed charges,9980.15,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,16467.25,165,,,Fee Schedule,165% of CMS OPPS Rate,10343.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,28666.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,39314,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,49244.77,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,9980.15,100,,,Fee Schedule,100% of CMS OPPS Rate,10343.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,972.9,14,,,percent of total billed charges,14% of total billed charges,972.9,49244.77,
37236-Renal Artery Intervention LT,3431915,CDM,360,RC,37236,HCPCS,Outpatient,,,6949.3,3474.65,,5211.98,75,,,percent of total billed charges,75% of total billed charges,5211.98,75,,,percent of total billed charges,75% of total billed charges,9980.15,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,16467.25,165,,,Fee Schedule,165% of CMS OPPS Rate,10343.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,28666.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,39314,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,49244.77,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,9980.15,100,,,Fee Schedule,100% of CMS OPPS Rate,10343.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,972.9,14,,,percent of total billed charges,14% of total billed charges,972.9,49244.77,
37236-Renal Artery Intervention RT,3431916,CDM,360,RC,37236,HCPCS,Outpatient,,,6949.3,3474.65,,5211.98,75,,,percent of total billed charges,75% of total billed charges,5211.98,75,,,percent of total billed charges,75% of total billed charges,9980.15,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,16467.25,165,,,Fee Schedule,165% of CMS OPPS Rate,10343.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,28666.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,39314,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,49244.77,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,9980.15,100,,,Fee Schedule,100% of CMS OPPS Rate,10343.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,972.9,14,,,percent of total billed charges,14% of total billed charges,972.9,49244.77,
37236-Stent Place S/I RT other,3560644,CDM,481,RC,37236,HCPCS,Outpatient,,,6949.3,3474.65,,5211.98,75,,,percent of total billed charges,75% of total billed charges,5211.98,75,,,percent of total billed charges,75% of total billed charges,9980.15,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,16467.25,165,,,Fee Schedule,165% of CMS OPPS Rate,10343.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,28666.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,39314,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,49244.77,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,9980.15,100,,,Fee Schedule,100% of CMS OPPS Rate,10343.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,972.9,14,,,percent of total billed charges,14% of total billed charges,972.9,49244.77,
37236-STENT PLMT LT LOWER EXT S&I,3431917,CDM,481,RC,37236,HCPCS,Outpatient,,,6949.3,3474.65,,5211.98,75,,,percent of total billed charges,75% of total billed charges,5211.98,75,,,percent of total billed charges,75% of total billed charges,9980.15,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,16467.25,165,,,Fee Schedule,165% of CMS OPPS Rate,10343.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,28666.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,39314,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,49244.77,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,9980.15,100,,,Fee Schedule,100% of CMS OPPS Rate,10343.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,972.9,14,,,percent of total billed charges,14% of total billed charges,972.9,49244.77,
37236-Subclavian Angiography with PTA,3431918,CDM,360,RC,37236,HCPCS,Outpatient,,,6949.3,3474.65,,5211.98,75,,,percent of total billed charges,75% of total billed charges,5211.98,75,,,percent of total billed charges,75% of total billed charges,9980.15,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,16467.25,165,,,Fee Schedule,165% of CMS OPPS Rate,10343.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,28666.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,39314,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,49244.77,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,9980.15,100,,,Fee Schedule,100% of CMS OPPS Rate,10343.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,972.9,14,,,percent of total billed charges,14% of total billed charges,972.9,49244.77,
37236-Subclavian Intervention LT,3431919,CDM,360,RC,37236,HCPCS,Outpatient,,,6949.3,3474.65,,5211.98,75,,,percent of total billed charges,75% of total billed charges,5211.98,75,,,percent of total billed charges,75% of total billed charges,9980.15,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,16467.25,165,,,Fee Schedule,165% of CMS OPPS Rate,10343.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,28666.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,39314,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,49244.77,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,9980.15,100,,,Fee Schedule,100% of CMS OPPS Rate,10343.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,972.9,14,,,percent of total billed charges,14% of total billed charges,972.9,49244.77,
37236-Subclavian Intervention RT,3431920,CDM,360,RC,37236,HCPCS,Outpatient,,,6949.3,3474.65,,5211.98,75,,,percent of total billed charges,75% of total billed charges,5211.98,75,,,percent of total billed charges,75% of total billed charges,9980.15,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,16467.25,165,,,Fee Schedule,165% of CMS OPPS Rate,10343.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,28666.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,39314,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,49244.77,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,9980.15,100,,,Fee Schedule,100% of CMS OPPS Rate,10343.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,972.9,14,,,percent of total billed charges,14% of total billed charges,972.9,49244.77,
Insertion of Aortic Stent,,,761,RC,37236,HCPCS,Outpatient,,,6576.19,3288.1,,4932.14,75,,,percent of total billed charges,75% of total billed charges,4932.14,75,,,percent of total billed charges,75% of total billed charges,9980.15,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,16467.25,165,,,Fee Schedule,165% of CMS OPPS Rate,10343.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,28666.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,39314,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,49244.77,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,9980.15,100,,,Fee Schedule,100% of CMS OPPS Rate,10343.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,920.67,14,,,percent of total billed charges,14% of total billed charges,920.67,49244.77,
IR Stent Placement Bilat S and I,603514,CDM,320,RC,37236,HCPCS,Outpatient,,,6576.19,3288.1,,4932.14,75,,,percent of total billed charges,75% of total billed charges,4932.14,75,,,percent of total billed charges,75% of total billed charges,9980.15,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,16467.25,165,,,Fee Schedule,165% of CMS OPPS Rate,10343.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,28666.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,39314,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,49244.77,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,9980.15,100,,,Fee Schedule,100% of CMS OPPS Rate,10343.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,920.67,14,,,percent of total billed charges,14% of total billed charges,920.67,49244.77,
IR Stent Placement Lt S and I,603484,CDM,320,RC,37236,HCPCS,Outpatient,,,6576.19,3288.1,,4932.14,75,,,percent of total billed charges,75% of total billed charges,4932.14,75,,,percent of total billed charges,75% of total billed charges,9980.15,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,16467.25,165,,,Fee Schedule,165% of CMS OPPS Rate,10343.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,28666.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,39314,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,49244.77,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,9980.15,100,,,Fee Schedule,100% of CMS OPPS Rate,10343.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,920.67,14,,,percent of total billed charges,14% of total billed charges,920.67,49244.77,
Peripheral Angio Stent w PTA,,,761,RC,37236,HCPCS,Outpatient,,,6576.19,3288.1,,4932.14,75,,,percent of total billed charges,75% of total billed charges,4932.14,75,,,percent of total billed charges,75% of total billed charges,9980.15,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,16467.25,165,,,Fee Schedule,165% of CMS OPPS Rate,10343.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,28666.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,39314,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,49244.77,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,9980.15,100,,,Fee Schedule,100% of CMS OPPS Rate,10343.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,920.67,14,,,percent of total billed charges,14% of total billed charges,920.67,49244.77,
Peripheral Intervention Celiac,,,761,RC,37236,HCPCS,Outpatient,,,6576.19,3288.1,,4932.14,75,,,percent of total billed charges,75% of total billed charges,4932.14,75,,,percent of total billed charges,75% of total billed charges,9980.15,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,16467.25,165,,,Fee Schedule,165% of CMS OPPS Rate,10343.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,28666.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,39314,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,49244.77,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,9980.15,100,,,Fee Schedule,100% of CMS OPPS Rate,10343.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,920.67,14,,,percent of total billed charges,14% of total billed charges,920.67,49244.77,
Peripheral Intervention Mesenteric,,,761,RC,37236,HCPCS,Outpatient,,,6576.19,3288.1,,4932.14,75,,,percent of total billed charges,75% of total billed charges,4932.14,75,,,percent of total billed charges,75% of total billed charges,9980.15,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,16467.25,165,,,Fee Schedule,165% of CMS OPPS Rate,10343.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,28666.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,39314,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,49244.77,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,9980.15,100,,,Fee Schedule,100% of CMS OPPS Rate,10343.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,920.67,14,,,percent of total billed charges,14% of total billed charges,920.67,49244.77,
Peripheral Intervention Splenic,,,761,RC,37236,HCPCS,Outpatient,,,6576.19,3288.1,,4932.14,75,,,percent of total billed charges,75% of total billed charges,4932.14,75,,,percent of total billed charges,75% of total billed charges,9980.15,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,16467.25,165,,,Fee Schedule,165% of CMS OPPS Rate,10343.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,28666.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,39314,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,49244.77,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,9980.15,100,,,Fee Schedule,100% of CMS OPPS Rate,10343.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,920.67,14,,,percent of total billed charges,14% of total billed charges,920.67,49244.77,
Renal Angiography stent w PTA,3427241,CDM,960,RC,37236,HCPCS,Outpatient,,,6576.19,3288.1,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
Renal Artery Intervention LT,3427304,CDM,960,RC,37236,HCPCS,Outpatient,,,6576.19,3288.1,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
Renal Artery Intervention RT,3427305,CDM,960,RC,37236,HCPCS,Outpatient,,,6576.19,3288.1,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
Subclavian Angiography with PTA,,,761,RC,37236,HCPCS,Outpatient,,,6576.19,3288.1,,4932.14,75,,,percent of total billed charges,75% of total billed charges,4932.14,75,,,percent of total billed charges,75% of total billed charges,9980.15,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,16467.25,165,,,Fee Schedule,165% of CMS OPPS Rate,10343.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,28666.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,39314,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,49244.77,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,9980.15,100,,,Fee Schedule,100% of CMS OPPS Rate,10343.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,920.67,14,,,percent of total billed charges,14% of total billed charges,920.67,49244.77,
Subclavian Intervention LT,,,761,RC,37236,HCPCS,Outpatient,,,6576.19,3288.1,,4932.14,75,,,percent of total billed charges,75% of total billed charges,4932.14,75,,,percent of total billed charges,75% of total billed charges,9980.15,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,16467.25,165,,,Fee Schedule,165% of CMS OPPS Rate,10343.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,28666.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,39314,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,49244.77,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,9980.15,100,,,Fee Schedule,100% of CMS OPPS Rate,10343.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,920.67,14,,,percent of total billed charges,14% of total billed charges,920.67,49244.77,
Subclavian Intervention RT,,,761,RC,37236,HCPCS,Outpatient,,,6576.19,3288.1,,4932.14,75,,,percent of total billed charges,75% of total billed charges,4932.14,75,,,percent of total billed charges,75% of total billed charges,9980.15,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,16467.25,165,,,Fee Schedule,165% of CMS OPPS Rate,10343.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,28666.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,39314,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,49244.77,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,9980.15,100,,,Fee Schedule,100% of CMS OPPS Rate,10343.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,920.67,14,,,percent of total billed charges,14% of total billed charges,920.67,49244.77,
37237 - PF Transcatheter placement of an intravascular stent(s) (except lower extremity artery(s) fo,3714921,CDM,510,RC,37237,HCPCS,Outpatient,,,3257.91,1628.96,,2443.43,75,,,percent of total billed charges,75% of total billed charges,2443.43,75,,,percent of total billed charges,75% of total billed charges,1042.53,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,456.11,14,,,percent of total billed charges,14% of total billed charges,456.11,2443.43,
37237-Periph Angio Stent w PTA ea add,3431921,CDM,481,RC,37237,HCPCS,Outpatient,,,3257.91,1628.96,,2443.43,75,,,percent of total billed charges,75% of total billed charges,2443.43,75,,,percent of total billed charges,75% of total billed charges,1042.53,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,456.11,14,,,percent of total billed charges,14% of total billed charges,456.11,2443.43,
37237-Renal Angiography stent w PTA add,3431922,CDM,360,RC,37237,HCPCS,Outpatient,,,3257.91,1628.96,,2443.43,75,,,percent of total billed charges,75% of total billed charges,2443.43,75,,,percent of total billed charges,75% of total billed charges,1042.53,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,456.11,14,,,percent of total billed charges,14% of total billed charges,456.11,2443.43,
37237-Subclavian Stent w PTA add,3431923,CDM,360,RC,37237,HCPCS,Outpatient,,,3257.91,1628.96,,2443.43,75,,,percent of total billed charges,75% of total billed charges,2443.43,75,,,percent of total billed charges,75% of total billed charges,1042.53,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,456.11,14,,,percent of total billed charges,14% of total billed charges,456.11,2443.43,
Periph Angio Stent w PTA ea add,,,761,RC,37237,HCPCS,Outpatient,,,3093.13,1546.57,,2319.85,75,,,percent of total billed charges,75% of total billed charges,2319.85,75,,,percent of total billed charges,75% of total billed charges,989.8,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,433.04,14,,,percent of total billed charges,14% of total billed charges,433.04,2319.85,
Renal Angiography stent w PTA add,,,761,RC,37237,HCPCS,Outpatient,,,3093.13,1546.57,,2319.85,75,,,percent of total billed charges,75% of total billed charges,2319.85,75,,,percent of total billed charges,75% of total billed charges,989.8,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,433.04,14,,,percent of total billed charges,14% of total billed charges,433.04,2319.85,
Subclavian Stent w PTA add,,,761,RC,37237,HCPCS,Outpatient,,,3093.13,1546.57,,2319.85,75,,,percent of total billed charges,75% of total billed charges,2319.85,75,,,percent of total billed charges,75% of total billed charges,989.8,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,433.04,14,,,percent of total billed charges,14% of total billed charges,433.04,2319.85,
"37238 - PF - Transcatheter placement of an intravascular stent(s), open or percutaneous, including r",3640917,CDM,510,RC,37238,HCPCS,Outpatient,,,8606.54,4303.27,,6454.91,75,,,percent of total billed charges,75% of total billed charges,6454.91,75,,,percent of total billed charges,75% of total billed charges,9980.15,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,16467.25,165,,,Fee Schedule,165% of CMS OPPS Rate,10343.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,28666.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,39314,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,49244.77,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,9980.15,100,,,Fee Schedule,100% of CMS OPPS Rate,10343.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1204.92,14,,,percent of total billed charges,14% of total billed charges,1204.92,49244.77,
37238-Venography Stent open/perc w PTA initial,3431924,CDM,481,RC,37238,HCPCS,Outpatient,,,8606.54,4303.27,,6454.91,75,,,percent of total billed charges,75% of total billed charges,6454.91,75,,,percent of total billed charges,75% of total billed charges,9980.15,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,16467.25,165,,,Fee Schedule,165% of CMS OPPS Rate,10343.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,28666.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,39314,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,49244.77,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,9980.15,100,,,Fee Schedule,100% of CMS OPPS Rate,10343.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1204.92,14,,,percent of total billed charges,14% of total billed charges,1204.92,49244.77,
Venography Stent open/perc w PTA initial,,,761,RC,37238,HCPCS,Outpatient,,,8153.18,4076.59,,6114.89,75,,,percent of total billed charges,75% of total billed charges,6114.89,75,,,percent of total billed charges,75% of total billed charges,9980.15,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,16467.25,165,,,Fee Schedule,165% of CMS OPPS Rate,10343.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,28666.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,39314,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,49244.77,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,9980.15,100,,,Fee Schedule,100% of CMS OPPS Rate,10343.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1141.45,14,,,percent of total billed charges,14% of total billed charges,1141.45,49244.77,
"37239 - PF - Transcatheter placement of an intravascular stent(s), open or percutaneous, including r",3640918,CDM,510,RC,37239,HCPCS,Outpatient,,,4254.69,2127.35,,3191.02,75,,,percent of total billed charges,75% of total billed charges,3191.02,75,,,percent of total billed charges,75% of total billed charges,1361.5,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,595.66,14,,,percent of total billed charges,14% of total billed charges,595.66,3191.02,
37239-Venography each add vein,3431925,CDM,481,RC,37239,HCPCS,Outpatient,,,4254.69,2127.35,,3191.02,75,,,percent of total billed charges,75% of total billed charges,3191.02,75,,,percent of total billed charges,75% of total billed charges,1361.5,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,595.66,14,,,percent of total billed charges,14% of total billed charges,595.66,3191.02,
Venography each add vein,,,761,RC,37239,HCPCS,Outpatient,,,4048.91,2024.46,,3036.68,75,,,percent of total billed charges,75% of total billed charges,3036.68,75,,,percent of total billed charges,75% of total billed charges,1295.65,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,566.85,14,,,percent of total billed charges,14% of total billed charges,566.85,3036.68,
"37241 Vascular embolization or occlusion, inclusive of all radiological supervision and interpretati",3621881,CDM,510,RC,37241,HCPCS,Outpatient,,,11686.98,5843.49,,8765.24,75,,,percent of total billed charges,75% of total billed charges,8765.24,75,,,percent of total billed charges,75% of total billed charges,9980.15,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,16467.25,165,,,Fee Schedule,165% of CMS OPPS Rate,10343.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,28666.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,39314,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,49244.77,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,9980.15,100,,,Fee Schedule,100% of CMS OPPS Rate,10343.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1636.18,14,,,percent of total billed charges,14% of total billed charges,1636.18,49244.77,
"37241-Embolization/Occlusion Venous, other than hemorrhage",4271183,CDM,481,RC,37241,HCPCS,Outpatient,,,8827.13,4413.57,,6620.35,75,,,percent of total billed charges,75% of total billed charges,6620.35,75,,,percent of total billed charges,75% of total billed charges,9980.15,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,16467.25,165,,,Fee Schedule,165% of CMS OPPS Rate,10343.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,28666.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,39314,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,49244.77,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,9980.15,100,,,Fee Schedule,100% of CMS OPPS Rate,10343.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1235.8,14,,,percent of total billed charges,14% of total billed charges,1235.8,49244.77,
"37241-PF Embolization/Occlusion Venous, other than hemorrhage",4271184,CDM,960,RC,37241,HCPCS,Outpatient,,,8827.13,4413.57,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
37242-Coil Embolization-AVM/AVF-Arterial,3938925,CDM,481,RC,37242,HCPCS,Outpatient,,,17804.35,8902.18,,13353.26,75,,,percent of total billed charges,75% of total billed charges,13353.26,75,,,percent of total billed charges,75% of total billed charges,9980.15,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,16467.25,165,,,Fee Schedule,165% of CMS OPPS Rate,10343.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,28666.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,39314,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,49244.77,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,9980.15,100,,,Fee Schedule,100% of CMS OPPS Rate,10343.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,2492.61,14,,,percent of total billed charges,14% of total billed charges,2492.61,49244.77,
37242-PF Coil Embolization-AVM/AVF-Arterial,3938927,CDM,960,RC,37242,HCPCS,Outpatient,,,17804.35,8902.18,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
Coil Embolization-AVM/AVF-Arterial,,,761,RC,37242,HCPCS,Outpatient,,,16783.25,8391.63,,12587.44,75,,,percent of total billed charges,75% of total billed charges,12587.44,75,,,percent of total billed charges,75% of total billed charges,9980.15,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,16467.25,165,,,Fee Schedule,165% of CMS OPPS Rate,10343.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,28666.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,39314,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,49244.77,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,9980.15,100,,,Fee Schedule,100% of CMS OPPS Rate,10343.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,2349.66,14,,,percent of total billed charges,14% of total billed charges,2349.66,49244.77,
Embolization (Cardiology),,,761,RC,37242,HCPCS,Outpatient,,,16783.25,8391.63,,12587.44,75,,,percent of total billed charges,75% of total billed charges,12587.44,75,,,percent of total billed charges,75% of total billed charges,9980.15,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,16467.25,165,,,Fee Schedule,165% of CMS OPPS Rate,10343.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,28666.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,39314,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,49244.77,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,9980.15,100,,,Fee Schedule,100% of CMS OPPS Rate,10343.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,2349.66,14,,,percent of total billed charges,14% of total billed charges,2349.66,49244.77,
37244-Coil Embolization-Art or Vein-W/Hemorrhage,3938926,CDM,481,RC,37244,HCPCS,Outpatient,,,16456.48,8228.24,,12342.36,75,,,percent of total billed charges,75% of total billed charges,12342.36,75,,,percent of total billed charges,75% of total billed charges,9980.15,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,16467.25,165,,,Fee Schedule,165% of CMS OPPS Rate,10343.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,28666.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,39314,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,49244.77,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,9980.15,100,,,Fee Schedule,100% of CMS OPPS Rate,10343.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,2303.91,14,,,percent of total billed charges,14% of total billed charges,2303.91,49244.77,
37244-PF Coil Embolization-Art or Vein-W/Hemorrhage,3938928,CDM,960,RC,37244,HCPCS,Outpatient,,,16456.48,8228.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
Coil Embolization-Art or Vein-W/Hemorrhage,,,761,RC,37244,HCPCS,Outpatient,,,15614.36,7807.18,,11710.77,75,,,percent of total billed charges,75% of total billed charges,11710.77,75,,,percent of total billed charges,75% of total billed charges,9980.15,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,16467.25,165,,,Fee Schedule,165% of CMS OPPS Rate,10343.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,28666.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,39314,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,49244.77,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,9980.15,100,,,Fee Schedule,100% of CMS OPPS Rate,10343.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,2186.01,14,,,percent of total billed charges,14% of total billed charges,2186.01,49244.77,
37246 - (50) Transluminal balloon angioplasty (except lower extremity artery(ies) for occlusive dise,3699318,CDM,510,RC,37246,HCPCS,Outpatient,,,4619.23,2309.62,,3464.42,75,,,percent of total billed charges,75% of total billed charges,3464.42,75,,,percent of total billed charges,75% of total billed charges,4903.32,100,,,Fee Schedule,100% of CMS OPPS Rate,2268.13,102,,,Fee Schedule,102% of WV Medicaid Rate,8090.5,165,,,Fee Schedule,165% of CMS OPPS Rate,5081.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,14084.18,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,19315.33,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,24194.41,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,2223.66,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,4903.32,100,,,Fee Schedule,100% of CMS OPPS Rate,5081.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,646.69,14,,,percent of total billed charges,14% of total billed charges,646.69,24194.41,
37246 - PF - Transluminal balloon angioplasty (except lower extremity artery(ies) for occlusive dise,3640899,CDM,510,RC,37246,HCPCS,Outpatient,,,4619.23,2309.62,,3464.42,75,,,percent of total billed charges,75% of total billed charges,3464.42,75,,,percent of total billed charges,75% of total billed charges,4903.32,100,,,Fee Schedule,100% of CMS OPPS Rate,2268.13,102,,,Fee Schedule,102% of WV Medicaid Rate,8090.5,165,,,Fee Schedule,165% of CMS OPPS Rate,5081.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,14084.18,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,19315.33,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,24194.41,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,2223.66,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,4903.32,100,,,Fee Schedule,100% of CMS OPPS Rate,5081.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,646.69,14,,,percent of total billed charges,14% of total billed charges,646.69,24194.41,
37247 Transcatheter placement of an intravascular stent(s) (except lower extremity artery(s) for occ,3621308,CDM,510,RC,37247,HCPCS,Outpatient,,,1400.67,700.34,,1050.5,75,,,percent of total billed charges,75% of total billed charges,1050.5,75,,,percent of total billed charges,75% of total billed charges,448.21,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,196.09,14,,,percent of total billed charges,14% of total billed charges,196.09,1050.5,
"37247-Balloon Angioplasty (except LE arteries, coronary, pulmonary, or dialysis) each add't",4271256,CDM,481,RC,37247,HCPCS,Outpatient,,,1103.76,551.88,,827.82,75,,,percent of total billed charges,75% of total billed charges,827.82,75,,,percent of total billed charges,75% of total billed charges,353.2,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,154.53,14,,,percent of total billed charges,14% of total billed charges,154.53,827.82,
"37247-PF Balloon Angioplasty (except LE arteries, coronary, pulmonary, or dialysis) each add't",4271257,CDM,960,RC,37247,HCPCS,Outpatient,,,1103.76,551.88,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
"37248 - (50) Transluminal balloon angioplasty (except dialysis circuit), open or percutaneous, inclu",3699319,CDM,510,RC,37248,HCPCS,Outpatient,,,3448.53,1724.27,,2586.4,75,,,percent of total billed charges,75% of total billed charges,2586.4,75,,,percent of total billed charges,75% of total billed charges,4903.32,100,,,Fee Schedule,100% of CMS OPPS Rate,1740.26,102,,,Fee Schedule,102% of WV Medicaid Rate,8090.5,165,,,Fee Schedule,165% of CMS OPPS Rate,5081.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,14084.18,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,19315.33,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,24194.41,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1706.14,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,4903.32,100,,,Fee Schedule,100% of CMS OPPS Rate,5081.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,482.79,14,,,percent of total billed charges,14% of total billed charges,482.79,24194.41,
"37248 - PF - Transluminal balloon angioplasty (except dialysis circuit), open or percutaneous, inclu",3640900,CDM,510,RC,37248,HCPCS,Outpatient,,,3448.53,1724.27,,2586.4,75,,,percent of total billed charges,75% of total billed charges,2586.4,75,,,percent of total billed charges,75% of total billed charges,4903.32,100,,,Fee Schedule,100% of CMS OPPS Rate,1740.26,102,,,Fee Schedule,102% of WV Medicaid Rate,8090.5,165,,,Fee Schedule,165% of CMS OPPS Rate,5081.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,14084.18,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,19315.33,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,24194.41,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1706.14,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,4903.32,100,,,Fee Schedule,100% of CMS OPPS Rate,5081.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,482.79,14,,,percent of total billed charges,14% of total billed charges,482.79,24194.41,
37248-PTA Vein,3560635,CDM,481,RC,37248,HCPCS,Outpatient,,,3448.53,1724.27,,2586.4,75,,,percent of total billed charges,75% of total billed charges,2586.4,75,,,percent of total billed charges,75% of total billed charges,4903.32,100,,,Fee Schedule,100% of CMS OPPS Rate,1740.26,102,,,Fee Schedule,102% of WV Medicaid Rate,8090.5,165,,,Fee Schedule,165% of CMS OPPS Rate,5081.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,14084.18,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,19315.33,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,24194.41,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1706.14,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,4903.32,100,,,Fee Schedule,100% of CMS OPPS Rate,5081.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,482.79,14,,,percent of total billed charges,14% of total billed charges,482.79,24194.41,
37248-Venography Transluminal PTA initial vein,3431928,CDM,481,RC,37248,HCPCS,Outpatient,,,3448.53,1724.27,,2586.4,75,,,percent of total billed charges,75% of total billed charges,2586.4,75,,,percent of total billed charges,75% of total billed charges,4903.32,100,,,Fee Schedule,100% of CMS OPPS Rate,1740.26,102,,,Fee Schedule,102% of WV Medicaid Rate,8090.5,165,,,Fee Schedule,165% of CMS OPPS Rate,5081.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,14084.18,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,19315.33,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,24194.41,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1706.14,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,4903.32,100,,,Fee Schedule,100% of CMS OPPS Rate,5081.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,482.79,14,,,percent of total billed charges,14% of total billed charges,482.79,24194.41,
Venography Transluminal PTA initial vein,3427277,CDM,481,RC,37248,HCPCS,Outpatient,,,3262.76,1631.38,,2447.07,75,,,percent of total billed charges,75% of total billed charges,2447.07,75,,,percent of total billed charges,75% of total billed charges,4903.32,100,,,Fee Schedule,100% of CMS OPPS Rate,1740.26,102,,,Fee Schedule,102% of WV Medicaid Rate,8090.5,165,,,Fee Schedule,165% of CMS OPPS Rate,5081.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,14084.18,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,19315.33,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,24194.41,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1706.14,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,4903.32,100,,,Fee Schedule,100% of CMS OPPS Rate,5081.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,456.79,14,,,percent of total billed charges,14% of total billed charges,456.79,24194.41,
37249-PF Venography each add vein,3580888,CDM,960,RC,37249,HCPCS,Outpatient,,,1128.33,564.17,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
37249-Venography each add vein,3431929,CDM,481,RC,37249,HCPCS,Outpatient,,,1128.33,564.17,,846.25,75,,,percent of total billed charges,75% of total billed charges,846.25,75,,,percent of total billed charges,75% of total billed charges,361.07,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,157.97,14,,,percent of total billed charges,14% of total billed charges,157.97,846.25,
37252 - PF - Intravascular ultrasound (noncoronary vessel) during diagnostic evaluation and/or thera,3640919,CDM,510,RC,37252,HCPCS,Outpatient,,,2375.36,1187.68,,1781.52,75,,,percent of total billed charges,75% of total billed charges,1781.52,75,,,percent of total billed charges,75% of total billed charges,760.12,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,332.55,14,,,percent of total billed charges,14% of total billed charges,332.55,1781.52,
37252-IVUS Non Coronary,3560638,CDM,481,RC,37252,HCPCS,Outpatient,,,2375.36,1187.68,,1781.52,75,,,percent of total billed charges,75% of total billed charges,1781.52,75,,,percent of total billed charges,75% of total billed charges,760.12,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,332.55,14,,,percent of total billed charges,14% of total billed charges,332.55,1781.52,
37252-Noncoronary IVUS,3431930,CDM,481,RC,37252,HCPCS,Outpatient,,,2375.36,1187.68,,1781.52,75,,,percent of total billed charges,75% of total billed charges,1781.52,75,,,percent of total billed charges,75% of total billed charges,760.12,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,332.55,14,,,percent of total billed charges,14% of total billed charges,332.55,1781.52,
Noncoronary IVUS,,,761,RC,37252,HCPCS,Outpatient,,,2254.17,1127.09,,1690.63,75,,,percent of total billed charges,75% of total billed charges,1690.63,75,,,percent of total billed charges,75% of total billed charges,721.33,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,315.58,14,,,percent of total billed charges,14% of total billed charges,315.58,1690.63,
37253 - PF - Intravascular ultrasound (noncoronary vessel) during diagnostic evaluation and/or thera,3640920,CDM,510,RC,37253,HCPCS,Outpatient,,,426.98,213.49,,320.24,75,,,percent of total billed charges,75% of total billed charges,320.24,75,,,percent of total billed charges,75% of total billed charges,136.63,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,59.78,14,,,percent of total billed charges,14% of total billed charges,59.78,320.24,
37253-IVUS non add,3431931,CDM,481,RC,37253,HCPCS,Outpatient,,,426.98,213.49,,320.24,75,,,percent of total billed charges,75% of total billed charges,320.24,75,,,percent of total billed charges,75% of total billed charges,136.63,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,59.78,14,,,percent of total billed charges,14% of total billed charges,59.78,320.24,
IVUS non add,,,761,RC,37253,HCPCS,Outpatient,,,422.99,211.5,,317.24,75,,,percent of total billed charges,75% of total billed charges,317.24,75,,,percent of total billed charges,75% of total billed charges,135.36,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,59.22,14,,,percent of total billed charges,14% of total billed charges,59.22,317.24,
37607- Ligation or banding of angioaccess AV fistula,3569416,CDM,510,RC,37607,HCPCS,Outpatient,,,998.13,499.07,,748.6,75,,,percent of total billed charges,75% of total billed charges,748.6,75,,,percent of total billed charges,75% of total billed charges,2800.71,100,,,Fee Schedule,100% of CMS OPPS Rate,1102.62,102,,,Fee Schedule,102% of WV Medicaid Rate,4621.18,165,,,Fee Schedule,165% of CMS OPPS Rate,2902.7,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8044.7,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11032.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13819.53,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1081,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2800.71,100,,,Fee Schedule,100% of CMS OPPS Rate,2902.7,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,139.74,14,,,percent of total billed charges,14% of total billed charges,139.74,13819.53,
37609- Ligation/biopsy/temporal artery,3430918,CDM,761,RC,37609,HCPCS,Outpatient,,,804.5,402.25,,603.38,75,,,percent of total billed charges,75% of total billed charges,603.38,75,,,percent of total billed charges,75% of total billed charges,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,479.67,102,,,Fee Schedule,102% of WV Medicaid Rate,2326.19,165,,,Fee Schedule,165% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4049.52,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5553.61,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6956.46,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,470.26,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,112.63,14,,,percent of total billed charges,14% of total billed charges,112.63,6956.46,
"37617 - PF Ligation, major artery (eg, post-traumatic, rupture); abdomen",3699320,CDM,510,RC,37617,HCPCS,Outpatient,,,3547.97,1773.99,,2660.98,75,,,percent of total billed charges,75% of total billed charges,2660.98,75,,,percent of total billed charges,75% of total billed charges,3547.97,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,3547.97,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3547.97,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3547.97,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3547.97,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3547.97,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,3547.97,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3547.97,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,496.72,14,,,percent of total billed charges,14% of total billed charges,496.72,3547.97,
"37618- Arteriovenous anastomosis, open; by upper arm cephalic vein transposition",3566785,CDM,510,RC,37618,HCPCS,Outpatient,,,1034.14,517.07,,775.61,75,,,percent of total billed charges,75% of total billed charges,775.61,75,,,percent of total billed charges,75% of total billed charges,1034.14,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,1034.14,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1034.14,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1034.14,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1034.14,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1034.14,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,1034.14,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1034.14,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,144.78,14,,,percent of total billed charges,14% of total billed charges,144.78,1034.14,
37700- Ligation/divis of long saph vein,3430748,CDM,510,RC,37700,HCPCS,Outpatient,,,651.32,325.66,,488.49,75,,,percent of total billed charges,75% of total billed charges,488.49,75,,,percent of total billed charges,75% of total billed charges,2800.71,100,,,Fee Schedule,100% of CMS OPPS Rate,1102.62,102,,,Fee Schedule,102% of WV Medicaid Rate,4621.18,165,,,Fee Schedule,165% of CMS OPPS Rate,2902.7,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8044.7,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11032.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13819.53,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1081,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2800.71,100,,,Fee Schedule,100% of CMS OPPS Rate,2902.7,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,91.18,14,,,percent of total billed charges,14% of total billed charges,91.18,13819.53,
"37722 - (50) Ligation, division, and stripping, long (greater) saphenous veins from saphenofemoral j",3699326,CDM,510,RC,37722,HCPCS,Outpatient,,,1258.4,629.2,,943.8,75,,,percent of total billed charges,75% of total billed charges,943.8,75,,,percent of total billed charges,75% of total billed charges,2800.71,100,,,Fee Schedule,100% of CMS OPPS Rate,1102.62,102,,,Fee Schedule,102% of WV Medicaid Rate,4621.18,165,,,Fee Schedule,165% of CMS OPPS Rate,2902.7,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8044.7,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11032.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13819.53,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1081,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2800.71,100,,,Fee Schedule,100% of CMS OPPS Rate,2902.7,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,176.18,14,,,percent of total billed charges,14% of total billed charges,176.18,13819.53,
"37722 - (PF) Ligation, division, and stripping, long (greater) saphenous veins from saphenofemoral",3634911,CDM,510,RC,37722,HCPCS,Outpatient,,,1258.4,629.2,,943.8,75,,,percent of total billed charges,75% of total billed charges,943.8,75,,,percent of total billed charges,75% of total billed charges,2800.71,100,,,Fee Schedule,100% of CMS OPPS Rate,1102.62,102,,,Fee Schedule,102% of WV Medicaid Rate,4621.18,165,,,Fee Schedule,165% of CMS OPPS Rate,2902.7,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8044.7,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11032.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13819.53,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1081,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2800.71,100,,,Fee Schedule,100% of CMS OPPS Rate,2902.7,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,176.18,14,,,percent of total billed charges,14% of total billed charges,176.18,13819.53,
37765- Stab phlebectomy/1 ext/10-20 incis,3430749,CDM,360,RC,37765,HCPCS,Outpatient,,,1113.38,556.69,,835.04,75,,,percent of total billed charges,75% of total billed charges,835.04,75,,,percent of total billed charges,75% of total billed charges,2800.71,100,,,Fee Schedule,100% of CMS OPPS Rate,192.19,102,,,Fee Schedule,102% of WV Medicaid Rate,4621.18,165,,,Fee Schedule,165% of CMS OPPS Rate,2902.7,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8044.7,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11032.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13819.53,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,188.42,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2800.71,100,,,Fee Schedule,100% of CMS OPPS Rate,2902.7,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,155.87,14,,,percent of total billed charges,14% of total billed charges,155.87,13819.53,
37766- Stab phlebectomy/1 ext/> 20 incis,3430750,CDM,510,RC,37766,HCPCS,Outpatient,,,1304.91,652.46,,978.68,75,,,percent of total billed charges,75% of total billed charges,978.68,75,,,percent of total billed charges,75% of total billed charges,2800.71,100,,,Fee Schedule,100% of CMS OPPS Rate,209.93,102,,,Fee Schedule,102% of WV Medicaid Rate,4621.18,165,,,Fee Schedule,165% of CMS OPPS Rate,2902.7,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8044.7,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11032.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13819.53,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,205.81,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2800.71,100,,,Fee Schedule,100% of CMS OPPS Rate,2902.7,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,182.69,14,,,percent of total billed charges,14% of total billed charges,182.69,13819.53,
37799- Vasc Surg/Unlisted Procedure,3430751,CDM,360,RC,37799,HCPCS,Outpatient,,,2993.07,1496.54,,2244.8,75,,,percent of total billed charges,75% of total billed charges,2244.8,75,,,percent of total billed charges,75% of total billed charges,543.88,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,897.4,165,,,Fee Schedule,165% of CMS OPPS Rate,563.67,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1562.23,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2142.48,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,2683.68,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,543.88,100,,,Fee Schedule,100% of CMS OPPS Rate,563.67,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,419.03,14,,,percent of total billed charges,14% of total billed charges,419.03,2683.68,
37799-Fibrin sheath disrupt/remove using angioplasty balloon,4331300,CDM,481,RC,37799,HCPCS,Outpatient,,,461.46,230.73,,346.1,75,,,percent of total billed charges,75% of total billed charges,346.1,75,,,percent of total billed charges,75% of total billed charges,543.88,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,897.4,165,,,Fee Schedule,165% of CMS OPPS Rate,563.67,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1562.23,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2142.48,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,2683.68,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,543.88,100,,,Fee Schedule,100% of CMS OPPS Rate,563.67,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,64.6,14,,,percent of total billed charges,14% of total billed charges,64.6,2683.68,
37799-PF Fibrin sheath disrupt/remove using angioplasty balloon,4331301,CDM,960,RC,37799,HCPCS,Outpatient,,,461.46,230.73,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
Fibrin sheath disrupt/remove using angioplasty balloon,,,761,RC,37799,HCPCS,Outpatient,,,461.46,230.73,,346.1,75,,,percent of total billed charges,75% of total billed charges,346.1,75,,,percent of total billed charges,75% of total billed charges,543.88,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,897.4,165,,,Fee Schedule,165% of CMS OPPS Rate,563.67,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1562.23,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2142.48,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,2683.68,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,543.88,100,,,Fee Schedule,100% of CMS OPPS Rate,563.67,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,64.6,14,,,percent of total billed charges,14% of total billed charges,64.6,2683.68,
38100 - PF Splenectomy Total Separate Procedure,4311503,CDM,960,RC,38100,HCPCS,Outpatient,,,2745.67,1372.84,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
38100- Splenectomy/total,3431444,CDM,510,RC,38100,HCPCS,Outpatient,,,3105.41,1552.71,,2329.06,75,,,percent of total billed charges,75% of total billed charges,2329.06,75,,,percent of total billed charges,75% of total billed charges,3105.41,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,3105.41,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3105.41,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3105.41,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3105.41,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3105.41,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,3105.41,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3105.41,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,434.76,14,,,percent of total billed charges,14% of total billed charges,434.76,3105.41,
38101- PF Spelenectomy Parital Separate Procedure,4311504,CDM,960,RC,38101,HCPCS,Outpatient,,,2784.54,1392.27,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
38102 - PF Splec Tot En Block Extnsv DS Conjunt w/ Oth Px,4311506,CDM,960,RC,38102,HCPCS,Outpatient,,,627.55,313.78,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
38102-PF REMOVAL OF SPLEEN,3429787,CDM,510,RC,38102,HCPCS,Outpatient,,,705.65,352.83,,529.24,75,,,percent of total billed charges,75% of total billed charges,529.24,75,,,percent of total billed charges,75% of total billed charges,705.65,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,705.65,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,705.65,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,705.65,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,705.65,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,705.65,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,705.65,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,705.65,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,98.79,14,,,percent of total billed charges,14% of total billed charges,98.79,705.65,
38120 - PF Laparascopic Surgical Splenectomy,4311507,CDM,960,RC,38120,HCPCS,Outpatient,,,2516.54,1258.27,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
38120- Splenectomy/laparoscopy,3431445,CDM,510,RC,38120,HCPCS,Outpatient,,,2843.19,1421.6,,2132.39,75,,,percent of total billed charges,75% of total billed charges,2132.39,75,,,percent of total billed charges,75% of total billed charges,8543.54,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,14096.88,165,,,Fee Schedule,165% of CMS OPPS Rate,8854.68,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,24540.24,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,33654.98,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,42156.28,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,8543.54,100,,,Fee Schedule,100% of CMS OPPS Rate,8854.68,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,398.05,14,,,percent of total billed charges,14% of total billed charges,398.05,42156.28,
38220- Bone marrow aspiration only,3431446,CDM,360,RC,38220,HCPCS,Outpatient,,,384.89,192.45,,288.67,75,,,percent of total billed charges,75% of total billed charges,288.67,75,,,percent of total billed charges,75% of total billed charges,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,2326.19,165,,,Fee Schedule,165% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4049.52,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5553.61,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6956.46,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,53.88,14,,,percent of total billed charges,14% of total billed charges,53.88,6956.46,
38221- Diagnostic bone marrow; biopsy(ies),3431447,CDM,360,RC,38221,HCPCS,Outpatient,,,400.91,200.46,,300.68,75,,,percent of total billed charges,75% of total billed charges,300.68,75,,,percent of total billed charges,75% of total billed charges,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,2326.19,165,,,Fee Schedule,165% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4049.52,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5553.61,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6956.46,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,56.13,14,,,percent of total billed charges,14% of total billed charges,56.13,6956.46,
38221-PF DIAGNOSTIC BONE MARROW BIOPSIES,4321447,CDM,981,RC,38221,HCPCS,Outpatient,,,135.54,67.77,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
38222-ZSW DX BONE MARROW BX & ASPIR,3435574,CDM,510,RC,38222,HCPCS,Outpatient,,,435.23,217.62,,326.42,75,,,percent of total billed charges,75% of total billed charges,326.42,75,,,percent of total billed charges,75% of total billed charges,2428.67,100,,,Fee Schedule,100% of CMS OPPS Rate,803.83,102,,,Fee Schedule,102% of WV Medicaid Rate,4007.32,165,,,Fee Schedule,165% of CMS OPPS Rate,2517.11,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,6976.06,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,9567.11,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,11983.78,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,788.07,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2428.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2517.11,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,60.93,14,,,percent of total billed charges,14% of total billed charges,60.93,11983.78,
38241- HPC/autologous transplantation,3431448,CDM,510,RC,38241,HCPCS,Outpatient,,,459.53,229.77,,344.65,75,,,percent of total billed charges,75% of total billed charges,344.65,75,,,percent of total billed charges,75% of total billed charges,1278.47,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,2109.46,165,,,Fee Schedule,165% of CMS OPPS Rate,1325.02,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,3672.24,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5036.18,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6308.34,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,1278.47,100,,,Fee Schedule,100% of CMS OPPS Rate,1325.02,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,64.33,14,,,percent of total billed charges,14% of total billed charges,64.33,6308.34,
38300-PF DRAINAGE LYMPH NODE LESION,4321448,CDM,981,RC,38300,HCPCS,Outpatient,,,404.66,202.33,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
MA DRAIN LYMPH NODE ABSCESS/LYMPHA,3527856,CDM,960,RC,38300,HCPCS,Outpatient,,,863.7,431.85,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
38305-PF DRG LYMPH NODE ABSC/LYMPHADENITIS EXTNSV,4321449,CDM,981,RC,38305,HCPCS,Outpatient,,,974.3,487.15,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
38308- Lymphangiotomy/lymph channel ops,3431449,CDM,510,RC,38308,HCPCS,Outpatient,,,1226.98,613.49,,920.24,75,,,percent of total billed charges,75% of total billed charges,920.24,75,,,percent of total billed charges,75% of total billed charges,3232.09,100,,,Fee Schedule,100% of CMS OPPS Rate,950.21,102,,,Fee Schedule,102% of WV Medicaid Rate,5332.96,165,,,Fee Schedule,165% of CMS OPPS Rate,3349.79,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,9283.77,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,12731.95,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,15948.06,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,931.58,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,3232.09,100,,,Fee Schedule,100% of CMS OPPS Rate,3349.79,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,171.78,14,,,percent of total billed charges,14% of total billed charges,171.78,15948.06,
38380 - Suture and/or ligation of thoracic duct; cervical approach,3760893,CDM,983,RC,38380,HCPCS,Outpatient,,,1487.23,743.62,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
38500 - PF Bx/ Exc Lymph Node Open Superficial,4311508,CDM,960,RC,38500,HCPCS,Outpatient,,,601.13,300.57,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
38500- Bx/exc lymph node/open/superfic,3431450,CDM,510,RC,38500,HCPCS,Outpatient,,,877.26,438.63,,657.95,75,,,percent of total billed charges,75% of total billed charges,657.95,75,,,percent of total billed charges,75% of total billed charges,3232.09,100,,,Fee Schedule,100% of CMS OPPS Rate,950.21,102,,,Fee Schedule,102% of WV Medicaid Rate,5332.96,165,,,Fee Schedule,165% of CMS OPPS Rate,3349.79,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,9283.77,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,12731.95,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,15948.06,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,931.58,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,3232.09,100,,,Fee Schedule,100% of CMS OPPS Rate,3349.79,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,122.82,14,,,percent of total billed charges,14% of total billed charges,122.82,15948.06,
38505 - BX/EXC LYMPH NODE NEEDLE SUPERFICIAL,4037465,CDM,510,RC,38505,HCPCS,Outpatient,,,446.02,223.01,,334.52,75,,,percent of total billed charges,75% of total billed charges,334.52,75,,,percent of total billed charges,75% of total billed charges,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,479.67,102,,,Fee Schedule,102% of WV Medicaid Rate,2326.19,165,,,Fee Schedule,165% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4049.52,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5553.61,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6956.46,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,470.26,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,62.44,14,,,percent of total billed charges,14% of total billed charges,62.44,6956.46,
38505- Bx/exc lymph node/needle/superfic,3431451,CDM,320,RC,38505,HCPCS,Outpatient,,,446.02,223.01,,334.52,75,,,percent of total billed charges,75% of total billed charges,334.52,75,,,percent of total billed charges,75% of total billed charges,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,479.67,102,,,Fee Schedule,102% of WV Medicaid Rate,2326.19,165,,,Fee Schedule,165% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4049.52,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5553.61,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6956.46,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,470.26,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,62.44,14,,,percent of total billed charges,14% of total billed charges,62.44,6956.46,
CT add Needle Bx Lymph Node,3347324,CDM,320,RC,38505,HCPCS,Outpatient,,,435.5,217.75,,326.63,75,,,percent of total billed charges,75% of total billed charges,326.63,75,,,percent of total billed charges,75% of total billed charges,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,479.67,102,,,Fee Schedule,102% of WV Medicaid Rate,2326.19,165,,,Fee Schedule,165% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4049.52,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5553.61,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6956.46,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,470.26,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,60.97,14,,,percent of total billed charges,14% of total billed charges,60.97,6956.46,
Read,4181202,CDM,972,RC,38505,HCPCS,Outpatient,,,174.2,87.1,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
US add Needle Bx Lymph Node,3334648,CDM,320,RC,38505,HCPCS,Outpatient,,,435.5,217.75,,326.63,75,,,percent of total billed charges,75% of total billed charges,326.63,75,,,percent of total billed charges,75% of total billed charges,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,479.67,102,,,Fee Schedule,102% of WV Medicaid Rate,2326.19,165,,,Fee Schedule,165% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4049.52,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5553.61,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6956.46,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,470.26,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,60.97,14,,,percent of total billed charges,14% of total billed charges,60.97,6956.46,
38510 - PF Bx/ Exc Lymph Node Open Deep Cervical Node,4311509,CDM,960,RC,38510,HCPCS,Outpatient,,,985.47,492.74,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
38510- Bx/exc lymph node/open/deep cervic,3431452,CDM,510,RC,38510,HCPCS,Outpatient,,,1378.41,689.21,,1033.81,75,,,percent of total billed charges,75% of total billed charges,1033.81,75,,,percent of total billed charges,75% of total billed charges,3232.09,100,,,Fee Schedule,100% of CMS OPPS Rate,950.21,102,,,Fee Schedule,102% of WV Medicaid Rate,5332.96,165,,,Fee Schedule,165% of CMS OPPS Rate,3349.79,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,9283.77,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,12731.95,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,15948.06,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,931.58,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,3232.09,100,,,Fee Schedule,100% of CMS OPPS Rate,3349.79,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,192.98,14,,,percent of total billed charges,14% of total billed charges,192.98,15948.06,
38525 - PF Bx/ Exc Lymph Node Open Deep Axillary Node,4311510,CDM,960,RC,38525,HCPCS,Outpatient,,,1038.51,519.26,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
38525- Bx/exc lymph node/open/deep axilla,3431453,CDM,510,RC,38525,HCPCS,Outpatient,,,1172.13,586.07,,879.1,75,,,percent of total billed charges,75% of total billed charges,879.1,75,,,percent of total billed charges,75% of total billed charges,3232.09,100,,,Fee Schedule,100% of CMS OPPS Rate,950.21,102,,,Fee Schedule,102% of WV Medicaid Rate,5332.96,165,,,Fee Schedule,165% of CMS OPPS Rate,3349.79,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,9283.77,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,12731.95,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,15948.06,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,931.58,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,3232.09,100,,,Fee Schedule,100% of CMS OPPS Rate,3349.79,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,164.1,14,,,percent of total billed charges,14% of total billed charges,164.1,15948.06,
38530- Bx/exc lymph node/open/int mammary,3431454,CDM,510,RC,38530,HCPCS,Outpatient,,,1480.66,740.33,,1110.5,75,,,percent of total billed charges,75% of total billed charges,1110.5,75,,,percent of total billed charges,75% of total billed charges,3232.09,100,,,Fee Schedule,100% of CMS OPPS Rate,950.21,102,,,Fee Schedule,102% of WV Medicaid Rate,5332.96,165,,,Fee Schedule,165% of CMS OPPS Rate,3349.79,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,9283.77,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,12731.95,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,15948.06,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,931.58,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,3232.09,100,,,Fee Schedule,100% of CMS OPPS Rate,3349.79,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,207.29,14,,,percent of total billed charges,14% of total billed charges,207.29,15948.06,
38531-MA EXCISION OF LYMPH NODE,3429800,CDM,510,RC,38531,HCPCS,Outpatient,,,1185.98,592.99,,889.49,75,,,percent of total billed charges,75% of total billed charges,889.49,75,,,percent of total billed charges,75% of total billed charges,3232.09,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,5332.96,165,,,Fee Schedule,165% of CMS OPPS Rate,3349.79,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,9283.77,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,12731.95,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,15948.06,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,3232.09,100,,,Fee Schedule,100% of CMS OPPS Rate,3349.79,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,166.04,14,,,percent of total billed charges,14% of total billed charges,166.04,15948.06,
38562 - Limited lymphadenectomy for staging (separate procedure); pelvic and para-aortic,3783256,CDM,510,RC,38562,HCPCS,Outpatient,,,1856.31,928.16,,1392.23,75,,,percent of total billed charges,75% of total billed charges,1392.23,75,,,percent of total billed charges,75% of total billed charges,1856.31,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,1856.31,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1856.31,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1856.31,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1856.31,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1856.31,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,1856.31,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1856.31,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,259.88,14,,,percent of total billed charges,14% of total billed charges,259.88,1856.31,
38562 - PF Lmtd Lmphadec Staging Spx Pel&Para-Aortic,4311511,CDM,960,RC,38562,HCPCS,Outpatient,,,1644.27,822.14,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
38562- Lymphadenect/stage/pelv/paraaortic,3431455,CDM,510,RC,38562,HCPCS,Outpatient,,,1856.31,928.16,,1392.23,75,,,percent of total billed charges,75% of total billed charges,1392.23,75,,,percent of total billed charges,75% of total billed charges,1856.31,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,1856.31,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1856.31,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1856.31,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1856.31,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1856.31,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,1856.31,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1856.31,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,259.88,14,,,percent of total billed charges,14% of total billed charges,259.88,1856.31,
38570- Laparoscopy/surg/retroper lymph bx,3431456,CDM,510,RC,38570,HCPCS,Outpatient,,,1360.33,680.17,,1020.25,75,,,percent of total billed charges,75% of total billed charges,1020.25,75,,,percent of total billed charges,75% of total billed charges,4900.27,100,,,Fee Schedule,100% of CMS OPPS Rate,1862.49,102,,,Fee Schedule,102% of WV Medicaid Rate,8085.46,165,,,Fee Schedule,165% of CMS OPPS Rate,5078.72,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,14075.4,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,19303.29,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,24179.33,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1825.97,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,4900.27,100,,,Fee Schedule,100% of CMS OPPS Rate,5078.72,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,190.45,14,,,percent of total billed charges,14% of total billed charges,190.45,24179.33,
38571- Lap/surg/bilat pelvic lymphadenect,3431457,CDM,510,RC,38571,HCPCS,Outpatient,,,1738.1,869.05,,1303.58,75,,,percent of total billed charges,75% of total billed charges,1303.58,75,,,percent of total billed charges,75% of total billed charges,8543.54,100,,,Fee Schedule,100% of CMS OPPS Rate,3066.62,102,,,Fee Schedule,102% of WV Medicaid Rate,14096.88,165,,,Fee Schedule,165% of CMS OPPS Rate,8854.68,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,24540.24,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,33654.98,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,42156.28,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,3006.49,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,8543.54,100,,,Fee Schedule,100% of CMS OPPS Rate,8854.68,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,243.33,14,,,percent of total billed charges,14% of total billed charges,243.33,42156.28,
"38572-PF LAPAROSCOPY, LYMPHADENECTOMY",3429808,CDM,510,RC,38572,HCPCS,Outpatient,,,2395.41,1197.71,,1796.56,75,,,percent of total billed charges,75% of total billed charges,1796.56,75,,,percent of total billed charges,75% of total billed charges,8543.54,100,,,Fee Schedule,100% of CMS OPPS Rate,3066.62,102,,,Fee Schedule,102% of WV Medicaid Rate,14096.88,165,,,Fee Schedule,165% of CMS OPPS Rate,8854.68,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,24540.24,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,33654.98,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,42156.28,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,3006.49,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,8543.54,100,,,Fee Schedule,100% of CMS OPPS Rate,8854.68,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,335.36,14,,,percent of total billed charges,14% of total billed charges,335.36,42156.28,
38573-PF LAPS PELVIC LYMPHADEC,3429810,CDM,510,RC,38573,HCPCS,Outpatient,,,3097.78,1548.89,,2323.34,75,,,percent of total billed charges,75% of total billed charges,2323.34,75,,,percent of total billed charges,75% of total billed charges,8543.54,100,,,Fee Schedule,100% of CMS OPPS Rate,3066.62,102,,,Fee Schedule,102% of WV Medicaid Rate,14096.88,165,,,Fee Schedule,165% of CMS OPPS Rate,8854.68,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,24540.24,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,33654.98,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,42156.28,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,3006.49,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,8543.54,100,,,Fee Schedule,100% of CMS OPPS Rate,8854.68,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,433.69,14,,,percent of total billed charges,14% of total billed charges,433.69,42156.28,
38700- Suprahyoid lymphadenectomy,3431458,CDM,510,RC,38700,HCPCS,Outpatient,,,2115.28,1057.64,,1586.46,75,,,percent of total billed charges,75% of total billed charges,1586.46,75,,,percent of total billed charges,75% of total billed charges,5587.54,100,,,Fee Schedule,100% of CMS OPPS Rate,1819.46,102,,,Fee Schedule,102% of WV Medicaid Rate,9219.44,165,,,Fee Schedule,165% of CMS OPPS Rate,5791.01,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,16049.47,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,22010.56,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,27570.47,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1783.78,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,5587.54,100,,,Fee Schedule,100% of CMS OPPS Rate,5791.01,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,296.14,14,,,percent of total billed charges,14% of total billed charges,296.14,27570.47,
38724- Radical neck dissection/modified,3431459,CDM,510,RC,38724,HCPCS,Outpatient,,,3812.41,1906.21,,2859.31,75,,,percent of total billed charges,75% of total billed charges,2859.31,75,,,percent of total billed charges,75% of total billed charges,3812.41,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,3812.41,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3812.41,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3812.41,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3812.41,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3812.41,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,3812.41,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3812.41,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,533.74,14,,,percent of total billed charges,14% of total billed charges,533.74,3812.41,
38740- Axillary lymphadenect/superficial,3431460,CDM,510,RC,38740,HCPCS,Outpatient,,,1872.88,936.44,,1404.66,75,,,percent of total billed charges,75% of total billed charges,1404.66,75,,,percent of total billed charges,75% of total billed charges,4900.27,100,,,Fee Schedule,100% of CMS OPPS Rate,1862.49,102,,,Fee Schedule,102% of WV Medicaid Rate,8085.46,165,,,Fee Schedule,165% of CMS OPPS Rate,5078.72,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,14075.4,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,19303.29,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,24179.33,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1825.97,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,4900.27,100,,,Fee Schedule,100% of CMS OPPS Rate,5078.72,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,262.2,14,,,percent of total billed charges,14% of total billed charges,262.2,24179.33,
38745- Axillary lymphadenectomy/complete,3431461,CDM,510,RC,38745,HCPCS,Outpatient,,,2363.05,1181.53,,1772.29,75,,,percent of total billed charges,75% of total billed charges,1772.29,75,,,percent of total billed charges,75% of total billed charges,4900.27,100,,,Fee Schedule,100% of CMS OPPS Rate,1862.49,102,,,Fee Schedule,102% of WV Medicaid Rate,8085.46,165,,,Fee Schedule,165% of CMS OPPS Rate,5078.72,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,14075.4,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,19303.29,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,24179.33,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1825.97,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,4900.27,100,,,Fee Schedule,100% of CMS OPPS Rate,5078.72,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,330.83,14,,,percent of total billed charges,14% of total billed charges,330.83,24179.33,
38746- Thoracic lymphadenect/thoracotomy,3431462,CDM,510,RC,38746,HCPCS,Outpatient,,,581.96,290.98,,436.47,75,,,percent of total billed charges,75% of total billed charges,436.47,75,,,percent of total billed charges,75% of total billed charges,581.96,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,581.96,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,581.96,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,581.96,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,581.96,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,581.96,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,581.96,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,581.96,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,81.47,14,,,percent of total billed charges,14% of total billed charges,81.47,581.96,
38746-PF Remove Thoracic Lymp Nodes,4322100,CDM,960,RC,38746,HCPCS,Outpatient,,,423.46,211.73,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
38747- Abdominal lymphadenectomy,3431463,CDM,510,RC,38747,HCPCS,Outpatient,,,723.39,361.7,,542.54,75,,,percent of total billed charges,75% of total billed charges,542.54,75,,,percent of total billed charges,75% of total billed charges,723.39,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,723.39,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,723.39,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,723.39,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,723.39,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,723.39,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,723.39,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,723.39,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,101.27,14,,,percent of total billed charges,14% of total billed charges,101.27,723.39,
38760- Inguinofem lymphadenec/superficial,3431464,CDM,510,RC,38760,HCPCS,Outpatient,,,2226.98,1113.49,,1670.24,75,,,percent of total billed charges,75% of total billed charges,1670.24,75,,,percent of total billed charges,75% of total billed charges,5587.54,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,9219.44,165,,,Fee Schedule,165% of CMS OPPS Rate,5791.01,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,16049.47,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,22010.56,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,27570.47,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,5587.54,100,,,Fee Schedule,100% of CMS OPPS Rate,5791.01,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,311.78,14,,,percent of total billed charges,14% of total billed charges,311.78,27570.47,
38765-MA REMOVE GROIN LYMPH NODES,3429825,CDM,510,RC,38765,HCPCS,Outpatient,,,3490.85,1745.43,,2618.14,75,,,percent of total billed charges,75% of total billed charges,2618.14,75,,,percent of total billed charges,75% of total billed charges,3490.85,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,3490.85,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3490.85,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3490.85,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3490.85,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3490.85,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,3490.85,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3490.85,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,488.72,14,,,percent of total billed charges,14% of total billed charges,488.72,3490.85,
38780-PF REMOVE ABDOMEN LYMPH NODES,3429827,CDM,510,RC,38780,HCPCS,Outpatient,,,2748.65,1374.33,,2061.49,75,,,percent of total billed charges,75% of total billed charges,2061.49,75,,,percent of total billed charges,75% of total billed charges,2748.65,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,2748.65,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2748.65,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2748.65,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2748.65,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2748.65,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,2748.65,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2748.65,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,384.81,14,,,percent of total billed charges,14% of total billed charges,384.81,2748.65,
MA INJECT FOR LYMPHATIC X-RAY,3527842,CDM,960,RC,38790,HCPCS,Outpatient,,,211.05,105.53,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
38792- Lymphangiography/sentinel node,3431465,CDM,510,RC,38792,HCPCS,Outpatient,,,205.57,102.79,,154.18,75,,,percent of total billed charges,75% of total billed charges,154.18,75,,,percent of total billed charges,75% of total billed charges,365.42,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,602.94,165,,,Fee Schedule,165% of CMS OPPS Rate,378.73,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1049.63,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1439.48,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1803.09,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,365.42,100,,,Fee Schedule,100% of CMS OPPS Rate,378.73,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,28.78,14,,,percent of total billed charges,14% of total billed charges,28.78,1803.09,
38900- Intraop map/sentinel node/inj dye,3431466,CDM,510,RC,38900,HCPCS,Outpatient,,,373.61,186.81,,280.21,75,,,percent of total billed charges,75% of total billed charges,280.21,75,,,percent of total billed charges,75% of total billed charges,119.56,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.31,14,,,percent of total billed charges,14% of total billed charges,52.31,280.21,
"38999 - Unlisted procedure, hemic or lymphatic system",4037546,CDM,983,RC,38999,HCPCS,Outpatient,,,979.11,489.56,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
"39010 - PF - Mediastinotomy with exploration, drainage, removal of foreign body, or biopsy; transtho",3640921,CDM,510,RC,39010,HCPCS,Outpatient,,,2104.86,1052.43,,1578.65,75,,,percent of total billed charges,75% of total billed charges,1578.65,75,,,percent of total billed charges,75% of total billed charges,2104.86,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,2104.86,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2104.86,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2104.86,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2104.86,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2104.86,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,2104.86,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2104.86,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,294.68,14,,,percent of total billed charges,14% of total billed charges,294.68,2104.86,
EXPLORATION OF CHEST,3527864,CDM,960,RC,39010,HCPCS,Outpatient,,,3050.25,1525.13,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
SURG AST EXPLORATION OF CHEST,3527878,CDM,960,RC,39010,HCPCS,Outpatient,,,610.32,305.16,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
39220 - PF Resection Mediasstinal Tumor,4301611,CDM,960,RC,39220,HCPCS,Outpatient,,,2394.84,1197.42,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
39401-MEDIASTINOSCOPY W/MEDSTNL BX,3430921,CDM,510,RC,39401,HCPCS,Outpatient,,,864.28,432.14,,648.21,75,,,percent of total billed charges,75% of total billed charges,648.21,75,,,percent of total billed charges,75% of total billed charges,4900.27,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,8085.46,165,,,Fee Schedule,165% of CMS OPPS Rate,5078.72,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,14075.4,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,19303.29,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,24179.33,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,4900.27,100,,,Fee Schedule,100% of CMS OPPS Rate,5078.72,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,121,14,,,percent of total billed charges,14% of total billed charges,121,24179.33,
39401-PF Mediastinoscopy w/Medstnl Bx,4322101,CDM,960,RC,39401,HCPCS,Outpatient,,,603.22,301.61,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
39402-MEDIASTINOSCOPY W/LMPH NOD BX,3430922,CDM,510,RC,39402,HCPCS,Outpatient,,,1134.2,567.1,,850.65,75,,,percent of total billed charges,75% of total billed charges,850.65,75,,,percent of total billed charges,75% of total billed charges,4900.27,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,8085.46,165,,,Fee Schedule,165% of CMS OPPS Rate,5078.72,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,14075.4,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,19303.29,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,24179.33,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,4900.27,100,,,Fee Schedule,100% of CMS OPPS Rate,5078.72,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,158.79,14,,,percent of total billed charges,14% of total billed charges,158.79,24179.33,
39402-PF Medistinoscopy w/Lmph Nod Bx,4322102,CDM,960,RC,39402,HCPCS,Outpatient,,,791.02,395.51,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
39501 - PF Repair Laceration Diaphragm Any Approach,4327194,CDM,960,RC,39501,HCPCS,Outpatient,,,1672,836,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
39545-PF Imbrication Diaphragm Eventration,4322103,CDM,960,RC,39545,HCPCS,Outpatient,,,1749.16,874.58,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
39560-PF Resect Diaphargm w/Smpl Rpr,4322104,CDM,960,RC,39560,HCPCS,Outpatient,,,1565.44,782.72,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
39561-PF Resect Disphragm w/Cmplx Rpr,4322105,CDM,960,RC,39561,HCPCS,Outpatient,,,2449.78,1224.89,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
40490- Biopsy of lip,3431096,CDM,510,RC,40490,HCPCS,Outpatient,,,139.2,69.6,,104.4,75,,,percent of total billed charges,75% of total billed charges,104.4,75,,,percent of total billed charges,75% of total billed charges,195.39,100,,,Fee Schedule,100% of CMS OPPS Rate,63.33,102,,,Fee Schedule,102% of WV Medicaid Rate,322.39,165,,,Fee Schedule,165% of CMS OPPS Rate,202.5,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,561.23,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,769.7,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,964.12,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,62.09,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,195.39,100,,,Fee Schedule,100% of CMS OPPS Rate,202.5,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,19.49,14,,,percent of total billed charges,14% of total billed charges,19.49,964.12,
40510- Lip exc/transverse wedge/w closure,3431097,CDM,510,RC,40510,HCPCS,Outpatient,,,1241.69,620.85,,931.27,75,,,percent of total billed charges,75% of total billed charges,931.27,75,,,percent of total billed charges,75% of total billed charges,2674.8,100,,,Fee Schedule,100% of CMS OPPS Rate,874.26,102,,,Fee Schedule,102% of WV Medicaid Rate,4413.39,165,,,Fee Schedule,165% of CMS OPPS Rate,2772.2,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,7682.99,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,10536.61,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13198.18,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,857.12,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2674.8,100,,,Fee Schedule,100% of CMS OPPS Rate,2772.2,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,173.84,14,,,percent of total billed charges,14% of total billed charges,173.84,13198.18,
40520- V-exc/lip/w/pri linear closure,3431098,CDM,510,RC,40520,HCPCS,Outpatient,,,1272.86,636.43,,954.65,75,,,percent of total billed charges,75% of total billed charges,954.65,75,,,percent of total billed charges,75% of total billed charges,2674.8,100,,,Fee Schedule,100% of CMS OPPS Rate,874.26,102,,,Fee Schedule,102% of WV Medicaid Rate,4413.39,165,,,Fee Schedule,165% of CMS OPPS Rate,2772.2,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,7682.99,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,10536.61,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13198.18,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,857.12,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2674.8,100,,,Fee Schedule,100% of CMS OPPS Rate,2772.2,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,178.2,14,,,percent of total billed charges,14% of total billed charges,178.2,13198.18,
40530- Resect lip/> one-fourth/w/o recon,3431099,CDM,510,RC,40530,HCPCS,Outpatient,,,1420.32,710.16,,1065.24,75,,,percent of total billed charges,75% of total billed charges,1065.24,75,,,percent of total billed charges,75% of total billed charges,2674.8,100,,,Fee Schedule,100% of CMS OPPS Rate,874.26,102,,,Fee Schedule,102% of WV Medicaid Rate,4413.39,165,,,Fee Schedule,165% of CMS OPPS Rate,2772.2,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,7682.99,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,10536.61,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13198.18,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,857.12,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2674.8,100,,,Fee Schedule,100% of CMS OPPS Rate,2772.2,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,198.84,14,,,percent of total billed charges,14% of total billed charges,198.84,13198.18,
40650- Rpr lip/full thick/vermilion only,3431100,CDM,510,RC,40650,HCPCS,Outpatient,,,1210.07,605.04,,907.55,75,,,percent of total billed charges,75% of total billed charges,907.55,75,,,percent of total billed charges,75% of total billed charges,429.48,100,,,Fee Schedule,100% of CMS OPPS Rate,184.6,102,,,Fee Schedule,102% of WV Medicaid Rate,708.64,165,,,Fee Schedule,165% of CMS OPPS Rate,445.12,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1233.63,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1691.83,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,2119.19,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,180.98,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,429.48,100,,,Fee Schedule,100% of CMS OPPS Rate,445.12,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,169.41,14,,,percent of total billed charges,14% of total billed charges,169.41,2119.19,
40650-PF RPR LIP FULL THICKNESS VERMILION ONLY,4321655,CDM,981,RC,40650,HCPCS,Outpatient,,,606.76,303.38,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
40654- Lip rpr/> half vert height/complex,3431101,CDM,510,RC,40654,HCPCS,Outpatient,,,1471.51,735.76,,1103.63,75,,,percent of total billed charges,75% of total billed charges,1103.63,75,,,percent of total billed charges,75% of total billed charges,1305.07,100,,,Fee Schedule,100% of CMS OPPS Rate,414.77,102,,,Fee Schedule,102% of WV Medicaid Rate,2153.38,165,,,Fee Schedule,165% of CMS OPPS Rate,1352.6,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,3748.66,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5141,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6439.62,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,406.64,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1305.07,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,206.01,14,,,percent of total billed charges,14% of total billed charges,206.01,6439.62,
40654-PF RPR LIP FULL THKNS >ONE-HALF VERT HEIGHT/COMPLE,4321654,CDM,981,RC,40654,HCPCS,Outpatient,,,819.46,409.73,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
40800- Vestibule mouth/drain abs/cyst/hem,3431103,CDM,510,RC,40800,HCPCS,Outpatient,,,502.29,251.15,,376.72,75,,,percent of total billed charges,75% of total billed charges,376.72,75,,,percent of total billed charges,75% of total billed charges,610.13,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1006.72,165,,,Fee Schedule,165% of CMS OPPS Rate,632.35,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1752.53,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2403.46,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,3010.58,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,610.13,100,,,Fee Schedule,100% of CMS OPPS Rate,632.35,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,70.32,14,,,percent of total billed charges,14% of total billed charges,70.32,3010.58,
40800-PF DRG ABSC CST HMTMA VESTIBULE MOUTH SMPL,4321450,CDM,981,RC,40800,HCPCS,Outpatient,,,221.3,110.65,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
40805- Foreign body remov/vest/mouth/comp,3431104,CDM,510,RC,40805,HCPCS,Outpatient,,,713.88,356.94,,535.41,75,,,percent of total billed charges,75% of total billed charges,535.41,75,,,percent of total billed charges,75% of total billed charges,429.48,100,,,Fee Schedule,100% of CMS OPPS Rate,148.5,102,,,Fee Schedule,102% of WV Medicaid Rate,708.64,165,,,Fee Schedule,165% of CMS OPPS Rate,445.12,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1233.63,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1691.83,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,2119.19,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,145.59,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,429.48,100,,,Fee Schedule,100% of CMS OPPS Rate,445.12,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,99.94,14,,,percent of total billed charges,14% of total billed charges,99.94,2119.19,
40806- Frenotomy,3431105,CDM,510,RC,40806,HCPCS,Outpatient,,,240.62,120.31,,180.47,75,,,percent of total billed charges,75% of total billed charges,180.47,75,,,percent of total billed charges,75% of total billed charges,429.48,100,,,Fee Schedule,100% of CMS OPPS Rate,71.79,102,,,Fee Schedule,102% of WV Medicaid Rate,708.64,165,,,Fee Schedule,165% of CMS OPPS Rate,445.12,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1233.63,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1691.83,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,2119.19,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,70.38,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,429.48,100,,,Fee Schedule,100% of CMS OPPS Rate,445.12,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,33.69,14,,,percent of total billed charges,14% of total billed charges,33.69,2119.19,
40808- Biopsy/vestibule of mouth,3431106,CDM,510,RC,40808,HCPCS,Outpatient,,,415.92,207.96,,311.94,75,,,percent of total billed charges,75% of total billed charges,311.94,75,,,percent of total billed charges,75% of total billed charges,429.48,100,,,Fee Schedule,100% of CMS OPPS Rate,106.19,102,,,Fee Schedule,102% of WV Medicaid Rate,708.64,165,,,Fee Schedule,165% of CMS OPPS Rate,445.12,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1233.63,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1691.83,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,2119.19,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,104.11,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,429.48,100,,,Fee Schedule,100% of CMS OPPS Rate,445.12,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,58.23,14,,,percent of total billed charges,14% of total billed charges,58.23,2119.19,
40810- Exc les/mucos/sub/ves mouth/no rpr,3431107,CDM,510,RC,40810,HCPCS,Outpatient,,,536.33,268.17,,402.25,75,,,percent of total billed charges,75% of total billed charges,402.25,75,,,percent of total billed charges,75% of total billed charges,2674.8,100,,,Fee Schedule,100% of CMS OPPS Rate,135.67,102,,,Fee Schedule,102% of WV Medicaid Rate,4413.39,165,,,Fee Schedule,165% of CMS OPPS Rate,2772.2,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,7682.99,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,10536.61,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13198.18,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,133.01,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2674.8,100,,,Fee Schedule,100% of CMS OPPS Rate,2772.2,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,75.09,14,,,percent of total billed charges,14% of total billed charges,75.09,13198.18,
40812- Exc les/mucos/sub/ves mouth/no rpr,3431108,CDM,510,RC,40812,HCPCS,Outpatient,,,714.69,357.35,,536.02,75,,,percent of total billed charges,75% of total billed charges,536.02,75,,,percent of total billed charges,75% of total billed charges,1305.07,100,,,Fee Schedule,100% of CMS OPPS Rate,162.16,102,,,Fee Schedule,102% of WV Medicaid Rate,2153.38,165,,,Fee Schedule,165% of CMS OPPS Rate,1352.6,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,3748.66,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5141,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6439.62,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,158.98,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1305.07,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,100.06,14,,,percent of total billed charges,14% of total billed charges,100.06,6439.62,
40814- Mouth vestibule bx/w complex rpr,3431109,CDM,510,RC,40814,HCPCS,Outpatient,,,937.99,469,,703.49,75,,,percent of total billed charges,75% of total billed charges,703.49,75,,,percent of total billed charges,75% of total billed charges,2674.8,100,,,Fee Schedule,100% of CMS OPPS Rate,874.26,102,,,Fee Schedule,102% of WV Medicaid Rate,4413.39,165,,,Fee Schedule,165% of CMS OPPS Rate,2772.2,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,7682.99,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,10536.61,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13198.18,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,857.12,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2674.8,100,,,Fee Schedule,100% of CMS OPPS Rate,2772.2,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,131.32,14,,,percent of total billed charges,14% of total billed charges,131.32,13198.18,
40819- Excision of frenum/labial/buccal,3431110,CDM,510,RC,40819,HCPCS,Outpatient,,,673.74,336.87,,505.31,75,,,percent of total billed charges,75% of total billed charges,505.31,75,,,percent of total billed charges,75% of total billed charges,1305.07,100,,,Fee Schedule,100% of CMS OPPS Rate,414.77,102,,,Fee Schedule,102% of WV Medicaid Rate,2153.38,165,,,Fee Schedule,165% of CMS OPPS Rate,1352.6,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,3748.66,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5141,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6439.62,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,406.64,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1305.07,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,94.32,14,,,percent of total billed charges,14% of total billed charges,94.32,6439.62,
40830- Close lac/mouth vest/2.5 cm or <,3431111,CDM,510,RC,40830,HCPCS,Outpatient,,,589.06,294.53,,441.8,75,,,percent of total billed charges,75% of total billed charges,441.8,75,,,percent of total billed charges,75% of total billed charges,195.39,100,,,Fee Schedule,100% of CMS OPPS Rate,86.35,102,,,Fee Schedule,102% of WV Medicaid Rate,322.39,165,,,Fee Schedule,165% of CMS OPPS Rate,202.5,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,561.23,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,769.7,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,964.12,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,84.66,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,195.39,100,,,Fee Schedule,100% of CMS OPPS Rate,202.5,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,82.47,14,,,percent of total billed charges,14% of total billed charges,82.47,964.12,
40830-PF CLOSURE LACERATION VESTIBULE MOUTH 2.5 CM/<,4321653,CDM,981,RC,40830,HCPCS,Outpatient,,,277.44,138.72,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
40831-PF CLOSURE LACERATION VESTIBULE MOUTH > 2.5 CM/CPL,4321652,CDM,981,RC,40831,HCPCS,Outpatient,,,383.24,191.62,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
41010- Incision/lingual frenum/frenotomy,3431113,CDM,510,RC,41010,HCPCS,Outpatient,,,540.19,270.1,,405.14,75,,,percent of total billed charges,75% of total billed charges,405.14,75,,,percent of total billed charges,75% of total billed charges,1305.07,100,,,Fee Schedule,100% of CMS OPPS Rate,414.77,102,,,Fee Schedule,102% of WV Medicaid Rate,2153.38,165,,,Fee Schedule,165% of CMS OPPS Rate,1352.6,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,3748.66,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5141,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6439.62,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,406.64,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1305.07,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,75.63,14,,,percent of total billed charges,14% of total billed charges,75.63,6439.62,
41100- Tongue biopsy/anterior two-thirds,3431114,CDM,510,RC,41100,HCPCS,Outpatient,,,469.05,234.53,,351.79,75,,,percent of total billed charges,75% of total billed charges,351.79,75,,,percent of total billed charges,75% of total billed charges,429.48,100,,,Fee Schedule,100% of CMS OPPS Rate,109.75,102,,,Fee Schedule,102% of WV Medicaid Rate,708.64,165,,,Fee Schedule,165% of CMS OPPS Rate,445.12,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1233.63,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1691.83,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,2119.19,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,107.6,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,429.48,100,,,Fee Schedule,100% of CMS OPPS Rate,445.12,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,65.67,14,,,percent of total billed charges,14% of total billed charges,65.67,2119.19,
41105- Tongue biopsy/posterior one-third,3431115,CDM,510,RC,41105,HCPCS,Outpatient,,,468.92,234.46,,351.69,75,,,percent of total billed charges,75% of total billed charges,351.69,75,,,percent of total billed charges,75% of total billed charges,2674.8,100,,,Fee Schedule,100% of CMS OPPS Rate,108.1,102,,,Fee Schedule,102% of WV Medicaid Rate,4413.39,165,,,Fee Schedule,165% of CMS OPPS Rate,2772.2,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,7682.99,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,10536.61,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13198.18,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,105.98,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2674.8,100,,,Fee Schedule,100% of CMS OPPS Rate,2772.2,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,65.65,14,,,percent of total billed charges,14% of total billed charges,65.65,13198.18,
41108- Biopsy/floor of mouth,3431116,CDM,510,RC,41108,HCPCS,Outpatient,,,415.92,207.96,,311.94,75,,,percent of total billed charges,75% of total billed charges,311.94,75,,,percent of total billed charges,75% of total billed charges,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,103.47,102,,,Fee Schedule,102% of WV Medicaid Rate,2326.19,165,,,Fee Schedule,165% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4049.52,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5553.61,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6956.46,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,101.44,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,58.23,14,,,percent of total billed charges,14% of total billed charges,58.23,6956.46,
41112- Ex tongue lesion/w clos/anter 2/3,3431117,CDM,510,RC,41112,HCPCS,Outpatient,,,848.3,424.15,,636.23,75,,,percent of total billed charges,75% of total billed charges,636.23,75,,,percent of total billed charges,75% of total billed charges,2674.8,100,,,Fee Schedule,100% of CMS OPPS Rate,874.26,102,,,Fee Schedule,102% of WV Medicaid Rate,4413.39,165,,,Fee Schedule,165% of CMS OPPS Rate,2772.2,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,7682.99,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,10536.61,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13198.18,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,857.12,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2674.8,100,,,Fee Schedule,100% of CMS OPPS Rate,2772.2,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,118.76,14,,,percent of total billed charges,14% of total billed charges,118.76,13198.18,
41115- Frenectomy,3431118,CDM,510,RC,41115,HCPCS,Outpatient,,,655.02,327.51,,491.27,75,,,percent of total billed charges,75% of total billed charges,491.27,75,,,percent of total billed charges,75% of total billed charges,1305.07,100,,,Fee Schedule,100% of CMS OPPS Rate,159.97,102,,,Fee Schedule,102% of WV Medicaid Rate,2153.38,165,,,Fee Schedule,165% of CMS OPPS Rate,1352.6,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,3748.66,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5141,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6439.62,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,156.83,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1305.07,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,91.7,14,,,percent of total billed charges,14% of total billed charges,91.7,6439.62,
41250-PF RPR LAC 2.5 CM/< MOUTH&/ANT TWO-THIRDS TONG,4321651,CDM,981,RC,41250,HCPCS,Outpatient,,,297.48,148.74,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
41251-PF RPR LAC 2.5 CM/< PST ONE-THIRD TONGUE,4321650,CDM,981,RC,41251,HCPCS,Outpatient,,,356.66,178.33,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
41252- Rpr lac/tong/mouth floor>2.6cm/com,3431119,CDM,510,RC,41252,HCPCS,Outpatient,,,833.68,416.84,,625.26,75,,,percent of total billed charges,75% of total billed charges,625.26,75,,,percent of total billed charges,75% of total billed charges,195.39,100,,,Fee Schedule,100% of CMS OPPS Rate,86.35,102,,,Fee Schedule,102% of WV Medicaid Rate,322.39,165,,,Fee Schedule,165% of CMS OPPS Rate,202.5,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,561.23,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,769.7,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,964.12,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,84.66,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,195.39,100,,,Fee Schedule,100% of CMS OPPS Rate,202.5,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,116.72,14,,,percent of total billed charges,14% of total billed charges,84.66,964.12,
41252-PF RPR LAC TONGUE FLOOR MOUTH > 2.6 CM/CPLX,4321649,CDM,981,RC,41252,HCPCS,Outpatient,,,408.18,204.09,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
41520- Frenoplasty/surgical revision,3431120,CDM,510,RC,41520,HCPCS,Outpatient,,,916.49,458.25,,687.37,75,,,percent of total billed charges,75% of total billed charges,687.37,75,,,percent of total billed charges,75% of total billed charges,2674.8,100,,,Fee Schedule,100% of CMS OPPS Rate,874.26,102,,,Fee Schedule,102% of WV Medicaid Rate,4413.39,165,,,Fee Schedule,165% of CMS OPPS Rate,2772.2,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,7682.99,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,10536.61,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13198.18,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,857.12,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2674.8,100,,,Fee Schedule,100% of CMS OPPS Rate,2772.2,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,128.31,14,,,percent of total billed charges,14% of total billed charges,128.31,13198.18,
41599-PF UNLISTED PROCEDURE TONGUE FLOOR MOUTH,4321451,CDM,981,RC,41599,HCPCS,Outpatient,,,587,293.5,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
41800- Dentoalveolar/drain abs/cyst/hema,3431122,CDM,510,RC,41800,HCPCS,Outpatient,,,715.33,357.67,,536.5,75,,,percent of total billed charges,75% of total billed charges,536.5,75,,,percent of total billed charges,75% of total billed charges,109.16,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,180.11,165,,,Fee Schedule,165% of CMS OPPS Rate,113.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,313.55,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,430.01,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,538.63,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,109.16,100,,,Fee Schedule,100% of CMS OPPS Rate,113.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,100.15,14,,,percent of total billed charges,14% of total billed charges,100.15,538.63,
41800-PF DRG ABSC CST HMTMA FROM DENTOALVEOLAR STRUXS,4321648,CDM,981,RC,41800,HCPCS,Outpatient,,,287.38,143.69,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
41821-PF OPRCULECTOMY EXC PRICORONAL TISSUE,4321452,CDM,981,RC,41821,HCPCS,Outpatient,,,113,56.5,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
41825-PF EXC LESION/TUMOR DENTOALVEOLAR STRUX W/O RPR,4321453,CDM,981,RC,41825,HCPCS,Outpatient,,,229.64,114.82,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
41872-PF GINGIVOPLASTY EACH QUADRANT SPECIFY,4321647,CDM,981,RC,41872,HCPCS,Outpatient,,,574.68,287.34,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
42000-PF DRAINAGE ABSCESS PALATE UVULA,4321454,CDM,981,RC,42000,HCPCS,Outpatient,,,207.96,103.98,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
42100- Biopsy/palate/uvula,3431124,CDM,510,RC,42100,HCPCS,Outpatient,,,370.84,185.42,,278.13,75,,,percent of total billed charges,75% of total billed charges,278.13,75,,,percent of total billed charges,75% of total billed charges,1305.07,100,,,Fee Schedule,100% of CMS OPPS Rate,78.07,102,,,Fee Schedule,102% of WV Medicaid Rate,2153.38,165,,,Fee Schedule,165% of CMS OPPS Rate,1352.6,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,3748.66,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5141,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6439.62,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,76.54,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1305.07,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,51.92,14,,,percent of total billed charges,14% of total billed charges,51.92,6439.62,
42104- Ex palate/uvula lesion w/o closure,3431125,CDM,510,RC,42104,HCPCS,Outpatient,,,541.44,270.72,,406.08,75,,,percent of total billed charges,75% of total billed charges,406.08,75,,,percent of total billed charges,75% of total billed charges,2674.8,100,,,Fee Schedule,100% of CMS OPPS Rate,125.03,102,,,Fee Schedule,102% of WV Medicaid Rate,4413.39,165,,,Fee Schedule,165% of CMS OPPS Rate,2772.2,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,7682.99,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,10536.61,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13198.18,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,122.58,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2674.8,100,,,Fee Schedule,100% of CMS OPPS Rate,2772.2,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,75.8,14,,,percent of total billed charges,14% of total billed charges,75.8,13198.18,
42140- Uvulectomy/excision of uvula,3431126,CDM,510,RC,42140,HCPCS,Outpatient,,,771.18,385.59,,578.39,75,,,percent of total billed charges,75% of total billed charges,578.39,75,,,percent of total billed charges,75% of total billed charges,2674.8,100,,,Fee Schedule,100% of CMS OPPS Rate,874.26,102,,,Fee Schedule,102% of WV Medicaid Rate,4413.39,165,,,Fee Schedule,165% of CMS OPPS Rate,2772.2,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,7682.99,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,10536.61,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13198.18,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,857.12,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2674.8,100,,,Fee Schedule,100% of CMS OPPS Rate,2772.2,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,107.97,14,,,percent of total billed charges,14% of total billed charges,107.97,13198.18,
42180- PF Repair Laceration Palate <2cm,4365276,CDM,960,RC,42180,HCPCS,Outpatient,,,360.42,180.21,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
42182 - PF Repair Laceration Palate >2cm/Complex,4311512,CDM,960,RC,42182,HCPCS,Outpatient,,,597.85,298.93,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
42330 Removal of salivary stone,3584870,CDM,960,RC,42330,HCPCS,Outpatient,,,589.6,294.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
"42400 Biopsy Salivary Gland, Needle",3584897,CDM,960,RC,42400,HCPCS,Outpatient,,,245.94,122.97,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
42405- Biopsy/salivary gland/incisional,3431128,CDM,510,RC,42405,HCPCS,Outpatient,,,771.22,385.61,,578.42,75,,,percent of total billed charges,75% of total billed charges,578.42,75,,,percent of total billed charges,75% of total billed charges,1305.07,100,,,Fee Schedule,100% of CMS OPPS Rate,414.77,102,,,Fee Schedule,102% of WV Medicaid Rate,2153.38,165,,,Fee Schedule,165% of CMS OPPS Rate,1352.6,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,3748.66,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5141,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6439.62,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,406.64,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1305.07,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,107.97,14,,,percent of total billed charges,14% of total billed charges,107.97,6439.62,
42410- Ex parot tum/lat lob/w/o ner disce,3431129,CDM,510,RC,42410,HCPCS,Outpatient,,,1645.09,822.55,,1233.82,75,,,percent of total billed charges,75% of total billed charges,1233.82,75,,,percent of total billed charges,75% of total billed charges,5020.17,100,,,Fee Schedule,100% of CMS OPPS Rate,1926.95,102,,,Fee Schedule,102% of WV Medicaid Rate,8283.28,165,,,Fee Schedule,165% of CMS OPPS Rate,5202.97,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,14419.76,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,19775.56,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,24770.9,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1889.17,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,5020.17,100,,,Fee Schedule,100% of CMS OPPS Rate,5202.97,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,230.31,14,,,percent of total billed charges,14% of total billed charges,230.31,24770.9,
42415- Ex parot tum/la lobe/presv fac ner,3431130,CDM,510,RC,42415,HCPCS,Outpatient,,,2773.94,1386.97,,2080.46,75,,,percent of total billed charges,75% of total billed charges,2080.46,75,,,percent of total billed charges,75% of total billed charges,5020.17,100,,,Fee Schedule,100% of CMS OPPS Rate,1926.95,102,,,Fee Schedule,102% of WV Medicaid Rate,8283.28,165,,,Fee Schedule,165% of CMS OPPS Rate,5202.97,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,14419.76,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,19775.56,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,24770.9,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1889.17,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,5020.17,100,,,Fee Schedule,100% of CMS OPPS Rate,5202.97,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,388.35,14,,,percent of total billed charges,14% of total billed charges,388.35,24770.9,
42420- Exc parot tum/tot/presv face nerv,3431131,CDM,510,RC,42420,HCPCS,Outpatient,,,3114.36,1557.18,,2335.77,75,,,percent of total billed charges,75% of total billed charges,2335.77,75,,,percent of total billed charges,75% of total billed charges,5020.17,100,,,Fee Schedule,100% of CMS OPPS Rate,1926.95,102,,,Fee Schedule,102% of WV Medicaid Rate,8283.28,165,,,Fee Schedule,165% of CMS OPPS Rate,5202.97,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,14419.76,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,19775.56,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,24770.9,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1889.17,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,5020.17,100,,,Fee Schedule,100% of CMS OPPS Rate,5202.97,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,436.01,14,,,percent of total billed charges,14% of total billed charges,436.01,24770.9,
42440- Excision of submandibular gland,3431132,CDM,510,RC,42440,HCPCS,Outpatient,,,1079.32,539.66,,809.49,75,,,percent of total billed charges,75% of total billed charges,809.49,75,,,percent of total billed charges,75% of total billed charges,5020.17,100,,,Fee Schedule,100% of CMS OPPS Rate,1926.95,102,,,Fee Schedule,102% of WV Medicaid Rate,8283.28,165,,,Fee Schedule,165% of CMS OPPS Rate,5202.97,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,14419.76,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,19775.56,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,24770.9,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1889.17,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,5020.17,100,,,Fee Schedule,100% of CMS OPPS Rate,5202.97,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,151.1,14,,,percent of total billed charges,14% of total billed charges,151.1,24770.9,
42450- Excision of sublingual gland,3431133,CDM,510,RC,42450,HCPCS,Outpatient,,,1197.84,598.92,,898.38,75,,,percent of total billed charges,75% of total billed charges,898.38,75,,,percent of total billed charges,75% of total billed charges,5020.17,100,,,Fee Schedule,100% of CMS OPPS Rate,1926.95,102,,,Fee Schedule,102% of WV Medicaid Rate,8283.28,165,,,Fee Schedule,165% of CMS OPPS Rate,5202.97,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,14419.76,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,19775.56,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,24770.9,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1889.17,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,5020.17,100,,,Fee Schedule,100% of CMS OPPS Rate,5202.97,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,167.7,14,,,percent of total billed charges,14% of total billed charges,167.7,24770.9,
42650- Dilation salivary duct,3431134,CDM,510,RC,42650,HCPCS,Outpatient,,,189.58,94.79,,142.19,75,,,percent of total billed charges,75% of total billed charges,142.19,75,,,percent of total billed charges,75% of total billed charges,1305.07,100,,,Fee Schedule,100% of CMS OPPS Rate,36.86,102,,,Fee Schedule,102% of WV Medicaid Rate,2153.38,165,,,Fee Schedule,165% of CMS OPPS Rate,1352.6,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,3748.66,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5141,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6439.62,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,36.14,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1305.07,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,26.54,14,,,percent of total billed charges,14% of total billed charges,26.54,6439.62,
42700- I & D abscess/peritonsillar,3431136,CDM,510,RC,42700,HCPCS,Outpatient,,,484.47,242.24,,363.35,75,,,percent of total billed charges,75% of total billed charges,363.35,75,,,percent of total billed charges,75% of total billed charges,195.39,100,,,Fee Schedule,100% of CMS OPPS Rate,86.35,102,,,Fee Schedule,102% of WV Medicaid Rate,322.39,165,,,Fee Schedule,165% of CMS OPPS Rate,202.5,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,561.23,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,769.7,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,964.12,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,84.66,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,195.39,100,,,Fee Schedule,100% of CMS OPPS Rate,202.5,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,67.83,14,,,percent of total billed charges,14% of total billed charges,67.83,964.12,
42700-PF I&D ABSCESS PERITONSILLAR,4321645,CDM,981,RC,42700,HCPCS,Outpatient,,,261.12,130.56,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
PHY-I&D ABSCESS PERITONSILLAR,3428509,CDM,981,RC,42700,HCPCS,Outpatient,,,484.47,242.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
42720- I & D abs/retro-paraphar/intraoral,3431137,CDM,510,RC,42720,HCPCS,Outpatient,,,1165.24,582.62,,873.93,75,,,percent of total billed charges,75% of total billed charges,873.93,75,,,percent of total billed charges,75% of total billed charges,2674.8,100,,,Fee Schedule,100% of CMS OPPS Rate,874.26,102,,,Fee Schedule,102% of WV Medicaid Rate,4413.39,165,,,Fee Schedule,165% of CMS OPPS Rate,2772.2,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,7682.99,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,10536.61,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13198.18,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,857.12,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2674.8,100,,,Fee Schedule,100% of CMS OPPS Rate,2772.2,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,163.13,14,,,percent of total billed charges,14% of total billed charges,163.13,13198.18,
42800- Biopsy/oropharyngeal,3431138,CDM,510,RC,42800,HCPCS,Outpatient,,,398.56,199.28,,298.92,75,,,percent of total billed charges,75% of total billed charges,298.92,75,,,percent of total billed charges,75% of total billed charges,1305.07,100,,,Fee Schedule,100% of CMS OPPS Rate,84.34,102,,,Fee Schedule,102% of WV Medicaid Rate,2153.38,165,,,Fee Schedule,165% of CMS OPPS Rate,1352.6,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,3748.66,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5141,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6439.62,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,82.69,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1305.07,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,55.8,14,,,percent of total billed charges,14% of total billed charges,55.8,6439.62,
42804- Bx/nasopharynx/visible lesion/simp,3431139,CDM,510,RC,42804,HCPCS,Outpatient,,,534.79,267.4,,401.09,75,,,percent of total billed charges,75% of total billed charges,401.09,75,,,percent of total billed charges,75% of total billed charges,2674.8,100,,,Fee Schedule,100% of CMS OPPS Rate,874.26,102,,,Fee Schedule,102% of WV Medicaid Rate,4413.39,165,,,Fee Schedule,165% of CMS OPPS Rate,2772.2,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,7682.99,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,10536.61,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13198.18,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,857.12,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2674.8,100,,,Fee Schedule,100% of CMS OPPS Rate,2772.2,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,74.87,14,,,percent of total billed charges,14% of total billed charges,74.87,13198.18,
42806- Bx nasopharynx/unknown pri lesion,3431140,CDM,510,RC,42806,HCPCS,Outpatient,,,597.02,298.51,,447.77,75,,,percent of total billed charges,75% of total billed charges,447.77,75,,,percent of total billed charges,75% of total billed charges,2674.8,100,,,Fee Schedule,100% of CMS OPPS Rate,874.26,102,,,Fee Schedule,102% of WV Medicaid Rate,4413.39,165,,,Fee Schedule,165% of CMS OPPS Rate,2772.2,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,7682.99,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,10536.61,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13198.18,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,857.12,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2674.8,100,,,Fee Schedule,100% of CMS OPPS Rate,2772.2,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,83.58,14,,,percent of total billed charges,14% of total billed charges,83.58,13198.18,
42809-PF Removal of foreign body from pharynx,4321455,CDM,981,RC,42809,HCPCS,Outpatient,,,246.54,123.27,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
42820- T & A < 12 yrs,3431141,CDM,510,RC,42820,HCPCS,Outpatient,,,753.79,376.9,,565.34,75,,,percent of total billed charges,75% of total billed charges,565.34,75,,,percent of total billed charges,75% of total billed charges,5020.17,100,,,Fee Schedule,100% of CMS OPPS Rate,1926.95,102,,,Fee Schedule,102% of WV Medicaid Rate,8283.28,165,,,Fee Schedule,165% of CMS OPPS Rate,5202.97,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,14419.76,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,19775.56,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,24770.9,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1889.17,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,5020.17,100,,,Fee Schedule,100% of CMS OPPS Rate,5202.97,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,105.53,14,,,percent of total billed charges,14% of total billed charges,105.53,24770.9,
42821- T & A/12 yrs or >,3431142,CDM,510,RC,42821,HCPCS,Outpatient,,,785.94,392.97,,589.46,75,,,percent of total billed charges,75% of total billed charges,589.46,75,,,percent of total billed charges,75% of total billed charges,2674.8,100,,,Fee Schedule,100% of CMS OPPS Rate,874.26,102,,,Fee Schedule,102% of WV Medicaid Rate,4413.39,165,,,Fee Schedule,165% of CMS OPPS Rate,2772.2,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,7682.99,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,10536.61,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13198.18,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,857.12,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2674.8,100,,,Fee Schedule,100% of CMS OPPS Rate,2772.2,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,110.03,14,,,percent of total billed charges,14% of total billed charges,110.03,13198.18,
42825- Tonsillectomy/pri/sec/<12 yrs,3431143,CDM,510,RC,42825,HCPCS,Outpatient,,,688.47,344.24,,516.35,75,,,percent of total billed charges,75% of total billed charges,516.35,75,,,percent of total billed charges,75% of total billed charges,5020.17,100,,,Fee Schedule,100% of CMS OPPS Rate,1926.95,102,,,Fee Schedule,102% of WV Medicaid Rate,8283.28,165,,,Fee Schedule,165% of CMS OPPS Rate,5202.97,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,14419.76,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,19775.56,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,24770.9,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1889.17,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,5020.17,100,,,Fee Schedule,100% of CMS OPPS Rate,5202.97,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,96.39,14,,,percent of total billed charges,14% of total billed charges,96.39,24770.9,
42826- Tonsillectomy/pri/sec/12 yrs or >,3431144,CDM,510,RC,42826,HCPCS,Outpatient,,,657.68,328.84,,493.26,75,,,percent of total billed charges,75% of total billed charges,493.26,75,,,percent of total billed charges,75% of total billed charges,2674.8,100,,,Fee Schedule,100% of CMS OPPS Rate,874.26,102,,,Fee Schedule,102% of WV Medicaid Rate,4413.39,165,,,Fee Schedule,165% of CMS OPPS Rate,2772.2,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,7682.99,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,10536.61,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13198.18,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,857.12,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2674.8,100,,,Fee Schedule,100% of CMS OPPS Rate,2772.2,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,92.08,14,,,percent of total billed charges,14% of total billed charges,92.08,13198.18,
42830- Adenoidectomy/primary/<12 yrs,3431145,CDM,510,RC,42830,HCPCS,Outpatient,,,542.72,271.36,,407.04,75,,,percent of total billed charges,75% of total billed charges,407.04,75,,,percent of total billed charges,75% of total billed charges,2674.8,100,,,Fee Schedule,100% of CMS OPPS Rate,874.26,102,,,Fee Schedule,102% of WV Medicaid Rate,4413.39,165,,,Fee Schedule,165% of CMS OPPS Rate,2772.2,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,7682.99,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,10536.61,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13198.18,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,857.12,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2674.8,100,,,Fee Schedule,100% of CMS OPPS Rate,2772.2,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,75.98,14,,,percent of total billed charges,14% of total billed charges,75.98,13198.18,
42831- Adenoidectomy/primary/12 yrs or >,3431146,CDM,510,RC,42831,HCPCS,Outpatient,,,587.76,293.88,,440.82,75,,,percent of total billed charges,75% of total billed charges,440.82,75,,,percent of total billed charges,75% of total billed charges,2674.8,100,,,Fee Schedule,100% of CMS OPPS Rate,874.26,102,,,Fee Schedule,102% of WV Medicaid Rate,4413.39,165,,,Fee Schedule,165% of CMS OPPS Rate,2772.2,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,7682.99,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,10536.61,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13198.18,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,857.12,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2674.8,100,,,Fee Schedule,100% of CMS OPPS Rate,2772.2,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,82.29,14,,,percent of total billed charges,14% of total billed charges,82.29,13198.18,
42900 - PF Suture Pharynx Wound/ Injury,4311513,CDM,960,RC,42900,HCPCS,Outpatient,,,771.91,385.96,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
42960- Control oropharyngeal hemorr/simp,3431147,CDM,510,RC,42960,HCPCS,Outpatient,,,418.87,209.44,,314.15,75,,,percent of total billed charges,75% of total billed charges,314.15,75,,,percent of total billed charges,75% of total billed charges,429.48,100,,,Fee Schedule,100% of CMS OPPS Rate,184.6,102,,,Fee Schedule,102% of WV Medicaid Rate,708.64,165,,,Fee Schedule,165% of CMS OPPS Rate,445.12,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1233.63,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1691.83,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,2119.19,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,180.98,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,429.48,100,,,Fee Schedule,100% of CMS OPPS Rate,445.12,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,58.64,14,,,percent of total billed charges,14% of total billed charges,58.64,2119.19,
42960-PF CONTROL OROPHARYNGEAL HEMORRHAGE SIMPLE,4321644,CDM,981,RC,42960,HCPCS,Outpatient,,,311.78,155.89,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
42961- Oropharyngeal hemorr/comp/hospital,3431148,CDM,510,RC,42961,HCPCS,Outpatient,,,1082.85,541.43,,812.14,75,,,percent of total billed charges,75% of total billed charges,812.14,75,,,percent of total billed charges,75% of total billed charges,1082.85,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,1082.85,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1082.85,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1082.85,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1082.85,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1082.85,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,1082.85,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1082.85,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,151.6,14,,,percent of total billed charges,14% of total billed charges,151.6,1082.85,
42961-PF CTRL OROPHARYNGEAL HEMORRHAGE COMP REQ HOSPITJ,4321643,CDM,981,RC,42961,HCPCS,Outpatient,,,813.46,406.73,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
42962- Oropharyngeal hemor/sec surg inter,3431149,CDM,510,RC,42962,HCPCS,Outpatient,,,1334.99,667.5,,1001.24,75,,,percent of total billed charges,75% of total billed charges,1001.24,75,,,percent of total billed charges,75% of total billed charges,2674.8,100,,,Fee Schedule,100% of CMS OPPS Rate,874.26,102,,,Fee Schedule,102% of WV Medicaid Rate,4413.39,165,,,Fee Schedule,165% of CMS OPPS Rate,2772.2,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,7682.99,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,10536.61,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13198.18,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,857.12,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2674.8,100,,,Fee Schedule,100% of CMS OPPS Rate,2772.2,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,186.9,14,,,percent of total billed charges,14% of total billed charges,186.9,13198.18,
42962-PF CTRL OROPHARYNGEAL HEMORRHAGE W/SEC SURG IVNTJ,4321642,CDM,981,RC,42962,HCPCS,Outpatient,,,1009.8,504.9,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
42970-PF CTRL NASOPHARYNGEAL HEMRRG SMPL W/PST NSL PACKS,4321640,CDM,981,RC,42970,HCPCS,Outpatient,,,799.36,399.68,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
42971-PF CTRL NASOPHARYNGEAL HEMRRG COMP REQ HOSPIZATION,4321641,CDM,981,RC,42971,HCPCS,Outpatient,,,882.38,441.19,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
42972-PF CTRL NASOPHARYNGEAL HEMORRHAGE W/SEC SURG IVNTJ,4321639,CDM,981,RC,42972,HCPCS,Outpatient,,,990.6,495.3,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
43130- Diverticulectomy/hypophar/esoph,3431152,CDM,510,RC,43130,HCPCS,Outpatient,,,2091.16,1045.58,,1568.37,75,,,percent of total billed charges,75% of total billed charges,1568.37,75,,,percent of total billed charges,75% of total billed charges,5020.17,100,,,Fee Schedule,100% of CMS OPPS Rate,1926.95,102,,,Fee Schedule,102% of WV Medicaid Rate,8283.28,165,,,Fee Schedule,165% of CMS OPPS Rate,5202.97,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,14419.76,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,19775.56,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,24770.9,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1889.17,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,5020.17,100,,,Fee Schedule,100% of CMS OPPS Rate,5202.97,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,292.76,14,,,percent of total billed charges,14% of total billed charges,292.76,24770.9,
43191- Esophagoscopy/rigid/diagnostic,3431153,CDM,510,RC,43191,HCPCS,Outpatient,,,403.39,201.7,,302.54,75,,,percent of total billed charges,75% of total billed charges,302.54,75,,,percent of total billed charges,75% of total billed charges,1637.37,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,2701.67,165,,,Fee Schedule,165% of CMS OPPS Rate,1697,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4703.14,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,6450,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,8079.28,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,1637.37,100,,,Fee Schedule,100% of CMS OPPS Rate,1697,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,56.47,14,,,percent of total billed charges,14% of total billed charges,56.47,8079.28,
43194- Esophagoscopy w/foreign body remov,3431154,CDM,510,RC,43194,HCPCS,Outpatient,,,512.21,256.11,,384.16,75,,,percent of total billed charges,75% of total billed charges,384.16,75,,,percent of total billed charges,75% of total billed charges,1637.37,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,2701.67,165,,,Fee Schedule,165% of CMS OPPS Rate,1697,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4703.14,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,6450,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,8079.28,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,1637.37,100,,,Fee Schedule,100% of CMS OPPS Rate,1697,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,71.71,14,,,percent of total billed charges,14% of total billed charges,71.71,8079.28,
43200 - PF Esophagoscopy Flexible Transoral Dx,4311514,CDM,960,RC,43200,HCPCS,Outpatient,,,202.4,101.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
43200- Esophagoscopy/flex/diagnostic,3431155,CDM,510,RC,43200,HCPCS,Outpatient,,,661.56,330.78,,496.17,75,,,percent of total billed charges,75% of total billed charges,496.17,75,,,percent of total billed charges,75% of total billed charges,776.11,100,,,Fee Schedule,100% of CMS OPPS Rate,330.28,102,,,Fee Schedule,102% of WV Medicaid Rate,1280.58,165,,,Fee Schedule,165% of CMS OPPS Rate,804.37,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,2229.28,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,3057.28,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,3829.56,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,323.8,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,776.11,100,,,Fee Schedule,100% of CMS OPPS Rate,804.37,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,92.62,14,,,percent of total billed charges,14% of total billed charges,92.62,3829.56,
43201- Esophagoscopy/submucosal injection,3431156,CDM,510,RC,43201,HCPCS,Outpatient,,,658.05,329.03,,493.54,75,,,percent of total billed charges,75% of total billed charges,493.54,75,,,percent of total billed charges,75% of total billed charges,1637.37,100,,,Fee Schedule,100% of CMS OPPS Rate,557.09,102,,,Fee Schedule,102% of WV Medicaid Rate,2701.67,165,,,Fee Schedule,165% of CMS OPPS Rate,1697,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4703.14,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,6450,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,8079.28,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,546.17,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1637.37,100,,,Fee Schedule,100% of CMS OPPS Rate,1697,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,92.13,14,,,percent of total billed charges,14% of total billed charges,92.13,8079.28,
43202 - PF Esophagoscopy Flexible Transoral w/ Bx,4311515,CDM,960,RC,43202,HCPCS,Outpatient,,,236.56,118.28,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
43202- Esophagoscopy/w bx/single/mult,3431157,CDM,510,RC,43202,HCPCS,Outpatient,,,903.77,451.89,,677.83,75,,,percent of total billed charges,75% of total billed charges,677.83,75,,,percent of total billed charges,75% of total billed charges,1637.37,100,,,Fee Schedule,100% of CMS OPPS Rate,557.09,102,,,Fee Schedule,102% of WV Medicaid Rate,2701.67,165,,,Fee Schedule,165% of CMS OPPS Rate,1697,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4703.14,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,6450,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,8079.28,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,546.17,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1637.37,100,,,Fee Schedule,100% of CMS OPPS Rate,1697,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,126.53,14,,,percent of total billed charges,14% of total billed charges,126.53,8079.28,
43204- Esophagoscopy/inj sclero/esoph var,3431158,CDM,510,RC,43204,HCPCS,Outpatient,,,349.38,174.69,,262.04,75,,,percent of total billed charges,75% of total billed charges,262.04,75,,,percent of total billed charges,75% of total billed charges,1637.37,100,,,Fee Schedule,100% of CMS OPPS Rate,557.09,102,,,Fee Schedule,102% of WV Medicaid Rate,2701.67,165,,,Fee Schedule,165% of CMS OPPS Rate,1697,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4703.14,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,6450,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,8079.28,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,546.17,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1637.37,100,,,Fee Schedule,100% of CMS OPPS Rate,1697,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,48.91,14,,,percent of total billed charges,14% of total billed charges,48.91,8079.28,
43205- Esophagoscopy/band ligat/esop vari,3431159,CDM,510,RC,43205,HCPCS,Outpatient,,,363.45,181.73,,272.59,75,,,percent of total billed charges,75% of total billed charges,272.59,75,,,percent of total billed charges,75% of total billed charges,1637.37,100,,,Fee Schedule,100% of CMS OPPS Rate,557.09,102,,,Fee Schedule,102% of WV Medicaid Rate,2701.67,165,,,Fee Schedule,165% of CMS OPPS Rate,1697,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4703.14,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,6450,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,8079.28,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,546.17,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1637.37,100,,,Fee Schedule,100% of CMS OPPS Rate,1697,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,50.88,14,,,percent of total billed charges,14% of total billed charges,50.88,8079.28,
43212- Esophagoscopy flex/transoral/stent placement,3431160,CDM,510,RC,43212,HCPCS,Outpatient,,,500.51,250.26,,375.38,75,,,percent of total billed charges,75% of total billed charges,375.38,75,,,percent of total billed charges,75% of total billed charges,4927.14,100,,,Fee Schedule,100% of CMS OPPS Rate,2630.31,102,,,Fee Schedule,102% of WV Medicaid Rate,8129.78,165,,,Fee Schedule,165% of CMS OPPS Rate,5106.56,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,14152.55,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,19409.09,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,24311.86,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,2578.74,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,4927.14,100,,,Fee Schedule,100% of CMS OPPS Rate,5106.56,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,70.07,14,,,percent of total billed charges,14% of total billed charges,70.07,24311.86,
43213 - PF Esophagoscopy Retro Dilate Balloon/ Other,4311516,CDM,960,RC,43213,HCPCS,Outpatient,,,606.04,303.02,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
43215 - Esophagoscopy Flexible Removal Foreign Body,3899035,CDM,983,RC,43215,HCPCS,Outpatient,,,1002.06,501.03,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
43215 - PF Esophagoscopy Flexible Removal Foreign Body,4311517,CDM,960,RC,43215,HCPCS,Outpatient,,,326.75,163.38,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
43216- Esophagoscopy/remov tum/hot bx for,3431161,CDM,510,RC,43216,HCPCS,Outpatient,,,1040.68,520.34,,780.51,75,,,percent of total billed charges,75% of total billed charges,780.51,75,,,percent of total billed charges,75% of total billed charges,1637.37,100,,,Fee Schedule,100% of CMS OPPS Rate,557.09,102,,,Fee Schedule,102% of WV Medicaid Rate,2701.67,165,,,Fee Schedule,165% of CMS OPPS Rate,1697,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4703.14,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,6450,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,8079.28,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,546.17,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1637.37,100,,,Fee Schedule,100% of CMS OPPS Rate,1697,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,145.7,14,,,percent of total billed charges,14% of total billed charges,145.7,8079.28,
43217- Esophagoscopy/remove tumor/snare,3431162,CDM,510,RC,43217,HCPCS,Outpatient,,,1069.64,534.82,,802.23,75,,,percent of total billed charges,75% of total billed charges,802.23,75,,,percent of total billed charges,75% of total billed charges,1637.37,100,,,Fee Schedule,100% of CMS OPPS Rate,557.09,102,,,Fee Schedule,102% of WV Medicaid Rate,2701.67,165,,,Fee Schedule,165% of CMS OPPS Rate,1697,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4703.14,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,6450,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,8079.28,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,546.17,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1637.37,100,,,Fee Schedule,100% of CMS OPPS Rate,1697,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,149.75,14,,,percent of total billed charges,14% of total billed charges,149.75,8079.28,
43220- Esophagoscopy/balloon dilat <30 mm,3431163,CDM,510,RC,43220,HCPCS,Outpatient,,,2266.97,1133.49,,1700.23,75,,,percent of total billed charges,75% of total billed charges,1700.23,75,,,percent of total billed charges,75% of total billed charges,1637.37,100,,,Fee Schedule,100% of CMS OPPS Rate,557.09,102,,,Fee Schedule,102% of WV Medicaid Rate,2701.67,165,,,Fee Schedule,165% of CMS OPPS Rate,1697,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4703.14,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,6450,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,8079.28,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,546.17,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1637.37,100,,,Fee Schedule,100% of CMS OPPS Rate,1697,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,317.38,14,,,percent of total billed charges,14% of total billed charges,317.38,8079.28,
43226- Esophagoscopy/dilator over GW,3431164,CDM,510,RC,43226,HCPCS,Outpatient,,,976.08,488.04,,732.06,75,,,percent of total billed charges,75% of total billed charges,732.06,75,,,percent of total billed charges,75% of total billed charges,1637.37,100,,,Fee Schedule,100% of CMS OPPS Rate,557.09,102,,,Fee Schedule,102% of WV Medicaid Rate,2701.67,165,,,Fee Schedule,165% of CMS OPPS Rate,1697,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4703.14,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,6450,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,8079.28,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,546.17,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1637.37,100,,,Fee Schedule,100% of CMS OPPS Rate,1697,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,136.65,14,,,percent of total billed charges,14% of total billed charges,136.65,8079.28,
43227- Esophagoscopy/w bleeding control,3431165,CDM,510,RC,43227,HCPCS,Outpatient,,,1508.4,754.2,,1131.3,75,,,percent of total billed charges,75% of total billed charges,1131.3,75,,,percent of total billed charges,75% of total billed charges,1637.37,100,,,Fee Schedule,100% of CMS OPPS Rate,557.09,102,,,Fee Schedule,102% of WV Medicaid Rate,2701.67,165,,,Fee Schedule,165% of CMS OPPS Rate,1697,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4703.14,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,6450,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,8079.28,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,546.17,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1637.37,100,,,Fee Schedule,100% of CMS OPPS Rate,1697,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,211.18,14,,,percent of total billed charges,14% of total billed charges,211.18,8079.28,
43229- Esophagoscopy/ablate tumor/polyp,3431166,CDM,360,RC,43229,HCPCS,Outpatient,,,1807.44,903.72,,1355.58,75,,,percent of total billed charges,75% of total billed charges,1355.58,75,,,percent of total billed charges,75% of total billed charges,3065.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1443.24,102,,,Fee Schedule,102% of WV Medicaid Rate,5058.21,165,,,Fee Schedule,165% of CMS OPPS Rate,3177.22,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8805.49,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,12076.02,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,15126.44,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1414.94,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,3065.58,100,,,Fee Schedule,100% of CMS OPPS Rate,3177.22,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,253.04,14,,,percent of total billed charges,14% of total billed charges,253.04,15126.44,
43231 - Esophagoscopy Ultrasound Exam,3896917,CDM,983,RC,43231,HCPCS,Outpatient,,,412.04,206.02,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
43232 - Esophagoscopy W/ US Needle Bx,3896923,CDM,983,RC,43232,HCPCS,Outpatient,,,519.47,259.74,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
"43233- Esophagogastroduodenoscopy, flexible, transoral; with dilation of esophagus with balloon (30",3621459,CDM,510,RC,43233,HCPCS,Outpatient,,,603.37,301.69,,452.53,75,,,percent of total billed charges,75% of total billed charges,452.53,75,,,percent of total billed charges,75% of total billed charges,1637.37,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,2701.67,165,,,Fee Schedule,165% of CMS OPPS Rate,1697,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4703.14,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,6450,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,8079.28,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,1637.37,100,,,Fee Schedule,100% of CMS OPPS Rate,1697,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,84.47,14,,,percent of total billed charges,14% of total billed charges,84.47,8079.28,
43233-PF EGD ESOPHAGUS BALLOON DILATION 30 MM OR LARGER,4321456,CDM,981,RC,43233,HCPCS,Outpatient,,,445.96,222.98,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
43235 - PF EGD Diagnostic Brush Wash,4311518,CDM,960,RC,43235,HCPCS,Outpatient,,,281.15,140.58,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
43235- EGD/flex/transoral/diag,3431167,CDM,510,RC,43235,HCPCS,Outpatient,,,752.89,376.45,,564.67,75,,,percent of total billed charges,75% of total billed charges,564.67,75,,,percent of total billed charges,75% of total billed charges,776.11,100,,,Fee Schedule,100% of CMS OPPS Rate,330.28,102,,,Fee Schedule,102% of WV Medicaid Rate,1280.58,165,,,Fee Schedule,165% of CMS OPPS Rate,804.37,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,2229.28,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,3057.28,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,3829.56,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,323.8,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,776.11,100,,,Fee Schedule,100% of CMS OPPS Rate,804.37,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,105.4,14,,,percent of total billed charges,14% of total billed charges,105.4,3829.56,
43235-PF ESOPHAGOGASTRODUODENOSCOPY TRANSORAL DIAGNOSTIC,4321461,CDM,981,RC,43235,HCPCS,Outpatient,,,236.82,118.41,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
43236- EGD/directed submucosal injection,3431168,CDM,510,RC,43236,HCPCS,Outpatient,,,1018.18,509.09,,763.64,75,,,percent of total billed charges,75% of total billed charges,763.64,75,,,percent of total billed charges,75% of total billed charges,776.11,100,,,Fee Schedule,100% of CMS OPPS Rate,330.28,102,,,Fee Schedule,102% of WV Medicaid Rate,1280.58,165,,,Fee Schedule,165% of CMS OPPS Rate,804.37,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,2229.28,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,3057.28,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,3829.56,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,323.8,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,776.11,100,,,Fee Schedule,100% of CMS OPPS Rate,804.37,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,142.55,14,,,percent of total billed charges,14% of total billed charges,142.55,3829.56,
43237 - Endoscopic US Exam Esoph,3899036,CDM,983,RC,43237,HCPCS,Outpatient,,,510.01,255.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
43238 - EGD US Fine Needle Bx/Aspir,3899037,CDM,983,RC,43238,HCPCS,Outpatient,,,603.48,301.74,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
43239 - PF EGD Transoral Bx Sngl/ Mult,4311519,CDM,960,RC,43239,HCPCS,Outpatient,,,317.34,158.67,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
43239- EGD w/biopsy/single/multiple,3431169,CDM,510,RC,43239,HCPCS,Outpatient,,,958,479,,718.5,75,,,percent of total billed charges,75% of total billed charges,718.5,75,,,percent of total billed charges,75% of total billed charges,776.11,100,,,Fee Schedule,100% of CMS OPPS Rate,330.28,102,,,Fee Schedule,102% of WV Medicaid Rate,1280.58,165,,,Fee Schedule,165% of CMS OPPS Rate,804.37,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,2229.28,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,3057.28,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,3829.56,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,323.8,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,776.11,100,,,Fee Schedule,100% of CMS OPPS Rate,804.37,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,134.12,14,,,percent of total billed charges,14% of total billed charges,134.12,3829.56,
43240 - EGD W/ Transmural Drain Cyst,3899038,CDM,983,RC,43240,HCPCS,Outpatient,,,1022.27,511.14,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
43241 - PF EGD Intraluminal Tube/ Cath Insertion,4311520,CDM,960,RC,43241,HCPCS,Outpatient,,,325.72,162.86,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
43241- EGD/insert intraluminal tube/cath,3431170,CDM,510,RC,43241,HCPCS,Outpatient,,,371.51,185.76,,278.63,75,,,percent of total billed charges,75% of total billed charges,278.63,75,,,percent of total billed charges,75% of total billed charges,1637.37,100,,,Fee Schedule,100% of CMS OPPS Rate,557.09,102,,,Fee Schedule,102% of WV Medicaid Rate,2701.67,165,,,Fee Schedule,165% of CMS OPPS Rate,1697,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4703.14,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,6450,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,8079.28,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,546.17,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1637.37,100,,,Fee Schedule,100% of CMS OPPS Rate,1697,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,52.01,14,,,percent of total billed charges,14% of total billed charges,52.01,8079.28,
43242- EGD/transendoscopic US needle asp,3431171,CDM,510,RC,43242,HCPCS,Outpatient,,,685.29,342.65,,513.97,75,,,percent of total billed charges,75% of total billed charges,513.97,75,,,percent of total billed charges,75% of total billed charges,1637.37,100,,,Fee Schedule,100% of CMS OPPS Rate,557.09,102,,,Fee Schedule,102% of WV Medicaid Rate,2701.67,165,,,Fee Schedule,165% of CMS OPPS Rate,1697,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4703.14,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,6450,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,8079.28,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,546.17,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1637.37,100,,,Fee Schedule,100% of CMS OPPS Rate,1697,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,95.94,14,,,percent of total billed charges,14% of total billed charges,95.94,8079.28,
43243- EGD/inj scleros/esoph/gast varices,3431172,CDM,510,RC,43243,HCPCS,Outpatient,,,618.64,309.32,,463.98,75,,,percent of total billed charges,75% of total billed charges,463.98,75,,,percent of total billed charges,75% of total billed charges,1637.37,100,,,Fee Schedule,100% of CMS OPPS Rate,557.09,102,,,Fee Schedule,102% of WV Medicaid Rate,2701.67,165,,,Fee Schedule,165% of CMS OPPS Rate,1697,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4703.14,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,6450,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,8079.28,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,546.17,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1637.37,100,,,Fee Schedule,100% of CMS OPPS Rate,1697,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,86.61,14,,,percent of total billed charges,14% of total billed charges,86.61,8079.28,
43244- EGD/ band ligat esoph/gast varices,3431173,CDM,510,RC,43244,HCPCS,Outpatient,,,637.57,318.79,,478.18,75,,,percent of total billed charges,75% of total billed charges,478.18,75,,,percent of total billed charges,75% of total billed charges,1637.37,100,,,Fee Schedule,100% of CMS OPPS Rate,557.09,102,,,Fee Schedule,102% of WV Medicaid Rate,2701.67,165,,,Fee Schedule,165% of CMS OPPS Rate,1697,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4703.14,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,6450,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,8079.28,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,546.17,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1637.37,100,,,Fee Schedule,100% of CMS OPPS Rate,1697,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,89.26,14,,,percent of total billed charges,14% of total billed charges,89.26,8079.28,
43245 - PF EGD Dilation Gastric/ Duodenal Stricture,4311521,CDM,960,RC,43245,HCPCS,Outpatient,,,405.81,202.91,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
43245- EGD/dilation gastric/duoden strict,3431174,CDM,510,RC,43245,HCPCS,Outpatient,,,1513.85,756.93,,1135.39,75,,,percent of total billed charges,75% of total billed charges,1135.39,75,,,percent of total billed charges,75% of total billed charges,1637.37,100,,,Fee Schedule,100% of CMS OPPS Rate,557.09,102,,,Fee Schedule,102% of WV Medicaid Rate,2701.67,165,,,Fee Schedule,165% of CMS OPPS Rate,1697,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4703.14,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,6450,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,8079.28,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,546.17,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1637.37,100,,,Fee Schedule,100% of CMS OPPS Rate,1697,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,211.94,14,,,percent of total billed charges,14% of total billed charges,211.94,8079.28,
43246 - PF EGD Percut Plcmnt Gastrostomy Tube,4311522,CDM,960,RC,43246,HCPCS,Outpatient,,,465.31,232.66,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
43246- EGD/perc gastrostomy tube place,3431175,CDM,510,RC,43246,HCPCS,Outpatient,,,526.31,263.16,,394.73,75,,,percent of total billed charges,75% of total billed charges,394.73,75,,,percent of total billed charges,75% of total billed charges,1637.37,100,,,Fee Schedule,100% of CMS OPPS Rate,557.09,102,,,Fee Schedule,102% of WV Medicaid Rate,2701.67,165,,,Fee Schedule,165% of CMS OPPS Rate,1697,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4703.14,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,6450,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,8079.28,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,546.17,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1637.37,100,,,Fee Schedule,100% of CMS OPPS Rate,1697,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,73.68,14,,,percent of total billed charges,14% of total billed charges,73.68,8079.28,
43247 - PF EGD Flexible Foreign Body Removal,4311523,CDM,960,RC,43247,HCPCS,Outpatient,,,407.23,203.62,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
43247- EGD/foreign body removal,3431176,CDM,510,RC,43247,HCPCS,Outpatient,,,980.63,490.32,,735.47,75,,,percent of total billed charges,75% of total billed charges,735.47,75,,,percent of total billed charges,75% of total billed charges,776.11,100,,,Fee Schedule,100% of CMS OPPS Rate,330.28,102,,,Fee Schedule,102% of WV Medicaid Rate,1280.58,165,,,Fee Schedule,165% of CMS OPPS Rate,804.37,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,2229.28,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,3057.28,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,3829.56,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,323.8,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,776.11,100,,,Fee Schedule,100% of CMS OPPS Rate,804.37,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,137.29,14,,,percent of total billed charges,14% of total billed charges,137.29,3829.56,
43247-PF EGD FLEXIBLE FOREIGN BODY REMOVAL,4321638,CDM,981,RC,43247,HCPCS,Outpatient,,,343.02,171.51,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
43248- EGD/dilator over guide wire,3431177,CDM,510,RC,43248,HCPCS,Outpatient,,,1051.95,525.98,,788.96,75,,,percent of total billed charges,75% of total billed charges,788.96,75,,,percent of total billed charges,75% of total billed charges,776.11,100,,,Fee Schedule,100% of CMS OPPS Rate,330.28,102,,,Fee Schedule,102% of WV Medicaid Rate,1280.58,165,,,Fee Schedule,165% of CMS OPPS Rate,804.37,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,2229.28,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,3057.28,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,3829.56,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,323.8,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,776.11,100,,,Fee Schedule,100% of CMS OPPS Rate,804.37,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,147.27,14,,,percent of total billed charges,14% of total billed charges,147.27,3829.56,
43248-PF EGD Guid Wire Insertion,4322106,CDM,960,RC,43248,HCPCS,Outpatient,,,314.58,157.29,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
43249 - PF EGD Balloon Dilation Esophagus <30 mm Diam,4311524,CDM,960,RC,43249,HCPCS,Outpatient,,,308.35,154.18,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
43249- PF EGD w/ balloon dilation/<30 mm,3431178,CDM,983,RC,43249,HCPCS,Outpatient,,,308.35,154.18,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
43250 - PF EGD Flex Removal Lesion(s0 by Hot Bx Forceps,4311525,CDM,960,RC,43250,HCPCS,Outpatient,,,393.48,196.74,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
43250- EGD/remov tum/polyp/hot bx forcep,3431179,CDM,510,RC,43250,HCPCS,Outpatient,,,1155.05,577.53,,866.29,75,,,percent of total billed charges,75% of total billed charges,866.29,75,,,percent of total billed charges,75% of total billed charges,1637.37,100,,,Fee Schedule,100% of CMS OPPS Rate,557.09,102,,,Fee Schedule,102% of WV Medicaid Rate,2701.67,165,,,Fee Schedule,165% of CMS OPPS Rate,1697,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4703.14,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,6450,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,8079.28,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,546.17,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1637.37,100,,,Fee Schedule,100% of CMS OPPS Rate,1697,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,161.71,14,,,percent of total billed charges,14% of total billed charges,161.71,8079.28,
43251 - PF EGD Remove Lesion Snare,4311526,CDM,960,RC,43251,HCPCS,Outpatient,,,450.68,225.34,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
43251- EGD/remove tumor/polyp/w snare,3431180,CDM,510,RC,43251,HCPCS,Outpatient,,,1266.76,633.38,,950.07,75,,,percent of total billed charges,75% of total billed charges,950.07,75,,,percent of total billed charges,75% of total billed charges,1637.37,100,,,Fee Schedule,100% of CMS OPPS Rate,557.09,102,,,Fee Schedule,102% of WV Medicaid Rate,2701.67,165,,,Fee Schedule,165% of CMS OPPS Rate,1697,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4703.14,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,6450,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,8079.28,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,546.17,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1637.37,100,,,Fee Schedule,100% of CMS OPPS Rate,1697,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,177.35,14,,,percent of total billed charges,14% of total billed charges,177.35,8079.28,
43253 - PF EGD US Guided Transmural Inj/Fiduc Mrkr,4361841,CDM,960,RC,43253,HCPCS,Outpatient,,,504.3,252.15,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
43254 - EGD Endo Mucosal Resection,3899039,CDM,983,RC,43254,HCPCS,Outpatient,,,706.52,353.26,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
43255 - PF EGD Transoral Control Bleeding Any Method,4311527,CDM,960,RC,43255,HCPCS,Outpatient,,,459.68,229.84,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
43255- EGD/control bleeding/any method,3431181,CDM,510,RC,43255,HCPCS,Outpatient,,,1597.19,798.6,,1197.89,75,,,percent of total billed charges,75% of total billed charges,1197.89,75,,,percent of total billed charges,75% of total billed charges,1637.37,100,,,Fee Schedule,100% of CMS OPPS Rate,557.09,102,,,Fee Schedule,102% of WV Medicaid Rate,2701.67,165,,,Fee Schedule,165% of CMS OPPS Rate,1697,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4703.14,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,6450,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,8079.28,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,546.17,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1637.37,100,,,Fee Schedule,100% of CMS OPPS Rate,1697,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,223.61,14,,,percent of total billed charges,14% of total billed charges,223.61,8079.28,
43257- EGD/themal energy/reflux disease,3431182,CDM,510,RC,43257,HCPCS,Outpatient,,,611.86,305.93,,458.9,75,,,percent of total billed charges,75% of total billed charges,458.9,75,,,percent of total billed charges,75% of total billed charges,3065.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1103.64,102,,,Fee Schedule,102% of WV Medicaid Rate,5058.21,165,,,Fee Schedule,165% of CMS OPPS Rate,3177.22,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8805.49,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,12076.02,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,15126.44,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1082,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,3065.58,100,,,Fee Schedule,100% of CMS OPPS Rate,3177.22,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,85.66,14,,,percent of total billed charges,14% of total billed charges,85.66,15126.44,
43259- PF EGD/US/esoph/sto/duod/surg alt sto,3431184,CDM,983,RC,43259,HCPCS,Outpatient,,,451.67,225.84,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
43260- ERCP/diagnostic,3431185,CDM,510,RC,43260,HCPCS,Outpatient,,,841.39,420.7,,631.04,75,,,percent of total billed charges,75% of total billed charges,631.04,75,,,percent of total billed charges,75% of total billed charges,3065.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1103.64,102,,,Fee Schedule,102% of WV Medicaid Rate,5058.21,165,,,Fee Schedule,165% of CMS OPPS Rate,3177.22,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8805.49,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,12076.02,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,15126.44,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1082,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,3065.58,100,,,Fee Schedule,100% of CMS OPPS Rate,3177.22,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,117.79,14,,,percent of total billed charges,14% of total billed charges,117.79,15126.44,
43261 - PF ERCP W/ Bx Sngl/ Multiple,4311528,CDM,960,RC,43261,HCPCS,Outpatient,,,778.54,389.27,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
43261- ERCP w/ biopsy/single/multiple,3431186,CDM,510,RC,43261,HCPCS,Outpatient,,,882.26,441.13,,661.7,75,,,percent of total billed charges,75% of total billed charges,661.7,75,,,percent of total billed charges,75% of total billed charges,3065.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1103.64,102,,,Fee Schedule,102% of WV Medicaid Rate,5058.21,165,,,Fee Schedule,165% of CMS OPPS Rate,3177.22,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8805.49,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,12076.02,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,15126.44,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1082,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,3065.58,100,,,Fee Schedule,100% of CMS OPPS Rate,3177.22,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,123.52,14,,,percent of total billed charges,14% of total billed charges,123.52,15126.44,
43262- ERCP/sphincterotomy/papillotomy,3431187,CDM,510,RC,43262,HCPCS,Outpatient,,,933.72,466.86,,700.29,75,,,percent of total billed charges,75% of total billed charges,700.29,75,,,percent of total billed charges,75% of total billed charges,3065.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1103.64,102,,,Fee Schedule,102% of WV Medicaid Rate,5058.21,165,,,Fee Schedule,165% of CMS OPPS Rate,3177.22,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8805.49,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,12076.02,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,15126.44,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1082,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,3065.58,100,,,Fee Schedule,100% of CMS OPPS Rate,3177.22,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,130.72,14,,,percent of total billed charges,14% of total billed charges,130.72,15126.44,
43264- ERCP/remov calc/debri/bili/pan duc,3431188,CDM,510,RC,43264,HCPCS,Outpatient,,,949.62,474.81,,712.22,75,,,percent of total billed charges,75% of total billed charges,712.22,75,,,percent of total billed charges,75% of total billed charges,3065.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1103.64,102,,,Fee Schedule,102% of WV Medicaid Rate,5058.21,165,,,Fee Schedule,165% of CMS OPPS Rate,3177.22,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8805.49,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,12076.02,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,15126.44,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1082,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,3065.58,100,,,Fee Schedule,100% of CMS OPPS Rate,3177.22,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,132.95,14,,,percent of total billed charges,14% of total billed charges,132.95,15126.44,
43265- ERCP w/destruction of calculi,3431189,CDM,510,RC,43265,HCPCS,Outpatient,,,1133.49,566.75,,850.12,75,,,percent of total billed charges,75% of total billed charges,850.12,75,,,percent of total billed charges,75% of total billed charges,4927.14,100,,,Fee Schedule,100% of CMS OPPS Rate,1662.64,102,,,Fee Schedule,102% of WV Medicaid Rate,8129.78,165,,,Fee Schedule,165% of CMS OPPS Rate,5106.56,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,14152.55,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,19409.09,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,24311.86,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1630.04,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,4927.14,100,,,Fee Schedule,100% of CMS OPPS Rate,5106.56,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,158.69,14,,,percent of total billed charges,14% of total billed charges,158.69,24311.86,
43266 -PF EGD Endoscopic Stent Place,3899040,CDM,983,RC,43266,HCPCS,Outpatient,,,438.71,219.36,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
43266-PF EGD Endoscopic Stent Place,4322107,CDM,960,RC,43266,HCPCS,Outpatient,,,438.71,219.36,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
43270 - PF EGD Ablate Tumor Polyp/ Les w/  Dilat & Wire,4311529,CDM,960,RC,43270,HCPCS,Outpatient,,,514.82,257.41,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
43270- EGD w/ablation/tumor/polyp/lesion,3431192,CDM,510,RC,43270,HCPCS,Outpatient,,,1858.29,929.15,,1393.72,75,,,percent of total billed charges,75% of total billed charges,1393.72,75,,,percent of total billed charges,75% of total billed charges,1637.37,100,,,Fee Schedule,100% of CMS OPPS Rate,557.09,102,,,Fee Schedule,102% of WV Medicaid Rate,2701.67,165,,,Fee Schedule,165% of CMS OPPS Rate,1697,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4703.14,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,6450,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,8079.28,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,546.17,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1637.37,100,,,Fee Schedule,100% of CMS OPPS Rate,1697,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,260.16,14,,,percent of total billed charges,14% of total billed charges,260.16,8079.28,
43273- PF Endoscop can/pap/vis panc/bile duc,3431194,CDM,983,RC,43273,HCPCS,Outpatient,,,239.39,119.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
43274- PF ERCP w/stent placement/ea stent,3431195,CDM,983,RC,43274,HCPCS,Outpatient,,,928.98,464.49,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
43275- ERCP w/foreign body/stent removal,3431196,CDM,510,RC,43275,HCPCS,Outpatient,,,982.01,491.01,,736.51,75,,,percent of total billed charges,75% of total billed charges,736.51,75,,,percent of total billed charges,75% of total billed charges,3065.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1103.64,102,,,Fee Schedule,102% of WV Medicaid Rate,5058.21,165,,,Fee Schedule,165% of CMS OPPS Rate,3177.22,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8805.49,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,12076.02,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,15126.44,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1082,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,3065.58,100,,,Fee Schedule,100% of CMS OPPS Rate,3177.22,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,137.48,14,,,percent of total billed charges,14% of total billed charges,137.48,15126.44,
43276- ERCP/remov/exch stent/bili/panc/ea,3431197,CDM,510,RC,43276,HCPCS,Outpatient,,,1258.74,629.37,,944.06,75,,,percent of total billed charges,75% of total billed charges,944.06,75,,,percent of total billed charges,75% of total billed charges,4927.14,100,,,Fee Schedule,100% of CMS OPPS Rate,2219.25,102,,,Fee Schedule,102% of WV Medicaid Rate,8129.78,165,,,Fee Schedule,165% of CMS OPPS Rate,5106.56,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,14152.55,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,19409.09,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,24311.86,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,2175.74,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,4927.14,100,,,Fee Schedule,100% of CMS OPPS Rate,5106.56,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,176.22,14,,,percent of total billed charges,14% of total billed charges,176.22,24311.86,
43277- ERCP/endoscop balloon dil/ea duct,3431198,CDM,510,RC,43277,HCPCS,Outpatient,,,988.05,494.03,,741.04,75,,,percent of total billed charges,75% of total billed charges,741.04,75,,,percent of total billed charges,75% of total billed charges,3065.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1103.64,102,,,Fee Schedule,102% of WV Medicaid Rate,5058.21,165,,,Fee Schedule,165% of CMS OPPS Rate,3177.22,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8805.49,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,12076.02,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,15126.44,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1082,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,3065.58,100,,,Fee Schedule,100% of CMS OPPS Rate,3177.22,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,138.33,14,,,percent of total billed charges,14% of total billed charges,138.33,15126.44,
"43278 - ERCP w/ ablation of tumor(s), polyp(s), other lesion(s), including pre/post dilation and gui",3783104,CDM,983,RC,43278,HCPCS,Outpatient,,,1131.78,565.89,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
"43279 - (PF) Laparoscopy, surgical, esophagomyotomy (Heller type), with fundoplasty, when",3634912,CDM,510,RC,43279,HCPCS,Outpatient,,,3475.34,1737.67,,2606.51,75,,,percent of total billed charges,75% of total billed charges,2606.51,75,,,percent of total billed charges,75% of total billed charges,3475.34,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,3475.34,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3475.34,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3475.34,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3475.34,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3475.34,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,3475.34,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3475.34,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,486.55,14,,,percent of total billed charges,14% of total billed charges,486.55,3475.34,
43279-PF Laparoscopy Myotomy Heller,4322108,CDM,960,RC,43279,HCPCS,Outpatient,,,2536.28,1268.14,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
43280 - PF Laps Surg Esopg/ Gstr Fundoplasty,4311530,CDM,960,RC,43280,HCPCS,Outpatient,,,2573.99,1287,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
"43280-Laparoscopy, surgical, esophagogastric fundoplasty (eg, Nissen, Toupet procedures)",3622755,CDM,510,RC,43280,HCPCS,Outpatient,,,2914.67,1457.34,,2186,75,,,percent of total billed charges,75% of total billed charges,2186,75,,,percent of total billed charges,75% of total billed charges,8543.54,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,14096.88,165,,,Fee Schedule,165% of CMS OPPS Rate,8854.68,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,24540.24,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,33654.98,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,42156.28,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,8543.54,100,,,Fee Schedule,100% of CMS OPPS Rate,8854.68,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,408.05,14,,,percent of total billed charges,14% of total billed charges,408.05,42156.28,
43281 - PF Laps Rpr Paraesphgl Hrna Incl Fundplsty w/ o Mesh,4311694,CDM,960,RC,43281,HCPCS,Outpatient,,,3683.17,1841.59,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
43281- Lap/surg/rpr paraeso hern w/o mesh,3431199,CDM,510,RC,43281,HCPCS,Outpatient,,,4171.5,2085.75,,3128.63,75,,,percent of total billed charges,75% of total billed charges,3128.63,75,,,percent of total billed charges,75% of total billed charges,8543.54,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,14096.88,165,,,Fee Schedule,165% of CMS OPPS Rate,8854.68,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,24540.24,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,33654.98,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,42156.28,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,8543.54,100,,,Fee Schedule,100% of CMS OPPS Rate,8854.68,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,584.01,14,,,percent of total billed charges,14% of total billed charges,584.01,42156.28,
43282 - PF Laps Rpr Paraesphgl Hrna Incl Fundplasty w/  Mesh,4311695,CDM,960,RC,43282,HCPCS,Outpatient,,,4145.47,2072.74,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
43282- Lap/surg/rpr paraesoph hernia/mesh,3431200,CDM,510,RC,43282,HCPCS,Outpatient,,,4693.46,2346.73,,3520.1,75,,,percent of total billed charges,75% of total billed charges,3520.1,75,,,percent of total billed charges,75% of total billed charges,8543.54,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,14096.88,165,,,Fee Schedule,165% of CMS OPPS Rate,8854.68,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,24540.24,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,33654.98,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,42156.28,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,8543.54,100,,,Fee Schedule,100% of CMS OPPS Rate,8854.68,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,657.08,14,,,percent of total billed charges,14% of total billed charges,657.08,42156.28,
43283 - PF Laps Esophageal Lengthening Addl,4311696,CDM,960,RC,43283,HCPCS,Outpatient,,,378.53,189.27,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
43287-PF Esophagetomy Distal 2/3 w/Laps Mobl,4322109,CDM,960,RC,43287,HCPCS,Outpatient,,,6985.4,3492.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
43289 - PF Unlisted Laparoscopic Procedure Esophagus,4311697,CDM,960,RC,43289,HCPCS,Outpatient,,,2374.4,1187.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
43327- EG fundoplasty partial or complete;laparotomy,3569396,CDM,510,RC,43327,HCPCS,Outpatient,,,2207.82,1103.91,,1655.87,75,,,percent of total billed charges,75% of total billed charges,1655.87,75,,,percent of total billed charges,75% of total billed charges,2207.82,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,2207.82,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2207.82,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2207.82,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2207.82,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2207.82,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,2207.82,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2207.82,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,309.09,14,,,percent of total billed charges,14% of total billed charges,309.09,2207.82,
43332- Lap rp/paraeso hiatal hern no mesh,3431201,CDM,510,RC,43332,HCPCS,Outpatient,,,3108.8,1554.4,,2331.6,75,,,percent of total billed charges,75% of total billed charges,2331.6,75,,,percent of total billed charges,75% of total billed charges,3108.8,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,3108.8,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3108.8,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3108.8,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3108.8,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3108.8,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,3108.8,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3108.8,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,435.23,14,,,percent of total billed charges,14% of total billed charges,435.23,3108.8,
43333 - PF Lapt Rpr Paraesoph Hiatal Hernia w/  Mesh,4311698,CDM,960,RC,43333,HCPCS,Outpatient,,,3000.53,1500.27,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
43333- Lap rpr/paraesoph hiatal hern/mesh,3431202,CDM,510,RC,43333,HCPCS,Outpatient,,,3396.6,1698.3,,2547.45,75,,,percent of total billed charges,75% of total billed charges,2547.45,75,,,percent of total billed charges,75% of total billed charges,3396.6,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,3396.6,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3396.6,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3396.6,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3396.6,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3396.6,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,3396.6,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3396.6,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,475.52,14,,,percent of total billed charges,14% of total billed charges,475.52,3396.6,
43415- Esophageal wnd sut/trans thor-abd,3431203,CDM,510,RC,43415,HCPCS,Outpatient,,,6866.34,3433.17,,5149.76,75,,,percent of total billed charges,75% of total billed charges,5149.76,75,,,percent of total billed charges,75% of total billed charges,6866.34,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,6866.34,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6866.34,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6866.34,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6866.34,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6866.34,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,6866.34,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6866.34,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,961.29,14,,,percent of total billed charges,14% of total billed charges,961.29,6866.34,
43450 - PF Dilation Esoph Unguided Sound/ Bougie 1/ Mult Pass,4311699,CDM,960,RC,43450,HCPCS,Outpatient,,,183.28,91.64,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
43450- Dilate esoph/unguide sound/bougie,3431204,CDM,510,RC,43450,HCPCS,Outpatient,,,471.99,236,,353.99,75,,,percent of total billed charges,75% of total billed charges,353.99,75,,,percent of total billed charges,75% of total billed charges,776.11,100,,,Fee Schedule,100% of CMS OPPS Rate,330.28,102,,,Fee Schedule,102% of WV Medicaid Rate,1280.58,165,,,Fee Schedule,165% of CMS OPPS Rate,804.37,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,2229.28,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,3057.28,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,3829.56,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,323.8,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,776.11,100,,,Fee Schedule,100% of CMS OPPS Rate,804.37,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,66.08,14,,,percent of total billed charges,14% of total billed charges,66.08,3829.56,
"43453 - Dilation of esophagus, over guide wire",3572802,CDM,983,RC,43453,HCPCS,Outpatient,,,2015.45,1007.73,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
43460-PF ESOPG/GSTR TAMPONADE W/BALO SENGSTAKEN TYPE,4321462,CDM,981,RC,43460,HCPCS,Outpatient,,,411.18,205.59,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
43497 - PF Per Oral Endoscopic Myotomy POEM,4347163,CDM,960,RC,43497,HCPCS,Outpatient,,,1595.02,797.51,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
"43499 - PF Unlisted procedure, esophagus",3641211,CDM,510,RC,43499,HCPCS,Outpatient,,,531.87,265.94,,398.9,75,,,percent of total billed charges,75% of total billed charges,398.9,75,,,percent of total billed charges,75% of total billed charges,776.11,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1280.58,165,,,Fee Schedule,165% of CMS OPPS Rate,804.37,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,2229.28,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,3057.28,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,3829.56,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,776.11,100,,,Fee Schedule,100% of CMS OPPS Rate,804.37,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,74.46,14,,,percent of total billed charges,14% of total billed charges,74.46,3829.56,
43500 - PF Gastrotomy w/ Exploration/ Foreign Body Removal,4311700,CDM,960,RC,43500,HCPCS,Outpatient,,,1863.05,931.53,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
43605- Biopsy/stomach/laparotomy,3431206,CDM,510,RC,43605,HCPCS,Outpatient,,,2258.63,1129.32,,1693.97,75,,,percent of total billed charges,75% of total billed charges,1693.97,75,,,percent of total billed charges,75% of total billed charges,2258.63,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,2258.63,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2258.63,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2258.63,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2258.63,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2258.63,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,2258.63,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2258.63,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,316.21,14,,,percent of total billed charges,14% of total billed charges,316.21,2258.63,
43610 - PF Exc Local Ulcer/ Benign Tumor Stomach,4311701,CDM,960,RC,43610,HCPCS,Outpatient,,,2337.48,1168.74,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
43610- Excision/ulcer/benign tum/stomach,3431207,CDM,510,RC,43610,HCPCS,Outpatient,,,2644.38,1322.19,,1983.29,75,,,percent of total billed charges,75% of total billed charges,1983.29,75,,,percent of total billed charges,75% of total billed charges,2644.38,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,2644.38,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2644.38,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2644.38,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2644.38,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2644.38,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,2644.38,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2644.38,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,370.21,14,,,percent of total billed charges,14% of total billed charges,370.21,2644.38,
43620 - PF Gstrct Tot W/  Esophagoenterostomy,4311702,CDM,960,RC,43620,HCPCS,Outpatient,,,4750.6,2375.3,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
43621 - PF Gastrectomy Tot w/ Roux-En-Y Rcnst,4311703,CDM,960,RC,43621,HCPCS,Outpatient,,,5433.93,2716.97,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
"43621 - PF Gastrectomy, total; with Roux-en-Y reconstruction",3714924,CDM,510,RC,43621,HCPCS,Outpatient,,,6159.11,3079.56,,4619.33,75,,,percent of total billed charges,75% of total billed charges,4619.33,75,,,percent of total billed charges,75% of total billed charges,6159.11,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,6159.11,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6159.11,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6159.11,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6159.11,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6159.11,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,6159.11,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6159.11,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,862.28,14,,,percent of total billed charges,14% of total billed charges,862.28,6159.11,
43622 - PF Gastrectomy Tot w/ Frm Intstinal Pouch Any Type,4311704,CDM,960,RC,43622,HCPCS,Outpatient,,,5538.98,2769.49,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
43631 - PF Gastrectomy Prtl Dstl w/ Gastroduodenostomy,4311705,CDM,960,RC,43631,HCPCS,Outpatient,,,3455.42,1727.71,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
43631- Gastrectomy/part/gastroduodenostom,3431208,CDM,510,RC,43631,HCPCS,Outpatient,,,3919.32,1959.66,,2939.49,75,,,percent of total billed charges,75% of total billed charges,2939.49,75,,,percent of total billed charges,75% of total billed charges,3919.32,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,3919.32,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3919.32,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3919.32,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3919.32,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3919.32,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,3919.32,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3919.32,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,548.7,14,,,percent of total billed charges,14% of total billed charges,548.7,3919.32,
43632 - PF Gastrectomy Prtl Dstl w/ Gastrojejunostomy,4311706,CDM,960,RC,43632,HCPCS,Outpatient,,,4872.88,2436.44,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
43632- Gastrectomy/part/gastrojejunostomy,3431209,CDM,510,RC,43632,HCPCS,Outpatient,,,5508.29,2754.15,,4131.22,75,,,percent of total billed charges,75% of total billed charges,4131.22,75,,,percent of total billed charges,75% of total billed charges,5508.29,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,5508.29,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5508.29,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5508.29,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5508.29,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5508.29,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,5508.29,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5508.29,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,771.16,14,,,percent of total billed charges,14% of total billed charges,771.16,5508.29,
43633 - PF Gastrectomy Prtl Dstl w/ Roux-En-Y Rcnst,4311707,CDM,960,RC,43633,HCPCS,Outpatient,,,4599.9,2299.95,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
"43633- Gastrectomy, partial, distal; with Roux-en-Y reconstruction",3623575,CDM,510,RC,43633,HCPCS,Outpatient,,,5205.31,2602.66,,3903.98,75,,,percent of total billed charges,75% of total billed charges,3903.98,75,,,percent of total billed charges,75% of total billed charges,5205.31,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,5205.31,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5205.31,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5205.31,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5205.31,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5205.31,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,5205.31,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5205.31,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,728.74,14,,,percent of total billed charges,14% of total billed charges,728.74,5205.31,
43634 - PF Gastrectomy Prtl Dstl w/ Frm Intstinal Pouch,4311708,CDM,960,RC,43634,HCPCS,Outpatient,,,5091.1,2545.55,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
43644 - PF Laps Gstr Rstcv Px w/ Byp Roux-En-Y Limb <150 cm,4311709,CDM,960,RC,43644,HCPCS,Outpatient,,,4157.12,2078.56,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
43645 - PF Laps Gstr Rstcv Px w/  Byp&Sm Int Rcnst,4311710,CDM,960,RC,43645,HCPCS,Outpatient,,,4417.36,2208.68,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
43651 - PF Laps Surg Trnsx Vagus Nrv Truncal,4311711,CDM,960,RC,43651,HCPCS,Outpatient,,,1559.25,779.63,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
43652 - PF Laps Surg Trnsx Vagus Nrv Slctv/ Hily Slctv,4311717,CDM,960,RC,43652,HCPCS,Outpatient,,,1824.02,912.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
43653 - PF Laps Surg Gastrostomy w/ o Const Gstr Tube Spx,4311718,CDM,960,RC,43653,HCPCS,Outpatient,,,1364.05,682.03,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
43653- Gastrostomy/laparoscopy,3431210,CDM,510,RC,43653,HCPCS,Outpatient,,,1543.03,771.52,,1157.27,75,,,percent of total billed charges,75% of total billed charges,1157.27,75,,,percent of total billed charges,75% of total billed charges,4900.27,100,,,Fee Schedule,100% of CMS OPPS Rate,1862.49,102,,,Fee Schedule,102% of WV Medicaid Rate,8085.46,165,,,Fee Schedule,165% of CMS OPPS Rate,5078.72,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,14075.4,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,19303.29,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,24179.33,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1825.97,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,4900.27,100,,,Fee Schedule,100% of CMS OPPS Rate,5078.72,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,216.02,14,,,percent of total billed charges,14% of total billed charges,216.02,24179.33,
43659 - PF Unlisted Laparoscopy Procedure Stomach,4311719,CDM,960,RC,43659,HCPCS,Outpatient,,,1424.64,712.32,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
"43659 - Unlisted laparoscopy procedure, stomach",4241828,CDM,960,RC,43659,HCPCS,Outpatient,,,4912.04,2456.02,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
43752 - PF Naso/ Oro-Gastric Tube Plmt Req Phys&Fluor Gdnce,4311720,CDM,960,RC,43752,HCPCS,Outpatient,,,94.74,47.37,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
43752-PF NASO/ORO-GASTRIC TUBE PLMT REQ PHYS&FLUOR GDNCE,4321463,CDM,981,RC,43752,HCPCS,Outpatient,,,79.8,39.9,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
Read,602156,CDM,972,RC,43752,HCPCS,Outpatient,,,42.29,21.15,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
43753 - PF Gastric Intubat & Aspira w/ Phys Skill/ Lavage,4311721,CDM,960,RC,43753,HCPCS,Outpatient,,,51.97,25.99,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
43753-PF GASTRIC INTUBATJ & ASPIRAJ W/PHYS SKILL/LAVAGE,4321466,CDM,981,RC,43753,HCPCS,Outpatient,,,43.78,21.89,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
43754 - PF Gastric Intubat Dx w/  Asp Sngl Spec,4311722,CDM,960,RC,43754,HCPCS,Outpatient,,,85.84,42.92,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
43755 - PF Gastric Intuba Dx & Aspirat Mult Spec,4311723,CDM,960,RC,43755,HCPCS,Outpatient,,,135.98,67.99,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
43761 - PF Repos Naso/ Oro Gastric Feeding Tube Thru Duo,4311724,CDM,960,RC,43761,HCPCS,Outpatient,,,247.89,123.95,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
43761-PF REPOS NASO/ORO GASTRIC FEEDING TUBE THRU DUO,4321637,CDM,981,RC,43761,HCPCS,Outpatient,,,208.8,104.4,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
43762 - PF Perq Replc Gtube Not Req Rev Gstrst Trc,4311725,CDM,960,RC,43762,HCPCS,Outpatient,,,87.81,43.91,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
43762-MSA CHANGE GASTROSTOMY TUBE W/O REV,3429902,CDM,360,RC,43762,HCPCS,Outpatient,,,567.08,283.54,,425.31,75,,,percent of total billed charges,75% of total billed charges,425.31,75,,,percent of total billed charges,75% of total billed charges,202.01,100,,,Fee Schedule,100% of CMS OPPS Rate,108.62,102,,,Fee Schedule,102% of WV Medicaid Rate,333.31,165,,,Fee Schedule,165% of CMS OPPS Rate,209.36,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,580.25,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,795.77,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,996.78,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,106.49,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,202.01,100,,,Fee Schedule,100% of CMS OPPS Rate,209.36,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,79.39,14,,,percent of total billed charges,14% of total billed charges,79.39,996.78,
43762-PF PERQ REPLACEMENT GTUBE NOT REQ REVJ GSTRST TRC,4321636,CDM,981,RC,43762,HCPCS,Outpatient,,,73.96,36.98,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
43763 - PF Perq Replc Gtube Req Rev Gstrst Trc,4311726,CDM,960,RC,43763,HCPCS,Outpatient,,,203.91,101.96,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
43763-MSA CHANGE GASTROSTOMY TUBE W/ REVI,3429903,CDM,360,RC,43763,HCPCS,Outpatient,,,812.23,406.12,,609.17,75,,,percent of total billed charges,75% of total billed charges,609.17,75,,,percent of total billed charges,75% of total billed charges,202.01,100,,,Fee Schedule,100% of CMS OPPS Rate,108.62,102,,,Fee Schedule,102% of WV Medicaid Rate,333.31,165,,,Fee Schedule,165% of CMS OPPS Rate,209.36,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,580.25,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,795.77,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,996.78,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,106.49,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,202.01,100,,,Fee Schedule,100% of CMS OPPS Rate,209.36,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,113.71,14,,,percent of total billed charges,14% of total billed charges,106.49,996.78,
43763-PF PERQ REPLACEMENT GTUBE REQ REVJ GSTRST TRC,4321467,CDM,981,RC,43763,HCPCS,Outpatient,,,171.76,85.88,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
43770 - PF Laps Gastric Restrictive Px Place Device,4311727,CDM,960,RC,43770,HCPCS,Outpatient,,,2681.33,1340.67,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
43771 - PF Laps Gastric Restrictive Px Revision Device,4311728,CDM,960,RC,43771,HCPCS,Outpatient,,,3051.51,1525.76,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
43772 - PF Laps Gastric Restrictive Px Remove Device,4311729,CDM,960,RC,43772,HCPCS,Outpatient,,,2264.39,1132.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
43773 - PF Laps Gastric Restrictive Px Remove&Rplcmt Device,4311730,CDM,960,RC,43773,HCPCS,Outpatient,,,3051.51,1525.76,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
43774 - PF Laps Gastric Restricitve Px Remove Device & Port,4311731,CDM,960,RC,43774,HCPCS,Outpatient,,,2295.33,1147.67,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
43774PF Lap Gastric Restrictive Procedure Remove Adjustable,4281202,CDM,960,RC,43774,HCPCS,Outpatient,,,2049.4,1024.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
43775 - PF Laps Gstrc Rstrictiv Px Longitudinal Gastrectomy,4311732,CDM,960,RC,43775,HCPCS,Outpatient,,,2677.63,1338.82,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
43820 - PF Gastrojejunostomy w/ o Vagotomy,4311733,CDM,960,RC,43820,HCPCS,Outpatient,,,3208.05,1604.03,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
43820- Gastrojejunostomy w/o vagotomy,3431213,CDM,510,RC,43820,HCPCS,Outpatient,,,3631.28,1815.64,,2723.46,75,,,percent of total billed charges,75% of total billed charges,2723.46,75,,,percent of total billed charges,75% of total billed charges,3631.28,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,3631.28,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3631.28,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3631.28,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3631.28,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3631.28,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,3631.28,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3631.28,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,508.38,14,,,percent of total billed charges,14% of total billed charges,508.38,3631.28,
43830- Gastrostomy w/o construct/g tube,3431214,CDM,510,RC,43830,HCPCS,Outpatient,,,1884.32,942.16,,1413.24,75,,,percent of total billed charges,75% of total billed charges,1413.24,75,,,percent of total billed charges,75% of total billed charges,1637.37,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,2701.67,165,,,Fee Schedule,165% of CMS OPPS Rate,1697,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4703.14,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,6450,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,8079.28,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,1637.37,100,,,Fee Schedule,100% of CMS OPPS Rate,1697,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,263.8,14,,,percent of total billed charges,14% of total billed charges,263.8,8079.28,
43830 -PF Gastrostomy Opn w/ o Const Gstr Tube Spx,4311734,CDM,960,RC,43830,HCPCS,Outpatient,,,1666.5,833.25,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
43840- Gastrorrhaphy,3431215,CDM,510,RC,43840,HCPCS,Outpatient,,,3674.18,1837.09,,2755.64,75,,,percent of total billed charges,75% of total billed charges,2755.64,75,,,percent of total billed charges,75% of total billed charges,3674.18,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,3674.18,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3674.18,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3674.18,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3674.18,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3674.18,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,3674.18,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3674.18,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,514.39,14,,,percent of total billed charges,14% of total billed charges,514.39,3674.18,
43842 - PF Gastric Rstcv w/ o Byp Vert-Banded Gastroply,4311735,CDM,960,RC,43842,HCPCS,Outpatient,,,2374.4,1187.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
43843 - PF Gstr Rstcv w/ o Byp Oth/ Thn Ver-Banded Gstp,4311736,CDM,960,RC,43843,HCPCS,Outpatient,,,3068.18,1534.09,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
43845 - PF Gastric Rstcv w/ Prtl Gastrectomy 50-100 cm,4311737,CDM,960,RC,43845,HCPCS,Outpatient,,,4686.55,2343.28,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
43846 - PF Gastric Rstcv w/ Byp w/ Short Limb 150 cm/ <,4311738,CDM,960,RC,43846,HCPCS,Outpatient,,,3948.39,1974.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
43847 - PF Gastric Rstcv w/ Byp w/ Sm Int Rcnst Limit Absrp,4311739,CDM,960,RC,43847,HCPCS,Outpatient,,,4324.99,2162.5,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
43848 - PF Revision Open Gastric Restrictive Px Not Device,4311740,CDM,960,RC,43848,HCPCS,Outpatient,,,4619.85,2309.93,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
43860 - PF Rev Gstr/  Anast w/ Rcnst w/ o Vgtmy,4311741,CDM,960,RC,43860,HCPCS,Outpatient,,,3911.21,1955.61,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
43860PF Revision Gastrojejunal Anastomosis w/Reconstruction,4281205,CDM,960,RC,43860,HCPCS,Outpatient,,,3492.15,1746.08,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
43865 - PF Rev Gstr/  Anast w/ Rcnst w/  Vgtmy,4311742,CDM,960,RC,43865,HCPCS,Outpatient,,,4093.42,2046.71,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
"43870 - Closure of gastrostomy, surgical",3800915,CDM,983,RC,43870,HCPCS,Outpatient,,,1908.12,954.06,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
43870 - PF Closure Gastrostomy Surg,4311743,CDM,960,RC,43870,HCPCS,Outpatient,,,1687.22,843.61,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
43886 - PF Gstr Rstcv Px Opn Rev Subq Port Component Only,4311744,CDM,960,RC,43886,HCPCS,Outpatient,,,857.2,428.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
43887 - PF Gstr Rstcv Px Opn Rmvl Subq Port Component Only,4311745,CDM,960,RC,43887,HCPCS,Outpatient,,,775.22,387.61,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
43888 - PF Gstr Rstcv Opn Rmvl & Rplcmt Subq Port,4311746,CDM,960,RC,43888,HCPCS,Outpatient,,,1093.2,546.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
43999 - PF Unlisted Procedure Stomach,4311747,CDM,960,RC,43999,HCPCS,Outpatient,,,949.76,474.88,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
44005 - PF Enterolss Fring Intstinal Adhesion Spx,4311748,CDM,960,RC,44005,HCPCS,Outpatient,,,2601.73,1300.87,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
44005- Enterolysis,3431217,CDM,510,RC,44005,HCPCS,Outpatient,,,2949.73,1474.87,,2212.3,75,,,percent of total billed charges,75% of total billed charges,2212.3,75,,,percent of total billed charges,75% of total billed charges,2949.73,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,2949.73,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2949.73,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2949.73,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2949.73,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2949.73,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,2949.73,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2949.73,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,412.96,14,,,percent of total billed charges,14% of total billed charges,412.96,2949.73,
44010- Duodenotomy/explore/bx/FB removal,3431218,CDM,510,RC,44010,HCPCS,Outpatient,,,2277.91,1138.96,,1708.43,75,,,percent of total billed charges,75% of total billed charges,1708.43,75,,,percent of total billed charges,75% of total billed charges,2277.91,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,2277.91,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2277.91,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2277.91,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2277.91,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2277.91,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,2277.91,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2277.91,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,318.91,14,,,percent of total billed charges,14% of total billed charges,318.91,2277.91,
44015 - PF Tube/ Needle Cath Jejunostomy Any Method,4311749,CDM,960,RC,44015,HCPCS,Outpatient,,,342.08,171.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
44015- Jejunostomy/tube/needle,3431219,CDM,510,RC,44015,HCPCS,Outpatient,,,385.9,192.95,,289.43,75,,,percent of total billed charges,75% of total billed charges,289.43,75,,,percent of total billed charges,75% of total billed charges,385.9,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,385.9,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,385.9,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,385.9,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,385.9,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,385.9,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,385.9,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,385.9,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,54.03,14,,,percent of total billed charges,14% of total billed charges,54.03,385.9,
44020 - Enterotomy- Explore Small Intestine,3899043,CDM,983,RC,44020,HCPCS,Outpatient,,,2633.03,1316.52,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
44025 - Incision of Large Bowel,4189306,CDM,960,RC,44025,HCPCS,Outpatient,,,2356.19,1178.1,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
44050 - PF Rdct Volvulus Intussusception Int Hrna Lapt,4311751,CDM,960,RC,44050,HCPCS,Outpatient,,,2231.44,1115.72,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
44050- Reduce bowel obstruct/laparotomy,3431220,CDM,510,RC,44050,HCPCS,Outpatient,,,2524.74,1262.37,,1893.56,75,,,percent of total billed charges,75% of total billed charges,1893.56,75,,,percent of total billed charges,75% of total billed charges,2524.74,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,2524.74,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2524.74,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2524.74,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2524.74,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2524.74,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,2524.74,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2524.74,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,353.46,14,,,percent of total billed charges,14% of total billed charges,353.46,2524.74,
44055 - CORRJ MALROTATION BANDS&/RDCTJ VOLVULUS,3999139,CDM,960,RC,44055,HCPCS,Outpatient,,,4027.7,2013.85,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
44110 - PF Exc 1/ > Sm/ Lg Lesions Intestine Enterotom,4311752,CDM,960,RC,44110,HCPCS,Outpatient,,,2001.83,1000.92,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
44110-PF EXCISE INTESTINE LESION(S),3429919,CDM,510,RC,44110,HCPCS,Outpatient,,,2262.77,1131.39,,1697.08,75,,,percent of total billed charges,75% of total billed charges,1697.08,75,,,percent of total billed charges,75% of total billed charges,2262.77,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,2262.77,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2262.77,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2262.77,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2262.77,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2262.77,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,2262.77,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2262.77,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,316.79,14,,,percent of total billed charges,14% of total billed charges,316.79,2262.77,
44120 - PF Entrc Resc Sm Intestine 1 Resc & Anast,4311753,CDM,960,RC,44120,HCPCS,Outpatient,,,2913.01,1456.51,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
44120-PF REMOVAL OF SMALL INTESTINE,3429921,CDM,510,RC,44120,HCPCS,Outpatient,,,3298,1649,,2473.5,75,,,percent of total billed charges,75% of total billed charges,2473.5,75,,,percent of total billed charges,75% of total billed charges,3298,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,3298,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3298,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3298,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3298,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3298,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,3298,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3298,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,461.72,14,,,percent of total billed charges,14% of total billed charges,461.72,3298,
44121 - PF Enterectomy Resc Sm Intestine Ea Resc & Ana,4313636,CDM,960,RC,44121,HCPCS,Outpatient,,,577.05,288.53,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
"44121- Enterectomy, resect small intes; ea addl resec & anast",3569415,CDM,510,RC,44121,HCPCS,Outpatient,,,652.15,326.08,,489.11,75,,,percent of total billed charges,75% of total billed charges,489.11,75,,,percent of total billed charges,75% of total billed charges,652.15,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,652.15,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,652.15,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,652.15,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,652.15,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,652.15,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,652.15,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,652.15,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,91.3,14,,,percent of total billed charges,14% of total billed charges,91.3,652.15,
44125 - PF Enterectomy Resc Sm Intestine w/ Enterostomy,4311754,CDM,960,RC,44125,HCPCS,Outpatient,,,2790.19,1395.1,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
"44125- Colectomy, partial; with coloproctostomy (low pelvic anastomosis",3622968,CDM,510,RC,44125,HCPCS,Outpatient,,,3166.96,1583.48,,2375.22,75,,,percent of total billed charges,75% of total billed charges,2375.22,75,,,percent of total billed charges,75% of total billed charges,3166.96,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,3166.96,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3166.96,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3166.96,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3166.96,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3166.96,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,3166.96,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3166.96,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,443.37,14,,,percent of total billed charges,14% of total billed charges,443.37,3166.96,
"44130- Enteroenterostomy, anastomosis of intestine, with or without cutaneous enterostomy (separ",3622980,CDM,510,RC,44130,HCPCS,Outpatient,,,3543.12,1771.56,,2657.34,75,,,percent of total billed charges,75% of total billed charges,2657.34,75,,,percent of total billed charges,75% of total billed charges,3543.12,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,3543.12,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3543.12,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3543.12,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3543.12,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3543.12,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,3543.12,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3543.12,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,496.04,14,,,percent of total billed charges,14% of total billed charges,496.04,3543.12,
44139 - PF Mobl Splenic Flxr Pfrmd Conjunt w/ Prtl Colct,4311755,CDM,960,RC,44139,HCPCS,Outpatient,,,287.47,143.74,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
44139-PF MOBILIZATION OF COLON,3429923,CDM,510,RC,44139,HCPCS,Outpatient,,,326.67,163.34,,245,75,,,percent of total billed charges,75% of total billed charges,245,75,,,percent of total billed charges,75% of total billed charges,326.67,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,326.67,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,326.67,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,326.67,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,326.67,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,326.67,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,326.67,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,326.67,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,45.73,14,,,percent of total billed charges,14% of total billed charges,45.73,326.67,
44140 - PF Colectomy Partial w/ Anastomosis,4311756,CDM,960,RC,44140,HCPCS,Outpatient,,,3190.1,1595.05,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
44140-PF PARTIAL REMOVAL OF COLON,3429925,CDM,510,RC,44140,HCPCS,Outpatient,,,3613.34,1806.67,,2710.01,75,,,percent of total billed charges,75% of total billed charges,2710.01,75,,,percent of total billed charges,75% of total billed charges,3613.34,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,3613.34,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3613.34,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3613.34,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3613.34,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3613.34,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,3613.34,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3613.34,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,505.87,14,,,percent of total billed charges,14% of total billed charges,505.87,3613.34,
MA PARTIAL REMOVAL OF COLON,3527854,CDM,960,RC,44140,HCPCS,Outpatient,,,3613.34,1806.67,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
"44141 - Colectomy, partial; with skin level cecostomy or colostomy",3572788,CDM,983,RC,44141,HCPCS,Outpatient,,,4876.65,2438.33,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
44141 - PF Colectomy Prtl w/ Skin Level Cecost/ Colostomy,4311757,CDM,960,RC,44141,HCPCS,Outpatient,,,4295.19,2147.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
44143 - PF Colectomy Prtl w/ End Colostomy & Clsr Dstl Sgmt,4311758,CDM,960,RC,44143,HCPCS,Outpatient,,,3927.3,1963.65,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
44143- Colectomy/end colost/close dis seg,3431221,CDM,510,RC,44143,HCPCS,Outpatient,,,4454.14,2227.07,,3340.61,75,,,percent of total billed charges,75% of total billed charges,3340.61,75,,,percent of total billed charges,75% of total billed charges,4454.14,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,4454.14,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4454.14,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4454.14,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4454.14,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4454.14,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,4454.14,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4454.14,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,623.58,14,,,percent of total billed charges,14% of total billed charges,623.58,4454.14,
44144 - PF Colectomy Prtl w/ Colost/ Ileost & Mucofistula,4311759,CDM,960,RC,44144,HCPCS,Outpatient,,,4192.9,2096.45,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
44144- Colectomy/w colostomy or ileostomy,3431222,CDM,510,RC,44144,HCPCS,Outpatient,,,4740.87,2370.44,,3555.65,75,,,percent of total billed charges,75% of total billed charges,3555.65,75,,,percent of total billed charges,75% of total billed charges,4740.87,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,4740.87,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4740.87,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4740.87,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4740.87,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4740.87,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,4740.87,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4740.87,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,663.72,14,,,percent of total billed charges,14% of total billed charges,663.72,4740.87,
"44145- Colectomy, partial; with coloproctostomy (low pelvic anastomosis",3623381,CDM,510,RC,44145,HCPCS,Outpatient,,,4423.53,2211.77,,3317.65,75,,,percent of total billed charges,75% of total billed charges,3317.65,75,,,percent of total billed charges,75% of total billed charges,4423.53,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,4423.53,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4423.53,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4423.53,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4423.53,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4423.53,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,4423.53,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4423.53,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,619.29,14,,,percent of total billed charges,14% of total billed charges,619.29,4423.53,
44145- PF PART REMOVAL OF COLON,4133405,CDM,960,RC,44145,HCPCS,Outpatient,,,4423.53,2211.77,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
MA AST PART REMOVAL OF COLON,3527849,CDM,960,RC,44145,HCPCS,Outpatient,,,4423.53,2211.77,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
"44146-PF COLECTOMY,PART W/END COLOSTOMY",3429931,CDM,510,RC,44146,HCPCS,Outpatient,,,5612.4,2806.2,,4209.3,75,,,percent of total billed charges,75% of total billed charges,4209.3,75,,,percent of total billed charges,75% of total billed charges,5612.4,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,5612.4,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5612.4,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5612.4,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5612.4,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5612.4,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,5612.4,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5612.4,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,785.74,14,,,percent of total billed charges,14% of total billed charges,785.74,5612.4,
"44147 - (PF) Colectomy, partial; abdominal and transanal approach",3634913,CDM,510,RC,44147,HCPCS,Outpatient,,,5200.83,2600.42,,3900.62,75,,,percent of total billed charges,75% of total billed charges,3900.62,75,,,percent of total billed charges,75% of total billed charges,5200.83,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,5200.83,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5200.83,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5200.83,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5200.83,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5200.83,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,5200.83,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5200.83,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,728.12,14,,,percent of total billed charges,14% of total billed charges,728.12,5200.83,
"44150 - (PF) Colectomy, total, abdominal, without proctectomy; with ileostomy or ileoproctostomy",3634914,CDM,510,RC,44150,HCPCS,Outpatient,,,4946.61,2473.31,,3709.96,75,,,percent of total billed charges,75% of total billed charges,3709.96,75,,,percent of total billed charges,75% of total billed charges,4946.61,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,4946.61,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4946.61,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4946.61,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4946.61,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4946.61,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,4946.61,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4946.61,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,692.53,14,,,percent of total billed charges,14% of total billed charges,692.53,4946.61,
44150 - PF Colct Tot Abdl w/ o Prctect w/ Iliost/ Ileopxts,4311760,CDM,960,RC,44150,HCPCS,Outpatient,,,4368.38,2184.19,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
44151 - PF Colct Tot Abdl w/ o Prctect w/ Continent Ileost,4311761,CDM,960,RC,44151,HCPCS,Outpatient,,,5113.37,2556.69,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
44155 - PF Colectomy Tot Abdl w/ Proctectomy w/ Ileostomy,4311762,CDM,960,RC,44155,HCPCS,Outpatient,,,4853.58,2426.79,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
44156 - PF Colectomy Tot Abdl w/ Proctectomy w/ Contnt Ileost,4311763,CDM,960,RC,44156,HCPCS,Outpatient,,,5470.02,2735.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
"44157 - (PF) Colectomy, total, abdominal, with proctectomy; with ileoanal anastomosis, includes loop",3635060,CDM,510,RC,44157,HCPCS,Outpatient,,,5901.29,2950.65,,4425.97,75,,,percent of total billed charges,75% of total billed charges,4425.97,75,,,percent of total billed charges,75% of total billed charges,5901.29,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,5901.29,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5901.29,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5901.29,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5901.29,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5901.29,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,5901.29,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5901.29,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,826.18,14,,,percent of total billed charges,14% of total billed charges,826.18,5901.29,
44160 - PF Colectomy Prtl w/ Rmvl Terminal Ileum & Ileocolos,4311764,CDM,960,RC,44160,HCPCS,Outpatient,,,2948.74,1474.37,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
44160-PF REMOVAL OF COLON,3429933,CDM,510,RC,44160,HCPCS,Outpatient,,,3336.71,1668.36,,2502.53,75,,,percent of total billed charges,75% of total billed charges,2502.53,75,,,percent of total billed charges,75% of total billed charges,3336.71,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,3336.71,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3336.71,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3336.71,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3336.71,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3336.71,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,3336.71,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3336.71,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,467.14,14,,,percent of total billed charges,14% of total billed charges,467.14,3336.71,
44180 - PF LAP ENTEROLYSIS,3527847,CDM,960,RC,44180,HCPCS,Outpatient,,,2480.59,1240.3,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
44180 - PF Laparoscopy Enterolysis Separate Proc,4311765,CDM,960,RC,44180,HCPCS,Outpatient,,,2191.4,1095.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
MA LAP ENTEROLYSIS,3527841,CDM,960,RC,44180,HCPCS,Outpatient,,,2480.59,1240.3,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
44186 - Laparoscopy Surgical Jejunostomy,4169584,CDM,983,RC,44186,HCPCS,Outpatient,,,1565.02,782.51,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
44186-PF Lap Surgical Jejunostomy,4322110,CDM,960,RC,44186,HCPCS,Outpatient,,,1281.58,640.79,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
"44188 - (PF) Laparoscopy, surgical, colostomy or skin level cecostomy",3635061,CDM,510,RC,44188,HCPCS,Outpatient,,,3236.21,1618.11,,2427.16,75,,,percent of total billed charges,75% of total billed charges,2427.16,75,,,percent of total billed charges,75% of total billed charges,3236.21,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,3236.21,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3236.21,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3236.21,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3236.21,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3236.21,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,3236.21,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3236.21,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,453.07,14,,,percent of total billed charges,14% of total billed charges,453.07,3236.21,
"44202 - (PF) Laparoscopy, surgical; enterectomy, resection of small intestine, single resection",3635062,CDM,510,RC,44202,HCPCS,Outpatient,,,3734.9,1867.45,,2801.18,75,,,percent of total billed charges,75% of total billed charges,2801.18,75,,,percent of total billed charges,75% of total billed charges,3734.9,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,3734.9,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3734.9,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3734.9,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3734.9,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3734.9,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,3734.9,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3734.9,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,522.89,14,,,percent of total billed charges,14% of total billed charges,522.89,3734.9,
44202 - PF Laps Enterect Resc 1 Sm Intest Resc & Ana,4311766,CDM,960,RC,44202,HCPCS,Outpatient,,,3300.78,1650.39,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
44203 - PF Laparoscopy Sm Intestine Resc & Anastomosis,4311767,CDM,960,RC,44203,HCPCS,Outpatient,,,580.09,290.05,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
"44204 - Laparoscopy, surgical; colectomy, partial, with anastomosis",3572789,CDM,960,RC,44204,HCPCS,Outpatient,,,4119.99,2060,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
44204 - PF Laparoscopy Colectomy Prtl w/ Anastomosis,4311768,CDM,960,RC,44204,HCPCS,Outpatient,,,3637.66,1818.83,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
44205 - PF Laps Colectomy Prtl w/ Rmvl Terminal Ileum,4311769,CDM,960,RC,44205,HCPCS,Outpatient,,,3153.99,1577,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
"44205- Laparoscopy, surgical; colectomy, partial, with removal of terminal ileum with ileocolostomy",3566786,CDM,510,RC,44205,HCPCS,Outpatient,,,3572.7,1786.35,,2679.53,75,,,percent of total billed charges,75% of total billed charges,2679.53,75,,,percent of total billed charges,75% of total billed charges,3572.7,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,3572.7,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3572.7,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3572.7,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3572.7,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3572.7,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,3572.7,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3572.7,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,500.18,14,,,percent of total billed charges,14% of total billed charges,500.18,3572.7,
44206 - Lap Part Colectomy W/Stoma,3899046,CDM,983,RC,44206,HCPCS,Outpatient,,,4668.85,2334.43,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
44206 - PF Laps Colectomy Prtl w/ End Clst & Clsr Dstl Sgm,4311770,CDM,960,RC,44206,HCPCS,Outpatient,,,4119.11,2059.56,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
44207 - PF Laps Colectomy Prtl w/ Colopxtstmy Lw Anast,4311771,CDM,960,RC,44207,HCPCS,Outpatient,,,4275.51,2137.76,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
"44207- Laparoscopy, surgical; colectomy, partial, with anastomosis, with coloproctostomy (low pelvic",3569387,CDM,510,RC,44207,HCPCS,Outpatient,,,4843.88,2421.94,,3632.91,75,,,percent of total billed charges,75% of total billed charges,3632.91,75,,,percent of total billed charges,75% of total billed charges,4843.88,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,4843.88,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4843.88,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4843.88,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4843.88,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4843.88,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,4843.88,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4843.88,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,678.14,14,,,percent of total billed charges,14% of total billed charges,678.14,4843.88,
44208 - PF Laps Colectomy Prtl w/ Colopxtstmy Lw Anast w/ Clst,4311772,CDM,960,RC,44208,HCPCS,Outpatient,,,4639.6,2319.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
"44208- Laparoscopy, surgical; colectomy, partial, with anastomosis, with coloproctostomy (low pelvic",3623578,CDM,510,RC,44208,HCPCS,Outpatient,,,5254.12,2627.06,,3940.59,75,,,percent of total billed charges,75% of total billed charges,3940.59,75,,,percent of total billed charges,75% of total billed charges,5254.12,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,5254.12,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5254.12,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5254.12,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5254.12,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5254.12,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,5254.12,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5254.12,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,735.58,14,,,percent of total billed charges,14% of total billed charges,735.58,5254.12,
44210 - PF Laps Colectomy Tot w/ o Prctect w/  Ileost/ Ileopxts,4311773,CDM,960,RC,44210,HCPCS,Outpatient,,,4147.1,2073.55,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
44211 - PF Laps Colct TTL Abd w/ Prctect Ileoanal Anastomsis,4311774,CDM,960,RC,44211,HCPCS,Outpatient,,,4902.21,2451.11,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
44212 - PF Laps Colectomy Abdl w/ Proctectomy w/ Ileostomy,4311775,CDM,960,RC,44212,HCPCS,Outpatient,,,4717.91,2358.96,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
"44213- Laparoscopy, surgical, mobilization (take-down) of splenic flexure performed in conjunction w",3566787,CDM,510,RC,44213,HCPCS,Outpatient,,,504.14,252.07,,378.11,75,,,percent of total billed charges,75% of total billed charges,378.11,75,,,percent of total billed charges,75% of total billed charges,504.14,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,504.14,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,504.14,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,504.14,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,504.14,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,504.14,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,504.14,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,504.14,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,70.58,14,,,percent of total billed charges,14% of total billed charges,70.58,504.14,
"44227 - PF Laparoscopy, surgical, closure of enterostomy, large or small intestine, with resection a",3714927,CDM,510,RC,44227,HCPCS,Outpatient,,,4457.14,2228.57,,3342.86,75,,,percent of total billed charges,75% of total billed charges,3342.86,75,,,percent of total billed charges,75% of total billed charges,4457.14,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,4457.14,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4457.14,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4457.14,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4457.14,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4457.14,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,4457.14,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4457.14,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,624,14,,,percent of total billed charges,14% of total billed charges,624,4457.14,
44238 - PF Unlisted Laparoscopy Px Intestine XCP Rectum,4311776,CDM,960,RC,44238,HCPCS,Outpatient,,,3561.6,1780.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
"44238 - Unlisted laparoscopy procedure, intestine (except rectum)",3572803,CDM,960,RC,44238,HCPCS,Outpatient,,,5318.66,2659.33,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
"44300- Placement, enterostomy or cecostomy, tube open (eg, for feeding or decompression) (separate p",3622392,CDM,510,RC,44300,HCPCS,Outpatient,,,2267.21,1133.61,,1700.41,75,,,percent of total billed charges,75% of total billed charges,1700.41,75,,,percent of total billed charges,75% of total billed charges,2267.21,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,2267.21,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2267.21,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2267.21,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2267.21,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2267.21,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,2267.21,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2267.21,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,317.41,14,,,percent of total billed charges,14% of total billed charges,317.41,2267.21,
44310 - PF ILEOSTOMY/JEJUNOSTOMY,3527859,CDM,960,RC,44310,HCPCS,Outpatient,,,2784.27,1392.14,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
44312-MA REVISION OF ILEOSTOMY,3429934,CDM,510,RC,44312,HCPCS,Outpatient,,,1587.86,793.93,,1190.9,75,,,percent of total billed charges,75% of total billed charges,1190.9,75,,,percent of total billed charges,75% of total billed charges,3058.39,100,,,Fee Schedule,100% of CMS OPPS Rate,1437.27,102,,,Fee Schedule,102% of WV Medicaid Rate,5046.34,165,,,Fee Schedule,165% of CMS OPPS Rate,3169.76,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8784.82,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,12047.69,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,15090.95,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1409.09,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,3058.39,100,,,Fee Schedule,100% of CMS OPPS Rate,3169.76,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,222.3,14,,,percent of total billed charges,14% of total billed charges,222.3,15090.95,
44320PF Colostomy or Skin Level Cecostomy,4281201,CDM,960,RC,44320,HCPCS,Outpatient,,,2534.61,1267.31,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
44340 - (PF) Revision of colostomy; simple (release of superficial scar) (separate proc,3635063,CDM,510,RC,44340,HCPCS,Outpatient,,,1657.43,828.72,,1243.07,75,,,percent of total billed charges,75% of total billed charges,1243.07,75,,,percent of total billed charges,75% of total billed charges,3058.39,100,,,Fee Schedule,100% of CMS OPPS Rate,1437.27,102,,,Fee Schedule,102% of WV Medicaid Rate,5046.34,165,,,Fee Schedule,165% of CMS OPPS Rate,3169.76,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8784.82,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,12047.69,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,15090.95,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1409.09,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,3058.39,100,,,Fee Schedule,100% of CMS OPPS Rate,3169.76,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,232.04,14,,,percent of total billed charges,14% of total billed charges,232.04,15090.95,
44345 - PF Rev Colostomy Comp Rcnst In-Depth Spx,4311777,CDM,960,RC,44345,HCPCS,Outpatient,,,2480.79,1240.4,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
44346 - Revision of colostomy; with repair of paracolostomy hernia (separate procedure,3572790,CDM,983,RC,44346,HCPCS,Outpatient,,,3160.56,1580.28,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
"44360- Small Bowel Endoscopy, Diagnostic",3431223,CDM,510,RC,44360,HCPCS,Outpatient,,,371.83,185.92,,278.87,75,,,percent of total billed charges,75% of total billed charges,278.87,75,,,percent of total billed charges,75% of total billed charges,1637.37,100,,,Fee Schedule,100% of CMS OPPS Rate,557.09,102,,,Fee Schedule,102% of WV Medicaid Rate,2701.67,165,,,Fee Schedule,165% of CMS OPPS Rate,1697,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4703.14,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,6450,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,8079.28,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,546.17,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1637.37,100,,,Fee Schedule,100% of CMS OPPS Rate,1697,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,52.06,14,,,percent of total billed charges,14% of total billed charges,52.06,8079.28,
"44361 - (PF) Small intestinal endoscopy, enteroscopy beyond second portion of duodenum, not includ",3635065,CDM,510,RC,44361,HCPCS,Outpatient,,,412.28,206.14,,309.21,75,,,percent of total billed charges,75% of total billed charges,309.21,75,,,percent of total billed charges,75% of total billed charges,1637.37,100,,,Fee Schedule,100% of CMS OPPS Rate,557.09,102,,,Fee Schedule,102% of WV Medicaid Rate,2701.67,165,,,Fee Schedule,165% of CMS OPPS Rate,1697,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4703.14,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,6450,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,8079.28,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,546.17,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1637.37,100,,,Fee Schedule,100% of CMS OPPS Rate,1697,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,57.72,14,,,percent of total billed charges,14% of total billed charges,57.72,8079.28,
44361 - PF Endoscopy Upper Sm Intestine w/ Bx,4311778,CDM,960,RC,44361,HCPCS,Outpatient,,,362.4,181.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
44364- Sm intes endo/remov tumor/snare,3431224,CDM,510,RC,44364,HCPCS,Outpatient,,,531.36,265.68,,398.52,75,,,percent of total billed charges,75% of total billed charges,398.52,75,,,percent of total billed charges,75% of total billed charges,1637.37,100,,,Fee Schedule,100% of CMS OPPS Rate,557.09,102,,,Fee Schedule,102% of WV Medicaid Rate,2701.67,165,,,Fee Schedule,165% of CMS OPPS Rate,1697,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4703.14,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,6450,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,8079.28,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,546.17,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1637.37,100,,,Fee Schedule,100% of CMS OPPS Rate,1697,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,74.39,14,,,percent of total billed charges,14% of total billed charges,74.39,8079.28,
44365- Sm intes/remov tum/hot bx for/caut,3431225,CDM,510,RC,44365,HCPCS,Outpatient,,,471.88,235.94,,353.91,75,,,percent of total billed charges,75% of total billed charges,353.91,75,,,percent of total billed charges,75% of total billed charges,1637.37,100,,,Fee Schedule,100% of CMS OPPS Rate,557.09,102,,,Fee Schedule,102% of WV Medicaid Rate,2701.67,165,,,Fee Schedule,165% of CMS OPPS Rate,1697,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4703.14,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,6450,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,8079.28,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,546.17,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1637.37,100,,,Fee Schedule,100% of CMS OPPS Rate,1697,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,66.06,14,,,percent of total billed charges,14% of total billed charges,66.06,8079.28,
44366- Sm intes endo/w bleeding control,3431226,CDM,510,RC,44366,HCPCS,Outpatient,,,622.2,311.1,,466.65,75,,,percent of total billed charges,75% of total billed charges,466.65,75,,,percent of total billed charges,75% of total billed charges,1637.37,100,,,Fee Schedule,100% of CMS OPPS Rate,557.09,102,,,Fee Schedule,102% of WV Medicaid Rate,2701.67,165,,,Fee Schedule,165% of CMS OPPS Rate,1697,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4703.14,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,6450,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,8079.28,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,546.17,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1637.37,100,,,Fee Schedule,100% of CMS OPPS Rate,1697,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,87.11,14,,,percent of total billed charges,14% of total billed charges,87.11,8079.28,
44369- Sm intes/abla/hot bx for/caut/snar,3431227,CDM,510,RC,44369,HCPCS,Outpatient,,,638.48,319.24,,478.86,75,,,percent of total billed charges,75% of total billed charges,478.86,75,,,percent of total billed charges,75% of total billed charges,1637.37,100,,,Fee Schedule,100% of CMS OPPS Rate,557.09,102,,,Fee Schedule,102% of WV Medicaid Rate,2701.67,165,,,Fee Schedule,165% of CMS OPPS Rate,1697,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4703.14,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,6450,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,8079.28,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,546.17,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1637.37,100,,,Fee Schedule,100% of CMS OPPS Rate,1697,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,89.39,14,,,percent of total billed charges,14% of total billed charges,89.39,8079.28,
44370- Sm intes endo/transendo stent plac,3431228,CDM,510,RC,44370,HCPCS,Outpatient,,,692.67,346.34,,519.5,75,,,percent of total billed charges,75% of total billed charges,519.5,75,,,percent of total billed charges,75% of total billed charges,4927.14,100,,,Fee Schedule,100% of CMS OPPS Rate,2876.24,102,,,Fee Schedule,102% of WV Medicaid Rate,8129.78,165,,,Fee Schedule,165% of CMS OPPS Rate,5106.56,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,14152.55,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,19409.09,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,24311.86,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,2819.84,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,4927.14,100,,,Fee Schedule,100% of CMS OPPS Rate,5106.56,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,96.97,14,,,percent of total billed charges,14% of total billed charges,96.97,24311.86,
44372 - ENTEROSCOPY > 2ND PRTN W/PLMT PRQ TUBE,3997184,CDM,960,RC,44372,HCPCS,Outpatient,,,626.92,313.46,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
"44373 - (PF) Small intestinal endoscopy, enteroscopy beyond second portion of duodenum, not includ",3635064,CDM,510,RC,44373,HCPCS,Outpatient,,,500.4,250.2,,375.3,75,,,percent of total billed charges,75% of total billed charges,375.3,75,,,percent of total billed charges,75% of total billed charges,1637.37,100,,,Fee Schedule,100% of CMS OPPS Rate,557.09,102,,,Fee Schedule,102% of WV Medicaid Rate,2701.67,165,,,Fee Schedule,165% of CMS OPPS Rate,1697,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4703.14,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,6450,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,8079.28,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,546.17,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1637.37,100,,,Fee Schedule,100% of CMS OPPS Rate,1697,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,70.06,14,,,percent of total billed charges,14% of total billed charges,70.06,8079.28,
44376PF Enteroscopy Beyond Second Portion Duodenum w/Ileum D,4281199,CDM,960,RC,44376,HCPCS,Outpatient,,,582.75,291.38,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
44377 - ENTEROSC >2ND PRTN W/ILEUM W/BX SINGLE/MULTIPLE,4037558,CDM,983,RC,44377,HCPCS,Outpatient,,,779.71,389.86,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
"44378 - PF Small intestinal endoscopy, enteroscopy beyond second portion of duodenum, including ileu",3714930,CDM,510,RC,44378,HCPCS,Outpatient,,,1004.14,502.07,,753.11,75,,,percent of total billed charges,75% of total billed charges,753.11,75,,,percent of total billed charges,75% of total billed charges,1637.37,100,,,Fee Schedule,100% of CMS OPPS Rate,557.09,102,,,Fee Schedule,102% of WV Medicaid Rate,2701.67,165,,,Fee Schedule,165% of CMS OPPS Rate,1697,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4703.14,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,6450,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,8079.28,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,546.17,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1637.37,100,,,Fee Schedule,100% of CMS OPPS Rate,1697,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,140.58,14,,,percent of total billed charges,14% of total billed charges,140.58,8079.28,
"44380 - (PF) Ileoscopy, through stoma; diagnostic, including collection of specimen(s) by brushing",3635066,CDM,510,RC,44380,HCPCS,Outpatient,,,486.68,243.34,,365.01,75,,,percent of total billed charges,75% of total billed charges,365.01,75,,,percent of total billed charges,75% of total billed charges,776.11,100,,,Fee Schedule,100% of CMS OPPS Rate,330.28,102,,,Fee Schedule,102% of WV Medicaid Rate,1280.58,165,,,Fee Schedule,165% of CMS OPPS Rate,804.37,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,2229.28,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,3057.28,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,3829.56,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,323.8,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,776.11,100,,,Fee Schedule,100% of CMS OPPS Rate,804.37,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,68.14,14,,,percent of total billed charges,14% of total billed charges,68.14,3829.56,
44381 - PF Ileoscopy Stoma w/ Balloon Dilation PF,4305372,CDM,960,RC,44381,HCPCS,Outpatient,,,173.88,86.94,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
44382- Ileoscopy/stoma/w bx/single/multi,3431229,CDM,510,RC,44382,HCPCS,Outpatient,,,748.65,374.33,,561.49,75,,,percent of total billed charges,75% of total billed charges,561.49,75,,,percent of total billed charges,75% of total billed charges,776.11,100,,,Fee Schedule,100% of CMS OPPS Rate,330.28,102,,,Fee Schedule,102% of WV Medicaid Rate,1280.58,165,,,Fee Schedule,165% of CMS OPPS Rate,804.37,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,2229.28,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,3057.28,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,3829.56,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,323.8,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,776.11,100,,,Fee Schedule,100% of CMS OPPS Rate,804.37,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,104.81,14,,,percent of total billed charges,14% of total billed charges,104.81,3829.56,
44385- Endoscopic eval/sm intest pouch,3431230,CDM,510,RC,44385,HCPCS,Outpatient,,,538.19,269.1,,403.64,75,,,percent of total billed charges,75% of total billed charges,403.64,75,,,percent of total billed charges,75% of total billed charges,781.31,100,,,Fee Schedule,100% of CMS OPPS Rate,323.92,102,,,Fee Schedule,102% of WV Medicaid Rate,1289.16,165,,,Fee Schedule,165% of CMS OPPS Rate,809.76,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,2244.21,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,3077.76,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,3855.21,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,317.57,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,781.31,100,,,Fee Schedule,100% of CMS OPPS Rate,809.76,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,75.35,14,,,percent of total billed charges,14% of total billed charges,75.35,3855.21,
44386- Endoscopic eval/sm intest pouch/bx,3431231,CDM,510,RC,44386,HCPCS,Outpatient,,,785.46,392.73,,589.1,75,,,percent of total billed charges,75% of total billed charges,589.1,75,,,percent of total billed charges,75% of total billed charges,781.31,100,,,Fee Schedule,100% of CMS OPPS Rate,323.92,102,,,Fee Schedule,102% of WV Medicaid Rate,1289.16,165,,,Fee Schedule,165% of CMS OPPS Rate,809.76,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,2244.21,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,3077.76,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,3855.21,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,317.57,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,781.31,100,,,Fee Schedule,100% of CMS OPPS Rate,809.76,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,109.96,14,,,percent of total billed charges,14% of total billed charges,109.96,3855.21,
"44388 - Colonoscopy through stoma; diagnostic, including collection of specimen(s) by brushing or wa",3572804,CDM,510,RC,44388,HCPCS,Outpatient,,,806.87,403.44,,605.15,75,,,percent of total billed charges,75% of total billed charges,605.15,75,,,percent of total billed charges,75% of total billed charges,781.31,100,,,Fee Schedule,100% of CMS OPPS Rate,323.92,102,,,Fee Schedule,102% of WV Medicaid Rate,1289.16,165,,,Fee Schedule,165% of CMS OPPS Rate,809.76,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,2244.21,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,3077.76,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,3855.21,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,317.57,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,781.31,100,,,Fee Schedule,100% of CMS OPPS Rate,809.76,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,112.96,14,,,percent of total billed charges,14% of total billed charges,112.96,3855.21,
44388 - PF Colonoscopy Stoma Dx Incl Coll Spec Spx,4311779,CDM,960,RC,44388,HCPCS,Outpatient,,,362.4,181.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
44389- Colonoscopy/stoma/w bx/single/mult,3431232,CDM,510,RC,44389,HCPCS,Outpatient,,,1048.95,524.48,,786.71,75,,,percent of total billed charges,75% of total billed charges,786.71,75,,,percent of total billed charges,75% of total billed charges,1018.11,100,,,Fee Schedule,100% of CMS OPPS Rate,423.26,102,,,Fee Schedule,102% of WV Medicaid Rate,1679.88,165,,,Fee Schedule,165% of CMS OPPS Rate,1055.19,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,2924.39,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,4010.57,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,5023.64,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,414.96,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1018.11,100,,,Fee Schedule,100% of CMS OPPS Rate,1055.19,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,146.85,14,,,percent of total billed charges,14% of total billed charges,146.85,5023.64,
44391- Colonoscopy/stoma/control bleeding,3431233,CDM,510,RC,44391,HCPCS,Outpatient,,,1630.53,815.27,,1222.9,75,,,percent of total billed charges,75% of total billed charges,1222.9,75,,,percent of total billed charges,75% of total billed charges,1018.11,100,,,Fee Schedule,100% of CMS OPPS Rate,423.26,102,,,Fee Schedule,102% of WV Medicaid Rate,1679.88,165,,,Fee Schedule,165% of CMS OPPS Rate,1055.19,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,2924.39,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,4010.57,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,5023.64,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,414.96,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1018.11,100,,,Fee Schedule,100% of CMS OPPS Rate,1055.19,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,228.27,14,,,percent of total billed charges,14% of total billed charges,228.27,5023.64,
"44394 - (PF) Colonoscopy through stoma; with removal of tumor(s), polyp(s), or other lesion(s) by",3635067,CDM,510,RC,44394,HCPCS,Outpatient,,,1126.86,563.43,,845.15,75,,,percent of total billed charges,75% of total billed charges,845.15,75,,,percent of total billed charges,75% of total billed charges,1018.11,100,,,Fee Schedule,100% of CMS OPPS Rate,423.26,102,,,Fee Schedule,102% of WV Medicaid Rate,1679.88,165,,,Fee Schedule,165% of CMS OPPS Rate,1055.19,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,2924.39,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,4010.57,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,5023.64,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,414.96,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1018.11,100,,,Fee Schedule,100% of CMS OPPS Rate,1055.19,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,157.76,14,,,percent of total billed charges,14% of total billed charges,157.76,5023.64,
44401- Colonoscopy/stoma/ablation,3431234,CDM,510,RC,44401,HCPCS,Outpatient,,,6006.14,3003.07,,4504.61,75,,,percent of total billed charges,75% of total billed charges,4504.61,75,,,percent of total billed charges,75% of total billed charges,1018.11,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1679.88,165,,,Fee Schedule,165% of CMS OPPS Rate,1055.19,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,2924.39,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,4010.57,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,5023.64,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,1018.11,100,,,Fee Schedule,100% of CMS OPPS Rate,1055.19,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,840.86,14,,,percent of total billed charges,14% of total billed charges,840.86,5023.64,
44404 - COLONOSCOPY STOMA W/SUBMUCOSAL INJECTION,4037561,CDM,983,RC,44404,HCPCS,Outpatient,,,1076.1,538.05,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
44602 - PF Enterorrhaphy Sngl Perforation,4311780,CDM,960,RC,44602,HCPCS,Outpatient,,,3365.54,1682.77,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
"44602 - PF Suture of small intestine (enterorrhaphy) for perforated ulcer, diverticulum, wound, inju",3714933,CDM,510,RC,44602,HCPCS,Outpatient,,,3809.68,1904.84,,2857.26,75,,,percent of total billed charges,75% of total billed charges,2857.26,75,,,percent of total billed charges,75% of total billed charges,3809.68,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,3809.68,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3809.68,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3809.68,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3809.68,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3809.68,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,3809.68,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3809.68,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,533.36,14,,,percent of total billed charges,14% of total billed charges,533.36,3809.68,
44603 - PF Enterorrhaphy Mult Perforations,4311781,CDM,960,RC,44603,HCPCS,Outpatient,,,3849.67,1924.84,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
"44603- Suture of small intestine (enterorrhaphy) for perforated ulcer, diverticulum, wound, injury o",3618862,CDM,510,RC,44603,HCPCS,Outpatient,,,4353.35,2176.68,,3265.01,75,,,percent of total billed charges,75% of total billed charges,3265.01,75,,,percent of total billed charges,75% of total billed charges,4353.35,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,4353.35,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4353.35,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4353.35,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4353.35,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4353.35,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,4353.35,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4353.35,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,609.47,14,,,percent of total billed charges,14% of total billed charges,609.47,4353.35,
44604 - PF Sutr Lg Intestine 1/ Mult Perforat w/o Colostomy,4311782,CDM,960,RC,44604,HCPCS,Outpatient,,,2512.97,1256.49,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
44604 - PF SUTURE OF LARGE INTESTINE,3527840,CDM,960,RC,44604,HCPCS,Outpatient,,,2838.99,1419.5,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
"44615 - PF Intestinal stricturoplasty (enterotomy and enterorrhaphy) with or without dilation, for i",3715386,CDM,510,RC,44615,HCPCS,Outpatient,,,2880.7,1440.35,,2160.53,75,,,percent of total billed charges,75% of total billed charges,2160.53,75,,,percent of total billed charges,75% of total billed charges,2880.7,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,2880.7,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2880.7,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2880.7,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2880.7,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2880.7,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,2880.7,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2880.7,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,403.3,14,,,percent of total billed charges,14% of total billed charges,403.3,2880.7,
44615 - PF Intestinal Stricturoplasty w/wo Dilat Obstrc,4311783,CDM,960,RC,44615,HCPCS,Outpatient,,,2525.31,1262.66,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
44620 - PF Closure Enterostomy Lg/ Sm Intestine,4311784,CDM,960,RC,44620,HCPCS,Outpatient,,,2044.05,1022.03,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
44620-PF REPAIR BOWEL OPENING,3429946,CDM,510,RC,44620,HCPCS,Outpatient,,,2309.37,1154.69,,1732.03,75,,,percent of total billed charges,75% of total billed charges,1732.03,75,,,percent of total billed charges,75% of total billed charges,2309.37,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,2309.37,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2309.37,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2309.37,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2309.37,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2309.37,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,2309.37,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2309.37,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,323.31,14,,,percent of total billed charges,14% of total billed charges,323.31,2309.37,
44625 - PF Clsr Ntrstm Lg/ Sm Resc & Anast Oth/Thn Clrct,4311785,CDM,960,RC,44625,HCPCS,Outpatient,,,2383.71,1191.86,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
44625 ? PF Repair Bowel Opening,3550406,CDM,510,RC,44625,HCPCS,Outpatient,,,2697.06,1348.53,,2022.8,75,,,percent of total billed charges,75% of total billed charges,2022.8,75,,,percent of total billed charges,75% of total billed charges,2697.06,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,2697.06,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2697.06,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2697.06,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2697.06,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2697.06,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,2697.06,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2697.06,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,377.59,14,,,percent of total billed charges,14% of total billed charges,377.59,2697.06,
"44626 - (PF) Closure of enterostomy, large or small intestine; with resection and colorectal anas",3635068,CDM,510,RC,44626,HCPCS,Outpatient,,,4295.18,2147.59,,3221.39,75,,,percent of total billed charges,75% of total billed charges,3221.39,75,,,percent of total billed charges,75% of total billed charges,4295.18,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,4295.18,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4295.18,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4295.18,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4295.18,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4295.18,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,4295.18,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4295.18,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,601.33,14,,,percent of total billed charges,14% of total billed charges,601.33,4295.18,
44626 - PF Clsr Ntrstm Lg/ Sm Resc & Colorectal Anastomosis,4311786,CDM,960,RC,44626,HCPCS,Outpatient,,,3787.24,1893.62,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
44640 - PF - Closure of intestinal cutaneous fistula,3640922,CDM,510,RC,44640,HCPCS,Outpatient,,,3760.05,1880.03,,2820.04,75,,,percent of total billed charges,75% of total billed charges,2820.04,75,,,percent of total billed charges,75% of total billed charges,3760.05,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,3760.05,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3760.05,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3760.05,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3760.05,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3760.05,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,3760.05,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3760.05,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,526.41,14,,,percent of total billed charges,14% of total billed charges,526.41,3760.05,
44640 - PF Closure Intestinal Cutaneous Fistula,4311787,CDM,960,RC,44640,HCPCS,Outpatient,,,3314.97,1657.49,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
44650 - Closure of enteroenteric or enterocolic fistula,3572791,CDM,983,RC,44650,HCPCS,Outpatient,,,3879.43,1939.72,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
44660- Closure of enterovesical fistula; without intestinal or bladder resection,3622986,CDM,510,RC,44660,HCPCS,Outpatient,,,3551.58,1775.79,,2663.69,75,,,percent of total billed charges,75% of total billed charges,2663.69,75,,,percent of total billed charges,75% of total billed charges,3551.58,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,3551.58,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3551.58,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3551.58,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3551.58,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3551.58,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,3551.58,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3551.58,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,497.22,14,,,percent of total billed charges,14% of total billed charges,497.22,3551.58,
44661 PF - MA REPAIR BOWEL-BLADDER FISTULA,4135114,CDM,960,RC,44661,HCPCS,Outpatient,,,3702.52,1851.26,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
44701 - PF Intraoperative colonic lavage (List separately in addition to code for primary procedure),3714936,CDM,510,RC,44701,HCPCS,Outpatient,,,461.8,230.9,,346.35,75,,,percent of total billed charges,75% of total billed charges,346.35,75,,,percent of total billed charges,75% of total billed charges,147.78,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.65,14,,,percent of total billed charges,14% of total billed charges,64.65,346.35,
44799 - PF Unlisted Px Sm Intestine,4311788,CDM,960,RC,44799,HCPCS,Outpatient,,,2374.4,1187.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
"44799- Unlisted procedure, small intestine",3623581,CDM,510,RC,44799,HCPCS,Outpatient,,,2659.33,1329.67,,1994.5,75,,,percent of total billed charges,75% of total billed charges,1994.5,75,,,percent of total billed charges,75% of total billed charges,776.11,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1280.58,165,,,Fee Schedule,165% of CMS OPPS Rate,804.37,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,2229.28,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,3057.28,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,3829.56,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,776.11,100,,,Fee Schedule,100% of CMS OPPS Rate,804.37,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,372.31,14,,,percent of total billed charges,14% of total billed charges,372.31,3829.56,
44800 - PF Exc Meckel's Diverticulum/ Omphalomesenteric Duct,4311789,CDM,960,RC,44800,HCPCS,Outpatient,,,1832.21,916.11,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
44880-EXCISION OF BOWEL POUCH,3429949,CDM,960,RC,44800,HCPCS,Outpatient,,,2058.21,1029.11,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
44820 - Excision of lesion of mesentery (separate procedure,3783253,CDM,510,RC,44820,HCPCS,Outpatient,,,2299.47,1149.74,,1724.6,75,,,percent of total billed charges,75% of total billed charges,1724.6,75,,,percent of total billed charges,75% of total billed charges,2299.47,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,2299.47,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2299.47,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2299.47,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2299.47,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2299.47,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,2299.47,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2299.47,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,321.93,14,,,percent of total billed charges,14% of total billed charges,321.93,2299.47,
44900 - PF I&D Appendiceal Abscess Open,4311790,CDM,960,RC,44900,HCPCS,Outpatient,,,1871.98,935.99,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
44950 - PF Appendectomy,4311791,CDM,960,RC,44950,HCPCS,Outpatient,,,1531.99,766,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
44950- Appendectomy,3431235,CDM,510,RC,44950,HCPCS,Outpatient,,,1733.41,866.71,,1300.06,75,,,percent of total billed charges,75% of total billed charges,1300.06,75,,,percent of total billed charges,75% of total billed charges,3329.99,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,5494.49,165,,,Fee Schedule,165% of CMS OPPS Rate,3451.26,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,9564.96,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,13117.59,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,16431.12,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,3329.99,100,,,Fee Schedule,100% of CMS OPPS Rate,3451.26,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,242.68,14,,,percent of total billed charges,14% of total billed charges,242.68,16431.12,
44955 - PF Appendec Indicated Purpose Oth Major Px Not Spx,4311792,CDM,960,RC,44955,HCPCS,Outpatient,,,199.95,99.98,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
44955- Appendectomy w/ other major procedure,3431236,CDM,510,RC,44955,HCPCS,Outpatient,,,224.56,112.28,,168.42,75,,,percent of total billed charges,75% of total billed charges,168.42,75,,,percent of total billed charges,75% of total billed charges,71.86,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.44,14,,,percent of total billed charges,14% of total billed charges,31.44,168.42,
44960 - PF Appendec Rptd Appendix Absc/ Pritonitis,4311793,CDM,960,RC,44960,HCPCS,Outpatient,,,2093.01,1046.51,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
44960- Appendectomy/ruptured w/abscess/peritonitis,3431237,CDM,510,RC,44960,HCPCS,Outpatient,,,2373.13,1186.57,,1779.85,75,,,percent of total billed charges,75% of total billed charges,1779.85,75,,,percent of total billed charges,75% of total billed charges,2373.13,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,2373.13,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2373.13,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2373.13,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2373.13,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2373.13,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,2373.13,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2373.13,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,332.24,14,,,percent of total billed charges,14% of total billed charges,332.24,2373.13,
44970 - PF Laparoscopic Appendectomy,4311794,CDM,960,RC,44970,HCPCS,Outpatient,,,1430.96,715.48,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
"44970-PF LAPAROSCOPY, APPENDECTOMY",3429957,CDM,510,RC,44970,HCPCS,Outpatient,,,1617.86,808.93,,1213.4,75,,,percent of total billed charges,75% of total billed charges,1213.4,75,,,percent of total billed charges,75% of total billed charges,4900.27,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,8085.46,165,,,Fee Schedule,165% of CMS OPPS Rate,5078.72,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,14075.4,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,19303.29,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,24179.33,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,4900.27,100,,,Fee Schedule,100% of CMS OPPS Rate,5078.72,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,226.5,14,,,percent of total billed charges,14% of total billed charges,226.5,24179.33,
"44979 - (PF) Unlisted laparoscopy procedure, appendix",3635069,CDM,510,RC,44979,HCPCS,Outpatient,,,1613.96,806.98,,1210.47,75,,,percent of total billed charges,75% of total billed charges,1210.47,75,,,percent of total billed charges,75% of total billed charges,4900.27,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,8085.46,165,,,Fee Schedule,165% of CMS OPPS Rate,5078.72,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,14075.4,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,19303.29,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,24179.33,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,4900.27,100,,,Fee Schedule,100% of CMS OPPS Rate,5078.72,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,225.95,14,,,percent of total billed charges,14% of total billed charges,225.95,24179.33,
44979 - PF Unlisted Laparoscopy Px Appendix,4311795,CDM,960,RC,44979,HCPCS,Outpatient,,,1424.64,712.32,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
45005- MSA DRAINAGE OF RECTAL ABSCESS,3514689,CDM,360,RC,45005,HCPCS,Outpatient,,,783.85,391.93,,587.89,75,,,percent of total billed charges,75% of total billed charges,587.89,75,,,percent of total billed charges,75% of total billed charges,1018.11,100,,,Fee Schedule,100% of CMS OPPS Rate,423.26,102,,,Fee Schedule,102% of WV Medicaid Rate,1679.88,165,,,Fee Schedule,165% of CMS OPPS Rate,1055.19,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,2924.39,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,4010.57,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,5023.64,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,414.96,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1018.11,100,,,Fee Schedule,100% of CMS OPPS Rate,1055.19,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,109.74,14,,,percent of total billed charges,14% of total billed charges,109.74,5023.64,
45005-PF I&D SUBMUCOSAL ABSCESS RECTUM,4321635,CDM,981,RC,45005,HCPCS,Outpatient,,,325.22,162.61,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
45020-PF I&D DP SUPRALEVATOR PELVIRCT/RETRORCT ABSC,4321634,CDM,981,RC,45020,HCPCS,Outpatient,,,1131.44,565.72,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
45100- Biopsy of rectum,3431238,CDM,361,RC,45100,HCPCS,Outpatient,,,784.55,392.28,,588.41,75,,,percent of total billed charges,75% of total billed charges,588.41,75,,,percent of total billed charges,75% of total billed charges,2415.71,100,,,Fee Schedule,100% of CMS OPPS Rate,926.81,102,,,Fee Schedule,102% of WV Medicaid Rate,3985.94,165,,,Fee Schedule,165% of CMS OPPS Rate,2503.69,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,6938.85,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,9516.07,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,11919.85,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,908.64,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2415.71,100,,,Fee Schedule,100% of CMS OPPS Rate,2503.69,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,109.84,14,,,percent of total billed charges,14% of total billed charges,109.84,11919.85,
"45110 - (PF) Proctectomy; complete, combined abdominoperineal, with colostomy",3635070,CDM,510,RC,45110,HCPCS,Outpatient,,,4830.35,2415.18,,3622.76,75,,,percent of total billed charges,75% of total billed charges,3622.76,75,,,percent of total billed charges,75% of total billed charges,4830.35,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,4830.35,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4830.35,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4830.35,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4830.35,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4830.35,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,4830.35,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4830.35,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,676.25,14,,,percent of total billed charges,14% of total billed charges,676.25,4830.35,
"45111 - (PF) Proctectomy; partial resection of rectum, transabdominal approach",3635071,CDM,510,RC,45111,HCPCS,Outpatient,,,2893.57,1446.79,,2170.18,75,,,percent of total billed charges,75% of total billed charges,2170.18,75,,,percent of total billed charges,75% of total billed charges,2893.57,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,2893.57,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2893.57,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2893.57,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2893.57,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2893.57,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,2893.57,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2893.57,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,405.1,14,,,percent of total billed charges,14% of total billed charges,405.1,2893.57,
"45119- Proctectomy, combined abdominoperineal pull-through procedure (eg, colo-anal anastomosis), wi",3566788,CDM,510,RC,45119,HCPCS,Outpatient,,,4935.26,2467.63,,3701.45,75,,,percent of total billed charges,75% of total billed charges,3701.45,75,,,percent of total billed charges,75% of total billed charges,4935.26,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,4935.26,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4935.26,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4935.26,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4935.26,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4935.26,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,4935.26,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4935.26,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,690.94,14,,,percent of total billed charges,14% of total billed charges,690.94,4935.26,
"45123 - Proctectomy, partial, without anastomosis, perineal approach",4037562,CDM,983,RC,45123,HCPCS,Outpatient,,,2953.2,1476.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
"45171 - (PF) Excision of rectal tumor, transanal approach; not including muscularis propria",3635072,CDM,510,RC,45171,HCPCS,Outpatient,,,1611.42,805.71,,1208.57,75,,,percent of total billed charges,75% of total billed charges,1208.57,75,,,percent of total billed charges,75% of total billed charges,2415.71,100,,,Fee Schedule,100% of CMS OPPS Rate,926.81,102,,,Fee Schedule,102% of WV Medicaid Rate,3985.94,165,,,Fee Schedule,165% of CMS OPPS Rate,2503.69,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,6938.85,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,9516.07,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,11919.85,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,908.64,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2415.71,100,,,Fee Schedule,100% of CMS OPPS Rate,2503.69,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,225.6,14,,,percent of total billed charges,14% of total billed charges,225.6,11919.85,
"45172 - PF Excision of rectal tumor, transanal approach; not including muscularis propria (ie, parti",3714941,CDM,510,RC,45172,HCPCS,Outpatient,,,2164.77,1082.39,,1623.58,75,,,percent of total billed charges,75% of total billed charges,1623.58,75,,,percent of total billed charges,75% of total billed charges,2415.71,100,,,Fee Schedule,100% of CMS OPPS Rate,926.81,102,,,Fee Schedule,102% of WV Medicaid Rate,3985.94,165,,,Fee Schedule,165% of CMS OPPS Rate,2503.69,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,6938.85,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,9516.07,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,11919.85,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,908.64,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2415.71,100,,,Fee Schedule,100% of CMS OPPS Rate,2503.69,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,303.07,14,,,percent of total billed charges,14% of total billed charges,303.07,11919.85,
45300 - PF Proctosgmdsc Rgd Dx w/ wo Coll Spec Br/ Wa Spx,4311796,CDM,960,RC,45300,HCPCS,Outpatient,,,111.88,55.94,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
"45300 - Proctosigmoidoscopy, rigid; diagnostic, with or without collection of specimen(s) by brushin",3572805,CDM,510,RC,45300,HCPCS,Outpatient,,,321.06,160.53,,240.8,75,,,percent of total billed charges,75% of total billed charges,240.8,75,,,percent of total billed charges,75% of total billed charges,781.31,100,,,Fee Schedule,100% of CMS OPPS Rate,81.36,102,,,Fee Schedule,102% of WV Medicaid Rate,1289.16,165,,,Fee Schedule,165% of CMS OPPS Rate,809.76,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,2244.21,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,3077.76,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,3855.21,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,79.76,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,781.31,100,,,Fee Schedule,100% of CMS OPPS Rate,809.76,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,44.95,14,,,percent of total billed charges,14% of total billed charges,44.95,3855.21,
"45303 - (PF) Proctosigmoidoscopy, rigid; with dilation",3635073,CDM,510,RC,45303,HCPCS,Outpatient,,,2371.11,1185.56,,1778.33,75,,,percent of total billed charges,75% of total billed charges,1778.33,75,,,percent of total billed charges,75% of total billed charges,1018.11,100,,,Fee Schedule,100% of CMS OPPS Rate,423.26,102,,,Fee Schedule,102% of WV Medicaid Rate,1679.88,165,,,Fee Schedule,165% of CMS OPPS Rate,1055.19,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,2924.39,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,4010.57,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,5023.64,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,414.96,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1018.11,100,,,Fee Schedule,100% of CMS OPPS Rate,1055.19,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,331.96,14,,,percent of total billed charges,14% of total billed charges,331.96,5023.64,
45303 - PF Proctosgmdsc Rigid w/ Dilation,4311797,CDM,960,RC,45303,HCPCS,Outpatient,,,198.36,99.18,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
45305 - PF Proctosgmdsc Rigid w/ Bx Sngl/ Mult,4311798,CDM,960,RC,45305,HCPCS,Outpatient,,,168.62,84.31,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
"45305 Proctosigmoidoscopy, rigid; with biopsy, single or multiple",3621146,CDM,510,RC,45305,HCPCS,Outpatient,,,457.94,228.97,,343.46,75,,,percent of total billed charges,75% of total billed charges,343.46,75,,,percent of total billed charges,75% of total billed charges,1018.11,100,,,Fee Schedule,100% of CMS OPPS Rate,423.26,102,,,Fee Schedule,102% of WV Medicaid Rate,1679.88,165,,,Fee Schedule,165% of CMS OPPS Rate,1055.19,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,2924.39,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,4010.57,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,5023.64,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,414.96,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1018.11,100,,,Fee Schedule,100% of CMS OPPS Rate,1055.19,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,64.11,14,,,percent of total billed charges,14% of total billed charges,64.11,5023.64,
45307 - PF Proctosgmdsc Rigid w/ Rmvl Foreign Body,4311799,CDM,960,RC,45307,HCPCS,Outpatient,,,237.3,118.65,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
45307-PF PROCTOSGMDSC RIGID W/RMVL FOREIGN BODY,4321468,CDM,981,RC,45307,HCPCS,Outpatient,,,199.88,99.94,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
45330 - Diagnostic sigmoidoscopy,3431239,CDM,360,RC,45330,HCPCS,Outpatient,,,462.14,231.07,,346.61,75,,,percent of total billed charges,75% of total billed charges,346.61,75,,,percent of total billed charges,75% of total billed charges,781.31,100,,,Fee Schedule,100% of CMS OPPS Rate,128.85,102,,,Fee Schedule,102% of WV Medicaid Rate,1289.16,165,,,Fee Schedule,165% of CMS OPPS Rate,809.76,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,2244.21,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,3077.76,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,3855.21,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,126.32,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,781.31,100,,,Fee Schedule,100% of CMS OPPS Rate,809.76,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,64.7,14,,,percent of total billed charges,14% of total billed charges,64.7,3855.21,
45330 - PF Sigmoidoscopy Flx Dx w/ Coll Spec Br/ Wa If Pfrmd,4311800,CDM,960,RC,45330,HCPCS,Outpatient,,,128.24,64.12,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
45330-PF SIGMOIDOSCOPY FLX DX W/COLLJ SPEC BR/WA IF PFRMD,4321633,CDM,981,RC,45330,HCPCS,Outpatient,,,108.02,54.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
45331 - PF Sigmoidoscopy Flx w/ Bx Sngl/Mult,4311801,CDM,960,RC,45331,HCPCS,Outpatient,,,164.12,82.06,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
45331 - Sigmoidoscopy and biopsy,3431240,CDM,360,RC,45331,HCPCS,Outpatient,,,716.67,358.34,,537.5,75,,,percent of total billed charges,75% of total billed charges,537.5,75,,,percent of total billed charges,75% of total billed charges,781.31,100,,,Fee Schedule,100% of CMS OPPS Rate,323.92,102,,,Fee Schedule,102% of WV Medicaid Rate,1289.16,165,,,Fee Schedule,165% of CMS OPPS Rate,809.76,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,2244.21,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,3077.76,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,3855.21,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,317.57,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,781.31,100,,,Fee Schedule,100% of CMS OPPS Rate,809.76,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,100.33,14,,,percent of total billed charges,14% of total billed charges,100.33,3855.21,
45332 - PF Sigmoidoscopy Flx w/ Rmvl Foreign Body,4311808,CDM,960,RC,45332,HCPCS,Outpatient,,,240.48,120.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
45332 SIGMOIDOSCOPY W/FB REMOVAL,3429958,CDM,960,RC,45332,HCPCS,Outpatient,,,701.37,350.69,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
45332-PF SIGMOIDOSCOPY FLX W/RMVL FOREIGN BODY,4321469,CDM,981,RC,45332,HCPCS,Outpatient,,,202.54,101.27,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
45333 - PF Sigoidoscopy Flx w/ Rmvl Tumor By Hot Bx Forceps,4311809,CDM,960,RC,45333,HCPCS,Outpatient,,,215.95,107.98,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
45333- Sigmoid/rmv tumor/polyp/hot bx for,3431241,CDM,510,RC,45333,HCPCS,Outpatient,,,830.16,415.08,,622.62,75,,,percent of total billed charges,75% of total billed charges,622.62,75,,,percent of total billed charges,75% of total billed charges,781.31,100,,,Fee Schedule,100% of CMS OPPS Rate,323.92,102,,,Fee Schedule,102% of WV Medicaid Rate,1289.16,165,,,Fee Schedule,165% of CMS OPPS Rate,809.76,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,2244.21,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,3077.76,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,3855.21,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,317.57,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,781.31,100,,,Fee Schedule,100% of CMS OPPS Rate,809.76,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,116.22,14,,,percent of total billed charges,14% of total billed charges,116.22,3855.21,
45334 - PF Signoidoscopy Flx Control Bleeding,4311810,CDM,960,RC,45334,HCPCS,Outpatient,,,270.11,135.06,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
45334- Sigmoidoscopy/control of bleeding,3431242,CDM,510,RC,45334,HCPCS,Outpatient,,,1246.96,623.48,,935.22,75,,,percent of total billed charges,75% of total billed charges,935.22,75,,,percent of total billed charges,75% of total billed charges,1018.11,100,,,Fee Schedule,100% of CMS OPPS Rate,423.26,102,,,Fee Schedule,102% of WV Medicaid Rate,1679.88,165,,,Fee Schedule,165% of CMS OPPS Rate,1055.19,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,2924.39,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,4010.57,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,5023.64,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,414.96,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1018.11,100,,,Fee Schedule,100% of CMS OPPS Rate,1055.19,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,174.57,14,,,percent of total billed charges,14% of total billed charges,174.57,5023.64,
45335- Sigmoidoscopy/submucosal injection,3431243,CDM,510,RC,45335,HCPCS,Outpatient,,,727.99,364,,545.99,75,,,percent of total billed charges,75% of total billed charges,545.99,75,,,percent of total billed charges,75% of total billed charges,781.31,100,,,Fee Schedule,100% of CMS OPPS Rate,323.92,102,,,Fee Schedule,102% of WV Medicaid Rate,1289.16,165,,,Fee Schedule,165% of CMS OPPS Rate,809.76,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,2244.21,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,3077.76,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,3855.21,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,317.57,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,781.31,100,,,Fee Schedule,100% of CMS OPPS Rate,809.76,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,101.92,14,,,percent of total billed charges,14% of total billed charges,101.92,3855.21,
45337- Sigmoidoscopy/decompression,3431244,CDM,510,RC,45337,HCPCS,Outpatient,,,300.58,150.29,,225.44,75,,,percent of total billed charges,75% of total billed charges,225.44,75,,,percent of total billed charges,75% of total billed charges,781.31,100,,,Fee Schedule,100% of CMS OPPS Rate,323.92,102,,,Fee Schedule,102% of WV Medicaid Rate,1289.16,165,,,Fee Schedule,165% of CMS OPPS Rate,809.76,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,2244.21,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,3077.76,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,3855.21,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,317.57,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,781.31,100,,,Fee Schedule,100% of CMS OPPS Rate,809.76,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,42.08,14,,,percent of total billed charges,14% of total billed charges,42.08,3855.21,
"45338 - (PF) Sigmoidoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by",3635074,CDM,510,RC,45338,HCPCS,Outpatient,,,758.68,379.34,,569.01,75,,,percent of total billed charges,75% of total billed charges,569.01,75,,,percent of total billed charges,75% of total billed charges,1018.11,100,,,Fee Schedule,100% of CMS OPPS Rate,423.26,102,,,Fee Schedule,102% of WV Medicaid Rate,1679.88,165,,,Fee Schedule,165% of CMS OPPS Rate,1055.19,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,2924.39,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,4010.57,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,5023.64,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,414.96,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1018.11,100,,,Fee Schedule,100% of CMS OPPS Rate,1055.19,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,106.22,14,,,percent of total billed charges,14% of total billed charges,106.22,5023.64,
45338 - PF Sgmdsc Flx Rmvl Tum Polyp/ Oth Les Snare Tq,4311811,CDM,960,RC,45338,HCPCS,Outpatient,,,275.85,137.93,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
45340- Sigmoidoscop/transendo balloon dil,3431245,CDM,510,RC,45340,HCPCS,Outpatient,,,1151.91,575.96,,863.93,75,,,percent of total billed charges,75% of total billed charges,863.93,75,,,percent of total billed charges,75% of total billed charges,1018.11,100,,,Fee Schedule,100% of CMS OPPS Rate,423.26,102,,,Fee Schedule,102% of WV Medicaid Rate,1679.88,165,,,Fee Schedule,165% of CMS OPPS Rate,1055.19,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,2924.39,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,4010.57,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,5023.64,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,414.96,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1018.11,100,,,Fee Schedule,100% of CMS OPPS Rate,1055.19,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,161.27,14,,,percent of total billed charges,14% of total billed charges,161.27,5023.64,
45341 SIGMOIDOSCOPY W/ULTRASOUND,3429961,CDM,960,RC,45341,HCPCS,Outpatient,,,321.83,160.92,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
45342 SIGMOIDOSCOPY W US GUIDE BX,3429962,CDM,960,RC,45342,HCPCS,Outpatient,,,440.92,220.46,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
45346- Sigmoidoscopy/ablate tumor/polyps,3431246,CDM,510,RC,45346,HCPCS,Outpatient,,,5796.99,2898.5,,4347.74,75,,,percent of total billed charges,75% of total billed charges,4347.74,75,,,percent of total billed charges,75% of total billed charges,1018.11,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1679.88,165,,,Fee Schedule,165% of CMS OPPS Rate,1055.19,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,2924.39,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,4010.57,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,5023.64,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,1018.11,100,,,Fee Schedule,100% of CMS OPPS Rate,1055.19,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,811.58,14,,,percent of total billed charges,14% of total billed charges,811.58,5023.64,
45347- Sigmoidoscopy/endoscopic stent,3431247,CDM,510,RC,45347,HCPCS,Outpatient,,,401.37,200.69,,301.03,75,,,percent of total billed charges,75% of total billed charges,301.03,75,,,percent of total billed charges,75% of total billed charges,4927.14,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,8129.78,165,,,Fee Schedule,165% of CMS OPPS Rate,5106.56,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,14152.55,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,19409.09,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,24311.86,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,4927.14,100,,,Fee Schedule,100% of CMS OPPS Rate,5106.56,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,56.19,14,,,percent of total billed charges,14% of total billed charges,56.19,24311.86,
45349 SIGMOIDOSCOPY W/RESECTION,3429963,CDM,960,RC,45349,HCPCS,Outpatient,,,516.5,258.25,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
45350 - SIGMOIDOSCOPY FLX WITH WITH BAND LIGATION(S),3997185,CDM,960,RC,45350,HCPCS,Outpatient,,,1689.87,844.94,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
45378 - PF Colonoscopy Flx Dx w/ Coll Spec When Pfrmd,4311812,CDM,960,RC,45378,HCPCS,Outpatient,,,371.08,185.54,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
45378 - PF DIAGNOSTIC COLONSCOPY,3429964,CDM,960,RC,45378,HCPCS,Outpatient,,,371.08,185.54,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
45379 - PF Colonoscopy Flx w/ Removal of Foreign Body(s),4311813,CDM,960,RC,45379,HCPCS,Outpatient,,,549.91,274.96,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
45379- Colonoscopy/remove foreign body,3431248,CDM,510,RC,45379,HCPCS,Outpatient,,,1118.44,559.22,,838.83,75,,,percent of total billed charges,75% of total billed charges,838.83,75,,,percent of total billed charges,75% of total billed charges,1018.11,100,,,Fee Schedule,100% of CMS OPPS Rate,423.26,102,,,Fee Schedule,102% of WV Medicaid Rate,1679.88,165,,,Fee Schedule,165% of CMS OPPS Rate,1055.19,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,2924.39,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,4010.57,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,5023.64,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,414.96,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1018.11,100,,,Fee Schedule,100% of CMS OPPS Rate,1055.19,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,156.58,14,,,percent of total billed charges,14% of total billed charges,156.58,5023.64,
45380 - Colonoscopy and biopsy,3431249,CDM,360,RC,45380,HCPCS,Outpatient,,,1109.52,554.76,,832.14,75,,,percent of total billed charges,75% of total billed charges,832.14,75,,,percent of total billed charges,75% of total billed charges,1018.11,100,,,Fee Schedule,100% of CMS OPPS Rate,423.26,102,,,Fee Schedule,102% of WV Medicaid Rate,1679.88,165,,,Fee Schedule,165% of CMS OPPS Rate,1055.19,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,2924.39,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,4010.57,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,5023.64,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,414.96,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1018.11,100,,,Fee Schedule,100% of CMS OPPS Rate,1055.19,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,155.33,14,,,percent of total billed charges,14% of total billed charges,155.33,5023.64,
45380 - PF Colonoscopy w/ Bx Sngl/Mult,4311814,CDM,960,RC,45380,HCPCS,Outpatient,,,462.05,231.03,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
"45381 COLONSCOPE, SUBMUCOUS INJ",3429965,CDM,510,RC,45381,HCPCS,Outpatient,,,1130.85,565.43,,848.14,75,,,percent of total billed charges,75% of total billed charges,848.14,75,,,percent of total billed charges,75% of total billed charges,1018.11,100,,,Fee Schedule,100% of CMS OPPS Rate,423.26,102,,,Fee Schedule,102% of WV Medicaid Rate,1679.88,165,,,Fee Schedule,165% of CMS OPPS Rate,1055.19,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,2924.39,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,4010.57,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,5023.64,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,414.96,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1018.11,100,,,Fee Schedule,100% of CMS OPPS Rate,1055.19,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,158.32,14,,,percent of total billed charges,14% of total billed charges,158.32,5023.64,
45382 COLONSCOPY/CONTROL BLEEDING,3429966,CDM,960,RC,45382,HCPCS,Outpatient,,,1703.6,851.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
45384 - PF Colsc Flx w/ Removal Lesion By Hot Bx Forceps,4311815,CDM,960,RC,45384,HCPCS,Outpatient,,,528.04,264.02,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
45384 LESION REMOVE COLONSCOPY,3429968,CDM,960,RC,45384,HCPCS,Outpatient,,,1254,627,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
45385 - PF Colsc Flx w/ Rmvl Of Tumor Polup Lesion Snare Tq,4311816,CDM,960,RC,45385,HCPCS,Outpatient,,,584.96,292.48,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
45385- Colonoscopy/snare rmv/tumor/polyp,3431250,CDM,510,RC,45385,HCPCS,Outpatient,,,1168.64,584.32,,876.48,75,,,percent of total billed charges,75% of total billed charges,876.48,75,,,percent of total billed charges,75% of total billed charges,1018.11,100,,,Fee Schedule,100% of CMS OPPS Rate,423.26,102,,,Fee Schedule,102% of WV Medicaid Rate,1679.88,165,,,Fee Schedule,165% of CMS OPPS Rate,1055.19,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,2924.39,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,4010.57,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,5023.64,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,414.96,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1018.11,100,,,Fee Schedule,100% of CMS OPPS Rate,1055.19,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,163.61,14,,,percent of total billed charges,14% of total billed charges,163.61,5023.64,
45386 COLONSOPE DILATE STICTURE,3429969,CDM,960,RC,45386,HCPCS,Outpatient,,,1555.39,777.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
45388 - PF Colonoscopy Flx Ablation Tumor Polyp/ Other Les,4311817,CDM,960,RC,45388,HCPCS,Outpatient,,,625.98,312.99,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
45388- Colonoscopy/w ablat tumor/polyps,3431251,CDM,510,RC,45388,HCPCS,Outpatient,,,6210.73,3105.37,,4658.05,75,,,percent of total billed charges,75% of total billed charges,4658.05,75,,,percent of total billed charges,75% of total billed charges,1018.11,100,,,Fee Schedule,100% of CMS OPPS Rate,423.26,102,,,Fee Schedule,102% of WV Medicaid Rate,1679.88,165,,,Fee Schedule,165% of CMS OPPS Rate,1055.19,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,2924.39,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,4010.57,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,5023.64,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,414.96,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1018.11,100,,,Fee Schedule,100% of CMS OPPS Rate,1055.19,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,869.5,14,,,percent of total billed charges,14% of total billed charges,414.96,5023.64,
45389- Colonoscopy/w endoscopic stent,3431252,CDM,510,RC,45389,HCPCS,Outpatient,,,756.84,378.42,,567.63,75,,,percent of total billed charges,75% of total billed charges,567.63,75,,,percent of total billed charges,75% of total billed charges,4927.14,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,8129.78,165,,,Fee Schedule,165% of CMS OPPS Rate,5106.56,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,14152.55,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,19409.09,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,24311.86,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,4927.14,100,,,Fee Schedule,100% of CMS OPPS Rate,5106.56,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,105.96,14,,,percent of total billed charges,14% of total billed charges,105.96,24311.86,
45390 - PF COLONOSCOPY W/RESECTION,3429970,CDM,960,RC,45390,HCPCS,Outpatient,,,667.21,333.61,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
45391 COLONOSCOPY W/ENDOSCOPE US,3429971,CDM,960,RC,45391,HCPCS,Outpatient,,,671.96,335.98,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
45392 COLONSOPY W ENDOSCOPIC FNB,3429972,CDM,960,RC,45392,HCPCS,Outpatient,,,792.14,396.07,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
45393- Colonoscopy w/decompression,3431253,CDM,510,RC,45393,HCPCS,Outpatient,,,664.25,332.13,,498.19,75,,,percent of total billed charges,75% of total billed charges,498.19,75,,,percent of total billed charges,75% of total billed charges,1018.11,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1679.88,165,,,Fee Schedule,165% of CMS OPPS Rate,1055.19,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,2924.39,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,4010.57,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,5023.64,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,1018.11,100,,,Fee Schedule,100% of CMS OPPS Rate,1055.19,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,93,14,,,percent of total billed charges,14% of total billed charges,93,5023.64,
"45395 LAP, REMOVAL OF RECTUM",3429973,CDM,960,RC,45395,HCPCS,Outpatient,,,5168.3,2584.15,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
"45397 LAP, REMOVCE RECTUM W/POUCH",3429974,CDM,960,RC,45397,HCPCS,Outpatient,,,5613.52,2806.76,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
45398- Colonoscopy/flex/w band ligation,3431254,CDM,510,RC,45398,HCPCS,Outpatient,,,2106.1,1053.05,,1579.58,75,,,percent of total billed charges,75% of total billed charges,1579.58,75,,,percent of total billed charges,75% of total billed charges,1018.11,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1679.88,165,,,Fee Schedule,165% of CMS OPPS Rate,1055.19,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,2924.39,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,4010.57,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,5023.64,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,1018.11,100,,,Fee Schedule,100% of CMS OPPS Rate,1055.19,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,294.85,14,,,percent of total billed charges,14% of total billed charges,294.85,5023.64,
45399 - PF Unlisted Procedure Colon,4311818,CDM,960,RC,45399,HCPCS,Outpatient,,,593.6,296.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
45541-PF PROCTOPEXY PERINEAL APPROACH,4321632,CDM,981,RC,45541,HCPCS,Outpatient,,,1848.86,924.43,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
45560- Rectocele repair,3431255,CDM,510,RC,45560,HCPCS,Outpatient,,,1824.04,912.02,,1368.03,75,,,percent of total billed charges,75% of total billed charges,1368.03,75,,,percent of total billed charges,75% of total billed charges,2415.71,100,,,Fee Schedule,100% of CMS OPPS Rate,926.81,102,,,Fee Schedule,102% of WV Medicaid Rate,3985.94,165,,,Fee Schedule,165% of CMS OPPS Rate,2503.69,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,6938.85,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,9516.07,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,11919.85,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,908.64,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2415.71,100,,,Fee Schedule,100% of CMS OPPS Rate,2503.69,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,255.37,14,,,percent of total billed charges,14% of total billed charges,255.37,11919.85,
45800- Closure of rectovesical fistula;,3566789,CDM,510,RC,45800,HCPCS,Outpatient,,,3431.2,1715.6,,2573.4,75,,,percent of total billed charges,75% of total billed charges,2573.4,75,,,percent of total billed charges,75% of total billed charges,3431.2,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,3431.2,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3431.2,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3431.2,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3431.2,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3431.2,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,3431.2,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3431.2,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,480.37,14,,,percent of total billed charges,14% of total billed charges,480.37,3431.2,
45905 - (PF) Dilation of anal sphincter (separate procedure) under anesthesia other than,3635075,CDM,510,RC,45905,HCPCS,Outpatient,,,439.93,219.97,,329.95,75,,,percent of total billed charges,75% of total billed charges,329.95,75,,,percent of total billed charges,75% of total billed charges,1018.11,100,,,Fee Schedule,100% of CMS OPPS Rate,423.26,102,,,Fee Schedule,102% of WV Medicaid Rate,1679.88,165,,,Fee Schedule,165% of CMS OPPS Rate,1055.19,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,2924.39,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,4010.57,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,5023.64,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,414.96,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1018.11,100,,,Fee Schedule,100% of CMS OPPS Rate,1055.19,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,61.59,14,,,percent of total billed charges,14% of total billed charges,61.59,5023.64,
45910 - (PF) Dilation of rectal stricture (separate procedure) under anesthesia other than,3635076,CDM,510,RC,45910,HCPCS,Outpatient,,,506.13,253.07,,379.6,75,,,percent of total billed charges,75% of total billed charges,379.6,75,,,percent of total billed charges,75% of total billed charges,1018.11,100,,,Fee Schedule,100% of CMS OPPS Rate,423.26,102,,,Fee Schedule,102% of WV Medicaid Rate,1679.88,165,,,Fee Schedule,165% of CMS OPPS Rate,1055.19,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,2924.39,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,4010.57,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,5023.64,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,414.96,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1018.11,100,,,Fee Schedule,100% of CMS OPPS Rate,1055.19,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,70.86,14,,,percent of total billed charges,14% of total billed charges,70.86,5023.64,
45915- Removal of fecal impaction or foreign body (separate procedure) under anesthesia,3569402,CDM,510,RC,45915,HCPCS,Outpatient,,,902.82,451.41,,677.12,75,,,percent of total billed charges,75% of total billed charges,677.12,75,,,percent of total billed charges,75% of total billed charges,1018.11,100,,,Fee Schedule,100% of CMS OPPS Rate,423.26,102,,,Fee Schedule,102% of WV Medicaid Rate,1679.88,165,,,Fee Schedule,165% of CMS OPPS Rate,1055.19,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,2924.39,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,4010.57,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,5023.64,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,414.96,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1018.11,100,,,Fee Schedule,100% of CMS OPPS Rate,1055.19,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,126.39,14,,,percent of total billed charges,14% of total billed charges,126.39,5023.64,
45990- Anorectal exam/surg/anesth/diag,3431256,CDM,510,RC,45990,HCPCS,Outpatient,,,278.01,139.01,,208.51,75,,,percent of total billed charges,75% of total billed charges,208.51,75,,,percent of total billed charges,75% of total billed charges,2415.71,100,,,Fee Schedule,100% of CMS OPPS Rate,926.81,102,,,Fee Schedule,102% of WV Medicaid Rate,3985.94,165,,,Fee Schedule,165% of CMS OPPS Rate,2503.69,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,6938.85,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,9516.07,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,11919.85,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,908.64,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2415.71,100,,,Fee Schedule,100% of CMS OPPS Rate,2503.69,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,38.92,14,,,percent of total billed charges,14% of total billed charges,38.92,11919.85,
"45999 - PF Unlisted procedure, rectum",3714944,CDM,510,RC,45999,HCPCS,Outpatient,,,1034.74,517.37,,776.06,75,,,percent of total billed charges,75% of total billed charges,776.06,75,,,percent of total billed charges,75% of total billed charges,781.31,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1289.16,165,,,Fee Schedule,165% of CMS OPPS Rate,809.76,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,2244.21,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,3077.76,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,3855.21,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,781.31,100,,,Fee Schedule,100% of CMS OPPS Rate,809.76,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,144.86,14,,,percent of total billed charges,14% of total billed charges,144.86,3855.21,
45999-PF UNLISTED PROCEDURE RECTUM,4321631,CDM,981,RC,45999,HCPCS,Outpatient,,,976.17,488.09,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
46020- Placement of seton,3566790,CDM,510,RC,46020,HCPCS,Outpatient,,,305,152.5,,228.75,75,,,percent of total billed charges,75% of total billed charges,228.75,75,,,percent of total billed charges,75% of total billed charges,2415.71,100,,,Fee Schedule,100% of CMS OPPS Rate,926.81,102,,,Fee Schedule,102% of WV Medicaid Rate,3985.94,165,,,Fee Schedule,165% of CMS OPPS Rate,2503.69,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,6938.85,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,9516.07,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,11919.85,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,908.64,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2415.71,100,,,Fee Schedule,100% of CMS OPPS Rate,2503.69,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,42.7,14,,,percent of total billed charges,14% of total billed charges,42.7,11919.85,
"46030 - Removal of anal seton, other marker",3572806,CDM,960,RC,46030,HCPCS,Outpatient,,,644.65,322.33,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
46040-PF I&D ISCHIORECTAL&/PERIRECTAL ABSCESS SPX,4321630,CDM,981,RC,46040,HCPCS,Outpatient,,,826.94,413.47,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
46045-PF I&D INTRAMURAL IM/ABSC TRANSANAL ANES,4321629,CDM,981,RC,46045,HCPCS,Outpatient,,,855,427.5,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
46050-MSA INCISION OF ANAL ABSCESS,3429979,CDM,361,RC,46050,HCPCS,Outpatient,,,591.44,295.72,,443.58,75,,,percent of total billed charges,75% of total billed charges,443.58,75,,,percent of total billed charges,75% of total billed charges,781.31,100,,,Fee Schedule,100% of CMS OPPS Rate,323.92,102,,,Fee Schedule,102% of WV Medicaid Rate,1289.16,165,,,Fee Schedule,165% of CMS OPPS Rate,809.76,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,2244.21,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,3077.76,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,3855.21,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,317.57,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,781.31,100,,,Fee Schedule,100% of CMS OPPS Rate,809.76,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,82.8,14,,,percent of total billed charges,14% of total billed charges,82.8,3855.21,
46050-PF I&D PERIANAL ABSCESS SUPERFICIAL,4321628,CDM,981,RC,46050,HCPCS,Outpatient,,,195.84,97.92,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
"46060 - PF Incision and drainage of ischiorectal or intramural abscess, with fistulectomy or fistulo",3714947,CDM,510,RC,46060,HCPCS,Outpatient,,,1266.05,633.03,,949.54,75,,,percent of total billed charges,75% of total billed charges,949.54,75,,,percent of total billed charges,75% of total billed charges,2415.71,100,,,Fee Schedule,100% of CMS OPPS Rate,926.81,102,,,Fee Schedule,102% of WV Medicaid Rate,3985.94,165,,,Fee Schedule,165% of CMS OPPS Rate,2503.69,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,6938.85,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,9516.07,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,11919.85,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,908.64,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2415.71,100,,,Fee Schedule,100% of CMS OPPS Rate,2503.69,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,177.25,14,,,percent of total billed charges,14% of total billed charges,177.25,11919.85,
46060-PF I&D ISCHIORCT/INTRAMURAL ABSC W/WO SETON,4321627,CDM,981,RC,46060,HCPCS,Outpatient,,,945.94,472.97,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
"46080- Sphincterotomy, anal, division of sphincter (separate procedure)",3621307,CDM,510,RC,46080,HCPCS,Outpatient,,,737.92,368.96,,553.44,75,,,percent of total billed charges,75% of total billed charges,553.44,75,,,percent of total billed charges,75% of total billed charges,2415.71,100,,,Fee Schedule,100% of CMS OPPS Rate,926.81,102,,,Fee Schedule,102% of WV Medicaid Rate,3985.94,165,,,Fee Schedule,165% of CMS OPPS Rate,2503.69,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,6938.85,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,9516.07,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,11919.85,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,908.64,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2415.71,100,,,Fee Schedule,100% of CMS OPPS Rate,2503.69,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,103.31,14,,,percent of total billed charges,14% of total billed charges,103.31,11919.85,
46083-Incise external hemorrhoid,3431258,CDM,510,RC,46083,HCPCS,Outpatient,,,212.94,106.47,,159.71,75,,,percent of total billed charges,75% of total billed charges,159.71,75,,,percent of total billed charges,75% of total billed charges,202.01,100,,,Fee Schedule,100% of CMS OPPS Rate,108.62,102,,,Fee Schedule,102% of WV Medicaid Rate,333.31,165,,,Fee Schedule,165% of CMS OPPS Rate,209.36,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,580.25,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,795.77,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,996.78,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,106.49,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,202.01,100,,,Fee Schedule,100% of CMS OPPS Rate,209.36,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,29.81,14,,,percent of total billed charges,14% of total billed charges,29.81,996.78,
46083-PF INCISION THROMBOSED HEMORRHOID EXTERNAL,4321626,CDM,981,RC,46083,HCPCS,Outpatient,,,212.94,106.47,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
"46200- Fissurectomy, including sphincterotomy, when performed",3621646,CDM,510,RC,46200,HCPCS,Outpatient,,,1198.61,599.31,,898.96,75,,,percent of total billed charges,75% of total billed charges,898.96,75,,,percent of total billed charges,75% of total billed charges,2415.71,100,,,Fee Schedule,100% of CMS OPPS Rate,926.81,102,,,Fee Schedule,102% of WV Medicaid Rate,3985.94,165,,,Fee Schedule,165% of CMS OPPS Rate,2503.69,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,6938.85,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,9516.07,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,11919.85,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,908.64,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2415.71,100,,,Fee Schedule,100% of CMS OPPS Rate,2503.69,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,167.81,14,,,percent of total billed charges,14% of total billed charges,167.81,11919.85,
46220-HKBT EXC PERIANAL SKIN TAG,3435933,CDM,510,RC,46220,HCPCS,Outpatient,,,235.42,117.71,,176.57,75,,,percent of total billed charges,75% of total billed charges,176.57,75,,,percent of total billed charges,75% of total billed charges,1018.11,100,,,Fee Schedule,100% of CMS OPPS Rate,423.26,102,,,Fee Schedule,102% of WV Medicaid Rate,1679.88,165,,,Fee Schedule,165% of CMS OPPS Rate,1055.19,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,2924.39,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,4010.57,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,5023.64,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,414.96,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1018.11,100,,,Fee Schedule,100% of CMS OPPS Rate,1055.19,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,32.96,14,,,percent of total billed charges,14% of total billed charges,32.96,5023.64,
46220-PF EXCISION SINGLE EXTERNAL PAPILLA OR TAG ANUS,4321625,CDM,981,RC,46220,HCPCS,Outpatient,,,235.42,117.71,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
46221 - PF Ligation of hemorroid(s),3700932,CDM,510,RC,46221,HCPCS,Outpatient,,,721.34,360.67,,541.01,75,,,percent of total billed charges,75% of total billed charges,541.01,75,,,percent of total billed charges,75% of total billed charges,781.31,100,,,Fee Schedule,100% of CMS OPPS Rate,161.33,102,,,Fee Schedule,102% of WV Medicaid Rate,1289.16,165,,,Fee Schedule,165% of CMS OPPS Rate,809.76,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,2244.21,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,3077.76,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,3855.21,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,158.17,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,781.31,100,,,Fee Schedule,100% of CMS OPPS Rate,809.76,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,100.99,14,,,percent of total billed charges,14% of total billed charges,100.99,3855.21,
46221-Ligation of hemorrhoid(s),3431259,CDM,361,RC,46221,HCPCS,Outpatient,,,721.34,360.67,,541.01,75,,,percent of total billed charges,75% of total billed charges,541.01,75,,,percent of total billed charges,75% of total billed charges,781.31,100,,,Fee Schedule,100% of CMS OPPS Rate,161.33,102,,,Fee Schedule,102% of WV Medicaid Rate,1289.16,165,,,Fee Schedule,165% of CMS OPPS Rate,809.76,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,2244.21,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,3077.76,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,3855.21,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,158.17,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,781.31,100,,,Fee Schedule,100% of CMS OPPS Rate,809.76,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,100.99,14,,,percent of total billed charges,14% of total billed charges,100.99,3855.21,
46221-PF Hemorrhoidectomy,4321624,CDM,981,RC,46221,HCPCS,Outpatient,,,368.34,184.17,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
46230- Excision/mult/ext skin tags/anus,3431260,CDM,510,RC,46230,HCPCS,Outpatient,,,791.19,395.6,,593.39,75,,,percent of total billed charges,75% of total billed charges,593.39,75,,,percent of total billed charges,75% of total billed charges,2415.71,100,,,Fee Schedule,100% of CMS OPPS Rate,926.81,102,,,Fee Schedule,102% of WV Medicaid Rate,3985.94,165,,,Fee Schedule,165% of CMS OPPS Rate,2503.69,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,6938.85,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,9516.07,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,11919.85,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,908.64,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2415.71,100,,,Fee Schedule,100% of CMS OPPS Rate,2503.69,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,110.77,14,,,percent of total billed charges,14% of total billed charges,110.77,11919.85,
"46250- Hemorrhoidectomy, external, 2 or more columns/groups",3569403,CDM,510,RC,46250,HCPCS,Outpatient,,,1224.58,612.29,,918.44,75,,,percent of total billed charges,75% of total billed charges,918.44,75,,,percent of total billed charges,75% of total billed charges,2415.71,100,,,Fee Schedule,100% of CMS OPPS Rate,926.81,102,,,Fee Schedule,102% of WV Medicaid Rate,3985.94,165,,,Fee Schedule,165% of CMS OPPS Rate,2503.69,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,6938.85,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,9516.07,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,11919.85,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,908.64,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2415.71,100,,,Fee Schedule,100% of CMS OPPS Rate,2503.69,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,171.44,14,,,percent of total billed charges,14% of total billed charges,171.44,11919.85,
"46255 - Hemorrhoidectomy, internal and external, single column/group;",3572807,CDM,510,RC,46255,HCPCS,Outpatient,,,1339.94,669.97,,1004.96,75,,,percent of total billed charges,75% of total billed charges,1004.96,75,,,percent of total billed charges,75% of total billed charges,2415.71,100,,,Fee Schedule,100% of CMS OPPS Rate,926.81,102,,,Fee Schedule,102% of WV Medicaid Rate,3985.94,165,,,Fee Schedule,165% of CMS OPPS Rate,2503.69,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,6938.85,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,9516.07,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,11919.85,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,908.64,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2415.71,100,,,Fee Schedule,100% of CMS OPPS Rate,2503.69,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,187.59,14,,,percent of total billed charges,14% of total billed charges,187.59,11919.85,
46257 - HEMORRHOID NTRNL & XTRNL 1 COLUMN W/FISSURECTO,4037565,CDM,983,RC,46257,HCPCS,Outpatient,,,1076.6,538.3,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
46260 - HEMORRHOIDECTOMY INT & EXT 2 OR MORE COL,4311819,CDM,983,RC,46260,HCPCS,Outpatient,,,1120.26,560.13,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
"46260- Hemorrhoidectomy, internal and external, 2 or more co",3566915,CDM,510,RC,46260,HCPCS,Outpatient,,,1269.46,634.73,,952.1,75,,,percent of total billed charges,75% of total billed charges,952.1,75,,,percent of total billed charges,75% of total billed charges,2415.71,100,,,Fee Schedule,100% of CMS OPPS Rate,926.81,102,,,Fee Schedule,102% of WV Medicaid Rate,3985.94,165,,,Fee Schedule,165% of CMS OPPS Rate,2503.69,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,6938.85,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,9516.07,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,11919.85,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,908.64,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2415.71,100,,,Fee Schedule,100% of CMS OPPS Rate,2503.69,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,177.72,14,,,percent of total billed charges,14% of total billed charges,177.72,11919.85,
46270- Surgical treatment of anal fistula (fistulectomy/fistulotomy); subcutaneous,3566791,CDM,510,RC,46270,HCPCS,Outpatient,,,1372.72,686.36,,1029.54,75,,,percent of total billed charges,75% of total billed charges,1029.54,75,,,percent of total billed charges,75% of total billed charges,2415.71,100,,,Fee Schedule,100% of CMS OPPS Rate,926.81,102,,,Fee Schedule,102% of WV Medicaid Rate,3985.94,165,,,Fee Schedule,165% of CMS OPPS Rate,2503.69,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,6938.85,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,9516.07,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,11919.85,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,908.64,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2415.71,100,,,Fee Schedule,100% of CMS OPPS Rate,2503.69,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,192.18,14,,,percent of total billed charges,14% of total billed charges,192.18,11919.85,
46280- Surgical tx of anal fistula,3431261,CDM,510,RC,46280,HCPCS,Outpatient,,,1251.32,625.66,,938.49,75,,,percent of total billed charges,75% of total billed charges,938.49,75,,,percent of total billed charges,75% of total billed charges,2415.71,100,,,Fee Schedule,100% of CMS OPPS Rate,926.81,102,,,Fee Schedule,102% of WV Medicaid Rate,3985.94,165,,,Fee Schedule,165% of CMS OPPS Rate,2503.69,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,6938.85,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,9516.07,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,11919.85,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,908.64,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2415.71,100,,,Fee Schedule,100% of CMS OPPS Rate,2503.69,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,175.18,14,,,percent of total billed charges,14% of total billed charges,175.18,11919.85,
46288 - PF Closure of anal fistula with rectal advancement flap,3715138,CDM,510,RC,46288,HCPCS,Outpatient,,,1455.08,727.54,,1091.31,75,,,percent of total billed charges,75% of total billed charges,1091.31,75,,,percent of total billed charges,75% of total billed charges,2415.71,100,,,Fee Schedule,100% of CMS OPPS Rate,926.81,102,,,Fee Schedule,102% of WV Medicaid Rate,3985.94,165,,,Fee Schedule,165% of CMS OPPS Rate,2503.69,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,6938.85,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,9516.07,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,11919.85,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,908.64,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2415.71,100,,,Fee Schedule,100% of CMS OPPS Rate,2503.69,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,203.71,14,,,percent of total billed charges,14% of total billed charges,203.71,11919.85,
46320 - PF Exc Thrombosed Hemorrhoid Xtrnl,4311820,CDM,960,RC,46320,HCPCS,Outpatient,,,261.18,130.59,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
46320-PF EXC THROMBOSED HEMORRHOID XTRNL,4321470,CDM,981,RC,46320,HCPCS,Outpatient,,,220,110,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
46320-Removal of hemorrhoid clot,3431262,CDM,361,RC,46320,HCPCS,Outpatient,,,540.29,270.15,,405.22,75,,,percent of total billed charges,75% of total billed charges,405.22,75,,,percent of total billed charges,75% of total billed charges,1018.11,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1679.88,165,,,Fee Schedule,165% of CMS OPPS Rate,1055.19,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,2924.39,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,4010.57,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,5023.64,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,1018.11,100,,,Fee Schedule,100% of CMS OPPS Rate,1055.19,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,75.64,14,,,percent of total billed charges,14% of total billed charges,75.64,5023.64,
46505-Internal anal shincter Botox ing,3768906,CDM,983,RC,46505,HCPCS,Outpatient,,,809.2,404.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
46600-Diagnostic anoscopy spx,3430923,CDM,361,RC,46600,HCPCS,Outpatient,,,299.02,149.51,,224.27,75,,,percent of total billed charges,75% of total billed charges,224.27,75,,,percent of total billed charges,75% of total billed charges,109.16,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,180.11,165,,,Fee Schedule,165% of CMS OPPS Rate,113.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,313.55,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,430.01,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,538.63,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,109.16,100,,,Fee Schedule,100% of CMS OPPS Rate,113.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,41.86,14,,,percent of total billed charges,14% of total billed charges,41.86,538.63,
46600-PF ANOSCOPY DX W/COLLJ SPEC BR/WA SPX WHEN PRFRMD,4321471,CDM,981,RC,46600,HCPCS,Outpatient,,,79.66,39.83,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
46606- Anoscopy/diag/w biopsy/single/mult,3431263,CDM,510,RC,46606,HCPCS,Outpatient,,,707.65,353.83,,530.74,75,,,percent of total billed charges,75% of total billed charges,530.74,75,,,percent of total billed charges,75% of total billed charges,1018.11,100,,,Fee Schedule,100% of CMS OPPS Rate,198.46,102,,,Fee Schedule,102% of WV Medicaid Rate,1679.88,165,,,Fee Schedule,165% of CMS OPPS Rate,1055.19,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,2924.39,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,4010.57,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,5023.64,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,194.57,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1018.11,100,,,Fee Schedule,100% of CMS OPPS Rate,1055.19,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,99.07,14,,,percent of total billed charges,14% of total billed charges,99.07,5023.64,
46608-PF ANOSCOPY W/RMVL FOREIGN BODY,4321472,CDM,981,RC,46608,HCPCS,Outpatient,,,168.58,84.29,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
"46610 - Anoscopy; with removal of single tumor, polyp, or other lesion by hot biopsy forceps or bipo",3572808,CDM,983,RC,46610,HCPCS,Outpatient,,,701.24,350.62,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
46611- Anoscopy/remove single tumor/snare,3431264,CDM,510,RC,46611,HCPCS,Outpatient,,,571.24,285.62,,428.43,75,,,percent of total billed charges,75% of total billed charges,428.43,75,,,percent of total billed charges,75% of total billed charges,781.31,100,,,Fee Schedule,100% of CMS OPPS Rate,323.92,102,,,Fee Schedule,102% of WV Medicaid Rate,1289.16,165,,,Fee Schedule,165% of CMS OPPS Rate,809.76,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,2244.21,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,3077.76,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,3855.21,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,317.57,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,781.31,100,,,Fee Schedule,100% of CMS OPPS Rate,809.76,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,79.97,14,,,percent of total billed charges,14% of total billed charges,79.97,3855.21,
46900 - PF Sstr Lesion Anus Simple Chemical,4309235,CDM,960,RC,46900,HCPCS,Outpatient,,,280.09,140.05,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
46916 - Cryosurgery Anal Les,4327324,CDM,510,RC,46916,HCPCS,Outpatient,,,281.6,140.8,,211.2,75,,,percent of total billed charges,75% of total billed charges,211.2,75,,,percent of total billed charges,75% of total billed charges,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,73.31,102,,,Fee Schedule,102% of WV Medicaid Rate,280.12,165,,,Fee Schedule,165% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,487.65,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,668.77,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,837.71,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,71.87,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,39.42,14,,,percent of total billed charges,14% of total billed charges,39.42,837.71,
46922-PF EXCISION OF ANAL LESION,3429981,CDM,510,RC,46922,HCPCS,Outpatient,,,789.69,394.85,,592.27,75,,,percent of total billed charges,75% of total billed charges,592.27,75,,,percent of total billed charges,75% of total billed charges,2415.71,100,,,Fee Schedule,100% of CMS OPPS Rate,926.81,102,,,Fee Schedule,102% of WV Medicaid Rate,3985.94,165,,,Fee Schedule,165% of CMS OPPS Rate,2503.69,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,6938.85,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,9516.07,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,11919.85,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,908.64,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2415.71,100,,,Fee Schedule,100% of CMS OPPS Rate,2503.69,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,110.56,14,,,percent of total billed charges,14% of total billed charges,110.56,11919.85,
46924 - DSTRJ LESION ANUS EXTENSIVE,3997186,CDM,960,RC,46924,HCPCS,Outpatient,,,1367.72,683.86,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
46940 - PF Curettage/Cautery Anal Fissure w/Dilation of Anal Sphincter Initial,4327335,CDM,960,RC,46940,HCPCS,Outpatient,,,277.86,138.93,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
"46945 - Hemorrhoidectomy, Internal by Ligation SNGL  w/o Ima",3896929,CDM,983,RC,46945,HCPCS,Outpatient,,,869.25,434.63,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
"46947- Hemorrhoidopexy (eg, for prolapsing internal hemorrhoids) by stapling",3566792,CDM,510,RC,46947,HCPCS,Outpatient,,,1026.29,513.15,,769.72,75,,,percent of total billed charges,75% of total billed charges,769.72,75,,,percent of total billed charges,75% of total billed charges,2415.71,100,,,Fee Schedule,100% of CMS OPPS Rate,926.81,102,,,Fee Schedule,102% of WV Medicaid Rate,3985.94,165,,,Fee Schedule,165% of CMS OPPS Rate,2503.69,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,6938.85,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,9516.07,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,11919.85,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,908.64,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2415.71,100,,,Fee Schedule,100% of CMS OPPS Rate,2503.69,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,143.68,14,,,percent of total billed charges,14% of total billed charges,143.68,11919.85,
"46999 - PF Unlisted procedure, anus",3641212,CDM,510,RC,46999,HCPCS,Outpatient,,,664.83,332.42,,498.62,75,,,percent of total billed charges,75% of total billed charges,498.62,75,,,percent of total billed charges,75% of total billed charges,781.31,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1289.16,165,,,Fee Schedule,165% of CMS OPPS Rate,809.76,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,2244.21,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,3077.76,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,3855.21,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,781.31,100,,,Fee Schedule,100% of CMS OPPS Rate,809.76,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,93.08,14,,,percent of total billed charges,14% of total billed charges,93.08,3855.21,
47000 - PF Bx Liver Needle Percutaneous,4311821,CDM,960,RC,47000,HCPCS,Outpatient,,,203.37,101.69,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
CT add Needle Bx Liver,645138,CDM,360,RC,47000,HCPCS,Outpatient,,,729.74,364.87,,547.31,75,,,percent of total billed charges,75% of total billed charges,547.31,75,,,percent of total billed charges,75% of total billed charges,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,479.67,102,,,Fee Schedule,102% of WV Medicaid Rate,2326.19,165,,,Fee Schedule,165% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4049.52,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5553.61,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6956.46,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,470.26,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,102.16,14,,,percent of total billed charges,14% of total billed charges,102.16,6956.46,
Read,4181198,CDM,972,RC,47000,HCPCS,Outpatient,,,291.89,145.95,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
47001 - PF Bx Lvr Ndl Done Purpose Tm Oth Major Px,4311822,CDM,960,RC,47001,HCPCS,Outpatient,,,248.86,124.43,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
"47001-MA NEEDLE BIOPSY, LIVER ADD ON",3429982,CDM,510,RC,47001,HCPCS,Outpatient,,,280.54,140.27,,210.41,75,,,percent of total billed charges,75% of total billed charges,210.41,75,,,percent of total billed charges,75% of total billed charges,89.77,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.28,14,,,percent of total billed charges,14% of total billed charges,39.28,210.41,
47100 - PF Bx Liver Wedge,4311823,CDM,960,RC,47100,HCPCS,Outpatient,,,2005.32,1002.66,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
47100-PF WEDGE BIOPSY OF LIVER,3429984,CDM,510,RC,47100,HCPCS,Outpatient,,,2272.42,1136.21,,1704.32,75,,,percent of total billed charges,75% of total billed charges,1704.32,75,,,percent of total billed charges,75% of total billed charges,2272.42,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,2272.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2272.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2272.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2272.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2272.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,2272.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2272.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,318.14,14,,,percent of total billed charges,14% of total billed charges,318.14,2272.42,
"47120 - Hepatectomy, resection of liver; partial lobectomy",3800924,CDM,983,RC,47120,HCPCS,Outpatient,,,6291.35,3145.68,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
47350 - PF Mgmt Lvr Hemrrg Smpl Sutr Lvr Wnd/ Inj,4311824,CDM,960,RC,47350,HCPCS,Outpatient,,,3251.43,1625.72,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
47379 - PF Unlisted Laparoscopic Px Liver,4311825,CDM,960,RC,47379,HCPCS,Outpatient,,,2374.4,1187.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
"47399 - Unlisted procedure, liver",3783262,CDM,510,RC,47399,HCPCS,Outpatient,,,1939.31,969.66,,1454.48,75,,,percent of total billed charges,75% of total billed charges,1454.48,75,,,percent of total billed charges,75% of total billed charges,610.13,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1006.72,165,,,Fee Schedule,165% of CMS OPPS Rate,632.35,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1752.53,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2403.46,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,3010.58,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,610.13,100,,,Fee Schedule,100% of CMS OPPS Rate,632.35,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,271.5,14,,,percent of total billed charges,14% of total billed charges,271.5,3010.58,
47531 - PF Njx Cholangio Prq w/ Img Gid RS&I Existing Access,4311826,CDM,960,RC,47531,HCPCS,Outpatient,,,160.41,80.21,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
Read,601985,CDM,972,RC,47531,HCPCS,Outpatient,,,405.56,202.78,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
47532 - PF Njx Cholangio Prq w/ Img Gid RS&I New Access,4311827,CDM,960,RC,47532,HCPCS,Outpatient,,,487.11,243.56,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
47533 - PF Prq Plmt Biliary Drg Cath w/ Img Gid RS&I External,4311828,CDM,960,RC,47533,HCPCS,Outpatient,,,611.39,305.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
Read,1449180,CDM,972,RC,47533,HCPCS,Outpatient,,,1124.62,562.31,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
47534 - PF Prq Pmt Biliary Drg Cath w/ Img GID RS&I Int-Ext,4311829,CDM,960,RC,47534,HCPCS,Outpatient,,,854.67,427.34,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
47535 - PF Conv Ext Bil Drg Cath To Int-Ext Bil Drg Cath,4311830,CDM,960,RC,47535,HCPCS,Outpatient,,,452.68,226.34,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
47536 - PF Exchange Biliary Drg Cath Prq w/ Img GID RS&I,4311831,CDM,960,RC,47536,HCPCS,Outpatient,,,302.93,151.47,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
47537 - PF Removal Biliary Drg Cath Req Fluor Gid RS&I,4311832,CDM,960,RC,47537,HCPCS,Outpatient,,,222.08,111.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
47538 - PF Plmt Bile Duct Stent Prq Existing Access,4311833,CDM,960,RC,47538,HCPCS,Outpatient,,,540.79,270.4,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
47539 - PF Plmt Bile Duct Stent Prq New Access w/o Sep Cath,4311834,CDM,960,RC,47539,HCPCS,Outpatient,,,985.24,492.62,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
47540 - PF Plmt Bile Duct Stent Prq New Access w/ Sep Cath,4311835,CDM,960,RC,47540,HCPCS,Outpatient,,,1015.1,507.55,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
47541 - PF Plmt Access Thru Biliary Tree Into Sm Bwl New,4311836,CDM,960,RC,47541,HCPCS,Outpatient,,,371.02,185.51,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
47562 - PF Laparoscopy Surg Cholecystectomy,4311837,CDM,960,RC,47562,HCPCS,Outpatient,,,1568.91,784.46,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
47562- Cholecystectomy/laparoscopy,3431265,CDM,510,RC,47562,HCPCS,Outpatient,,,1778.76,889.38,,1334.07,75,,,percent of total billed charges,75% of total billed charges,1334.07,75,,,percent of total billed charges,75% of total billed charges,4900.27,100,,,Fee Schedule,100% of CMS OPPS Rate,1862.49,102,,,Fee Schedule,102% of WV Medicaid Rate,8085.46,165,,,Fee Schedule,165% of CMS OPPS Rate,5078.72,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,14075.4,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,19303.29,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,24179.33,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1825.97,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,4900.27,100,,,Fee Schedule,100% of CMS OPPS Rate,5078.72,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,249.03,14,,,percent of total billed charges,14% of total billed charges,249.03,24179.33,
47563 - PF Laps urg Cholecystectomy w/ Cholagniography,4311838,CDM,960,RC,47563,HCPCS,Outpatient,,,1712.15,856.08,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
47563- Lapchol w/cholangiography,3431266,CDM,510,RC,47563,HCPCS,Outpatient,,,1936.74,968.37,,1452.56,75,,,percent of total billed charges,75% of total billed charges,1452.56,75,,,percent of total billed charges,75% of total billed charges,4900.27,100,,,Fee Schedule,100% of CMS OPPS Rate,1862.49,102,,,Fee Schedule,102% of WV Medicaid Rate,8085.46,165,,,Fee Schedule,165% of CMS OPPS Rate,5078.72,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,14075.4,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,19303.29,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,24179.33,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1825.97,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,4900.27,100,,,Fee Schedule,100% of CMS OPPS Rate,5078.72,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,271.14,14,,,percent of total billed charges,14% of total billed charges,271.14,24179.33,
47564 - PF Laps Surg Cholecstc w/ Expl Common Duct,4311839,CDM,960,RC,47564,HCPCS,Outpatient,,,2660.75,1330.38,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
47564- Lap/surg/chol w/explor common duct,3431267,CDM,510,RC,47564,HCPCS,Outpatient,,,3008.6,1504.3,,2256.45,75,,,percent of total billed charges,75% of total billed charges,2256.45,75,,,percent of total billed charges,75% of total billed charges,4900.27,100,,,Fee Schedule,100% of CMS OPPS Rate,1862.49,102,,,Fee Schedule,102% of WV Medicaid Rate,8085.46,165,,,Fee Schedule,165% of CMS OPPS Rate,5078.72,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,14075.4,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,19303.29,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,24179.33,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1825.97,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,4900.27,100,,,Fee Schedule,100% of CMS OPPS Rate,5078.72,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,421.2,14,,,percent of total billed charges,14% of total billed charges,421.2,24179.33,
47570 - PF Laparoscopy Surg Cholecystoeneterostomy,4311840,CDM,960,RC,47570,HCPCS,Outpatient,,,1854.58,927.29,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
47579 - PF Unlisted Laparoscopy Px Biliary Tract,4311841,CDM,960,RC,47579,HCPCS,Outpatient,,,1662.08,831.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
47600 - PF Cholecystectomy,4311842,CDM,960,RC,47600,HCPCS,Outpatient,,,2547.69,1273.85,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
47600- Cholecystectomy,3431268,CDM,510,RC,47600,HCPCS,Outpatient,,,2882.95,1441.48,,2162.21,75,,,percent of total billed charges,75% of total billed charges,2162.21,75,,,percent of total billed charges,75% of total billed charges,2882.95,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,2882.95,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2882.95,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2882.95,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2882.95,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2882.95,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,2882.95,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2882.95,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,403.61,14,,,percent of total billed charges,14% of total billed charges,403.61,2882.95,
47605 - PF Cholecystectomy w/ Cholangiography,4311843,CDM,960,RC,47605,HCPCS,Outpatient,,,2690.5,1345.25,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
47605- Cholecystectomy; with cholangiography,3622764,CDM,510,RC,47605,HCPCS,Outpatient,,,3045.49,1522.75,,2284.12,75,,,percent of total billed charges,75% of total billed charges,2284.12,75,,,percent of total billed charges,75% of total billed charges,3045.49,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,3045.49,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3045.49,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3045.49,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3045.49,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3045.49,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,3045.49,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3045.49,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,426.37,14,,,percent of total billed charges,14% of total billed charges,426.37,3045.49,
47610 - PF Cholecystectomy w/ Exploration Common Duct,4311844,CDM,960,RC,47610,HCPCS,Outpatient,,,2993.62,1496.81,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
47610- Cholecystectomy/explor common duct,3431269,CDM,510,RC,47610,HCPCS,Outpatient,,,3394.93,1697.47,,2546.2,75,,,percent of total billed charges,75% of total billed charges,2546.2,75,,,percent of total billed charges,75% of total billed charges,3394.93,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,3394.93,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3394.93,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3394.93,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3394.93,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3394.93,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,3394.93,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3394.93,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,475.29,14,,,percent of total billed charges,14% of total billed charges,475.29,3394.93,
47612 - PF Cholecystectomy Expl Duct Choledochoenterostomy,4311845,CDM,960,RC,47612,HCPCS,Outpatient,,,3044.65,1522.33,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
47620 - PF Cholecstc Expl Dux Sphntrotomy/ Sphnctrop,4311846,CDM,960,RC,47620,HCPCS,Outpatient,,,3290.61,1645.31,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
47711- Bile duct tumor exc/extrahepatic,3431270,CDM,510,RC,47711,HCPCS,Outpatient,,,4204.59,2102.3,,3153.44,75,,,percent of total billed charges,75% of total billed charges,3153.44,75,,,percent of total billed charges,75% of total billed charges,4204.59,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,4204.59,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4204.59,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4204.59,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4204.59,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4204.59,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,4204.59,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4204.59,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,588.64,14,,,percent of total billed charges,14% of total billed charges,588.64,4204.59,
47720 - PF Cholecystoenterostomy Direct,4311847,CDM,960,RC,47720,HCPCS,Outpatient,,,2751.07,1375.54,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
47721- PF Cholecystoenterostomy w/ Gastroenterostomy,4311848,CDM,960,RC,47721,HCPCS,Outpatient,,,3231.89,1615.95,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
47740 - PF Cholecystoenterostomy Roux-En-Y,4311849,CDM,960,RC,47740,HCPCS,Outpatient,,,3129.98,1564.99,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
47741 - PF Cholecstontrstm Roux-En-Y w/ Gastrontrstm,4311850,CDM,960,RC,47741,HCPCS,Outpatient,,,3522.28,1761.14,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
47760 - PF Anast Xtrhepatc Biliary Ducts & GI Tract,4311852,CDM,960,RC,47760,HCPCS,Outpatient,,,5376.28,2688.14,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
47760- Anastamo/extrahep bil duct/gi trac,3431271,CDM,510,RC,47760,HCPCS,Outpatient,,,6088.1,3044.05,,4566.08,75,,,percent of total billed charges,75% of total billed charges,4566.08,75,,,percent of total billed charges,75% of total billed charges,6088.1,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,6088.1,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6088.1,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6088.1,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6088.1,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6088.1,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,6088.1,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6088.1,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,852.33,14,,,percent of total billed charges,14% of total billed charges,852.33,6088.1,
47765 - PF Anast Intrahepatc Ducts & GI Tract,4311853,CDM,960,RC,47765,HCPCS,Outpatient,,,7044.42,3522.21,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
47780 - PF Anast Roux-En-Y Xtrhepatc Biliary Ducts & GI,4311854,CDM,960,RC,47780,HCPCS,Outpatient,,,5914.54,2957.27,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
47780- Anastamo/Roux-en-Y/extrahep bil/gi,3431272,CDM,510,RC,47780,HCPCS,Outpatient,,,6689.99,3345,,5017.49,75,,,percent of total billed charges,75% of total billed charges,5017.49,75,,,percent of total billed charges,75% of total billed charges,6689.99,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,6689.99,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6689.99,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6689.99,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6689.99,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6689.99,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,6689.99,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6689.99,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,936.6,14,,,percent of total billed charges,14% of total billed charges,936.6,6689.99,
47785 - PF Anast Roux-En-Y Intrahepatc Biliary Ducts & GI,4311855,CDM,960,RC,47785,HCPCS,Outpatient,,,7746.96,3873.48,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
Read,4181204,CDM,972,RC,48102,HCPCS,Outpatient,,,509.47,254.74,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
"48140 - (PF) Pancreatectomy, distal subtotal, with or without splenectomy; without pancreaticoj",3635077,CDM,510,RC,48140,HCPCS,Outpatient,,,4222.05,2111.03,,3166.54,75,,,percent of total billed charges,75% of total billed charges,3166.54,75,,,percent of total billed charges,75% of total billed charges,4222.05,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,4222.05,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4222.05,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4222.05,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4222.05,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4222.05,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,4222.05,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4222.05,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,591.09,14,,,percent of total billed charges,14% of total billed charges,591.09,4222.05,
48153- Pancreatectomy,3431273,CDM,510,RC,48153,HCPCS,Outpatient,,,8401.14,4200.57,,6300.86,75,,,percent of total billed charges,75% of total billed charges,6300.86,75,,,percent of total billed charges,75% of total billed charges,8401.14,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,8401.14,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,8401.14,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,8401.14,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,8401.14,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,8401.14,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,8401.14,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,8401.14,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1176.16,14,,,percent of total billed charges,14% of total billed charges,1176.16,8401.14,
49000 - PF Exploratory Laparotomy Celiotomy w/ wo Bx Spx,4311856,CDM,960,RC,49000,HCPCS,Outpatient,,,1824.44,912.22,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
49000-PF EXPLORATION OF ABDOMEN,3430004,CDM,510,RC,49000,HCPCS,Outpatient,,,2065.34,1032.67,,1549.01,75,,,percent of total billed charges,75% of total billed charges,1549.01,75,,,percent of total billed charges,75% of total billed charges,2065.34,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,2065.34,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2065.34,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2065.34,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2065.34,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2065.34,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,2065.34,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2065.34,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,289.15,14,,,percent of total billed charges,14% of total billed charges,289.15,2065.34,
49002 - PF Reopening of recent laparotomy,3715139,CDM,510,RC,49002,HCPCS,Outpatient,,,2813.09,1406.55,,2109.82,75,,,percent of total billed charges,75% of total billed charges,2109.82,75,,,percent of total billed charges,75% of total billed charges,2813.09,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,2813.09,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2813.09,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2813.09,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2813.09,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2813.09,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,2813.09,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2813.09,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,393.83,14,,,percent of total billed charges,14% of total billed charges,393.83,2813.09,
49002 - PF Reopening Recent Lapartomy,4311857,CDM,960,RC,49002,HCPCS,Outpatient,,,2484.17,1242.09,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
49010 - PF Expl Retroperitoneum w/ wo Bx Spx,4311858,CDM,960,RC,49010,HCPCS,Outpatient,,,2199.52,1099.76,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
49010- Retroperitoneal exploration,3431274,CDM,510,RC,49010,HCPCS,Outpatient,,,2494.23,1247.12,,1870.67,75,,,percent of total billed charges,75% of total billed charges,1870.67,75,,,percent of total billed charges,75% of total billed charges,2494.23,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,2494.23,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2494.23,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2494.23,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2494.23,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2494.23,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,2494.23,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2494.23,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,349.19,14,,,percent of total billed charges,14% of total billed charges,349.19,2494.23,
"49020 - Drainage of peritoneal abscess or localized peritonitis, exclusive of appendiceal abscess, o",3783250,CDM,510,RC,49020,HCPCS,Outpatient,,,4288.59,2144.3,,3216.44,75,,,percent of total billed charges,75% of total billed charges,3216.44,75,,,percent of total billed charges,75% of total billed charges,4288.59,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,4288.59,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4288.59,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4288.59,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4288.59,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4288.59,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,4288.59,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4288.59,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,600.4,14,,,percent of total billed charges,14% of total billed charges,600.4,4288.59,
49020 - PF Drainage Periton Abscess/ Local Peritonitis Open,4311859,CDM,960,RC,49020,HCPCS,Outpatient,,,3785.18,1892.59,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
"49060 - (PF) Drainage of retroperitoneal abscess, open",3635078,CDM,510,RC,49060,HCPCS,Outpatient,,,2954.19,1477.1,,2215.64,75,,,percent of total billed charges,75% of total billed charges,2215.64,75,,,percent of total billed charges,75% of total billed charges,2954.19,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,2954.19,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2954.19,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2954.19,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2954.19,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2954.19,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,2954.19,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2954.19,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,413.59,14,,,percent of total billed charges,14% of total billed charges,413.59,2954.19,
49082 - PF Abd Paracentesis Dx/ Ther w/o Imaging Guid,4311860,CDM,960,RC,49082,HCPCS,Outpatient,,,169.65,84.83,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
49082- Abd paracentesis/w/o image guide,3431275,CDM,510,RC,49082,HCPCS,Outpatient,,,533.82,266.91,,400.37,75,,,percent of total billed charges,75% of total billed charges,400.37,75,,,percent of total billed charges,75% of total billed charges,776.11,100,,,Fee Schedule,100% of CMS OPPS Rate,330.28,102,,,Fee Schedule,102% of WV Medicaid Rate,1280.58,165,,,Fee Schedule,165% of CMS OPPS Rate,804.37,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,2229.28,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,3057.28,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,3829.56,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,323.8,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,776.11,100,,,Fee Schedule,100% of CMS OPPS Rate,804.37,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,74.73,14,,,percent of total billed charges,14% of total billed charges,74.73,3829.56,
49082-PF ABDOM PARACENTESIS DX/THER W/O IMAGING GUIDANCE,4321473,CDM,981,RC,49082,HCPCS,Outpatient,,,142.9,71.45,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
PHY-ABDOMINAL PARACENTESIS W/O IMG GUIDE,3428504,CDM,981,RC,49082,HCPCS,Outpatient,,,533.82,266.91,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
49083- Abd paracentesis/w image guide,3431276,CDM,360,RC,49083,HCPCS,Outpatient,,,740.36,370.18,,555.27,75,,,percent of total billed charges,75% of total billed charges,555.27,75,,,percent of total billed charges,75% of total billed charges,776.11,100,,,Fee Schedule,100% of CMS OPPS Rate,330.28,102,,,Fee Schedule,102% of WV Medicaid Rate,1280.58,165,,,Fee Schedule,165% of CMS OPPS Rate,804.37,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,2229.28,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,3057.28,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,3829.56,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,323.8,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,776.11,100,,,Fee Schedule,100% of CMS OPPS Rate,804.37,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,103.65,14,,,percent of total billed charges,14% of total billed charges,103.65,3829.56,
49083-PF ABDOM PARACENTESIS DX/THER W/IMAGING GUIDANCE,4321623,CDM,981,RC,49083,HCPCS,Outpatient,,,206.06,103.03,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
CT add Paracentesis,645112,CDM,360,RC,49083,HCPCS,Outpatient,,,715.55,357.78,,536.66,75,,,percent of total billed charges,75% of total billed charges,536.66,75,,,percent of total billed charges,75% of total billed charges,776.11,100,,,Fee Schedule,100% of CMS OPPS Rate,330.28,102,,,Fee Schedule,102% of WV Medicaid Rate,1280.58,165,,,Fee Schedule,165% of CMS OPPS Rate,804.37,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,2229.28,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,3057.28,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,3829.56,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,323.8,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,776.11,100,,,Fee Schedule,100% of CMS OPPS Rate,804.37,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,100.18,14,,,percent of total billed charges,14% of total billed charges,100.18,3829.56,
Read,2964107,CDM,972,RC,49083,HCPCS,Outpatient,,,286.22,143.11,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
Read,3318437,CDM,972,RC,49083,HCPCS,Outpatient,,,286.22,143.11,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
Read,3318471,CDM,972,RC,49083,HCPCS,Outpatient,,,286.22,143.11,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
US add Paracentesis,645148,CDM,360,RC,49083,HCPCS,Outpatient,,,715.55,357.78,,536.66,75,,,percent of total billed charges,75% of total billed charges,536.66,75,,,percent of total billed charges,75% of total billed charges,776.11,100,,,Fee Schedule,100% of CMS OPPS Rate,330.28,102,,,Fee Schedule,102% of WV Medicaid Rate,1280.58,165,,,Fee Schedule,165% of CMS OPPS Rate,804.37,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,2229.28,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,3057.28,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,3829.56,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,323.8,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,776.11,100,,,Fee Schedule,100% of CMS OPPS Rate,804.37,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,100.18,14,,,percent of total billed charges,14% of total billed charges,100.18,3829.56,
"49084 - (PF) Peritoneal lavage, including imaging guidance, when performed",3635079,CDM,510,RC,49084,HCPCS,Outpatient,,,288.8,144.4,,216.6,75,,,percent of total billed charges,75% of total billed charges,216.6,75,,,percent of total billed charges,75% of total billed charges,776.11,100,,,Fee Schedule,100% of CMS OPPS Rate,330.28,102,,,Fee Schedule,102% of WV Medicaid Rate,1280.58,165,,,Fee Schedule,165% of CMS OPPS Rate,804.37,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,2229.28,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,3057.28,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,3829.56,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,323.8,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,776.11,100,,,Fee Schedule,100% of CMS OPPS Rate,804.37,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,40.43,14,,,percent of total billed charges,14% of total billed charges,40.43,3829.56,
49084-PF PERITONEAL LAVAGE W/WO IMAGING GUIDANCE,4321474,CDM,981,RC,49084,HCPCS,Outpatient,,,216.44,108.22,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
CT add Needle Bx Abdominal Mass,645126,CDM,360,RC,49180,HCPCS,Outpatient,,,433.75,216.88,,325.31,75,,,percent of total billed charges,75% of total billed charges,325.31,75,,,percent of total billed charges,75% of total billed charges,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,479.67,102,,,Fee Schedule,102% of WV Medicaid Rate,2326.19,165,,,Fee Schedule,165% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4049.52,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5553.61,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6956.46,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,470.26,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,60.73,14,,,percent of total billed charges,14% of total billed charges,60.73,6956.46,
Read,4181190,CDM,972,RC,49180,HCPCS,Outpatient,,,173.5,86.75,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
49203-PF EXC ABD TUM 5CM OR LESS,3430008,CDM,510,RC,49203,HCPCS,Outpatient,,,3207.18,1603.59,,2405.39,75,,,percent of total billed charges,75% of total billed charges,2405.39,75,,,percent of total billed charges,75% of total billed charges,3207.18,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,3207.18,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3207.18,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3207.18,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3207.18,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3207.18,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,3207.18,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3207.18,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,449.01,14,,,percent of total billed charges,14% of total billed charges,449.01,3207.18,
49204 - PF EXC ABD TUM OVER 5 CM,3527860,CDM,960,RC,49204,HCPCS,Outpatient,,,4079.6,2039.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
49205-PF EXC ABD TUM OVER 10CM,3430010,CDM,510,RC,49205,HCPCS,Outpatient,,,4682.57,2341.29,,3511.93,75,,,percent of total billed charges,75% of total billed charges,3511.93,75,,,percent of total billed charges,75% of total billed charges,4682.57,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,4682.57,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4682.57,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4682.57,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4682.57,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4682.57,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,4682.57,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4682.57,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,655.56,14,,,percent of total billed charges,14% of total billed charges,655.56,4682.57,
49250-PF EXCISION OF UMBILICUS,3430012,CDM,510,RC,49250,HCPCS,Outpatient,,,1580.44,790.22,,1185.33,75,,,percent of total billed charges,75% of total billed charges,1185.33,75,,,percent of total billed charges,75% of total billed charges,3329.99,100,,,Fee Schedule,100% of CMS OPPS Rate,1135.46,102,,,Fee Schedule,102% of WV Medicaid Rate,5494.49,165,,,Fee Schedule,165% of CMS OPPS Rate,3451.26,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,9564.96,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,13117.59,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,16431.12,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1113.2,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,3329.99,100,,,Fee Schedule,100% of CMS OPPS Rate,3451.26,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,221.26,14,,,percent of total billed charges,14% of total billed charges,221.26,16431.12,
"49255 - (PF) Omentectomy, epiploectomy, resection of omentum (separate proc",3635080,CDM,510,RC,49255,HCPCS,Outpatient,,,2105.96,1052.98,,1579.47,75,,,percent of total billed charges,75% of total billed charges,1579.47,75,,,percent of total billed charges,75% of total billed charges,2105.96,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,2105.96,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2105.96,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2105.96,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2105.96,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2105.96,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,2105.96,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2105.96,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,294.83,14,,,percent of total billed charges,14% of total billed charges,294.83,2105.96,
49320 - PF Laps Abd Prtm & Omentum Dx w/ wo Spec Br/Wa Spx,4311861,CDM,960,RC,49320,HCPCS,Outpatient,,,777.35,388.68,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
49320-PF DIAG LAPARO,3430014,CDM,510,RC,49320,HCPCS,Outpatient,,,877.13,438.57,,657.85,75,,,percent of total billed charges,75% of total billed charges,657.85,75,,,percent of total billed charges,75% of total billed charges,4900.27,100,,,Fee Schedule,100% of CMS OPPS Rate,1862.49,102,,,Fee Schedule,102% of WV Medicaid Rate,8085.46,165,,,Fee Schedule,165% of CMS OPPS Rate,5078.72,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,14075.4,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,19303.29,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,24179.33,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1825.97,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,4900.27,100,,,Fee Schedule,100% of CMS OPPS Rate,5078.72,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,122.8,14,,,percent of total billed charges,14% of total billed charges,122.8,24179.33,
49321 - PF Laparoscopy Surg w/ Bx Sngl/Mult,4311862,CDM,960,RC,49321,HCPCS,Outpatient,,,813.9,406.95,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
"49321-PF LAPAROSCOPY, BIOPSY",3430016,CDM,510,RC,49321,HCPCS,Outpatient,,,918.78,459.39,,689.09,75,,,percent of total billed charges,75% of total billed charges,689.09,75,,,percent of total billed charges,75% of total billed charges,4900.27,100,,,Fee Schedule,100% of CMS OPPS Rate,1862.49,102,,,Fee Schedule,102% of WV Medicaid Rate,8085.46,165,,,Fee Schedule,165% of CMS OPPS Rate,5078.72,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,14075.4,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,19303.29,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,24179.33,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1825.97,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,4900.27,100,,,Fee Schedule,100% of CMS OPPS Rate,5078.72,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,128.63,14,,,percent of total billed charges,14% of total billed charges,128.63,24179.33,
49322 - PF Laps Surg w/ Aspir Cavity/Cyst Sngl/Mult,4311863,CDM,960,RC,49322,HCPCS,Outpatient,,,889.21,444.61,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
"49322-PF LAPAROSCOPY, ASPIRATION",3430018,CDM,510,RC,49322,HCPCS,Outpatient,,,1004.19,502.1,,753.14,75,,,percent of total billed charges,75% of total billed charges,753.14,75,,,percent of total billed charges,75% of total billed charges,4900.27,100,,,Fee Schedule,100% of CMS OPPS Rate,1862.49,102,,,Fee Schedule,102% of WV Medicaid Rate,8085.46,165,,,Fee Schedule,165% of CMS OPPS Rate,5078.72,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,14075.4,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,19303.29,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,24179.33,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1825.97,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,4900.27,100,,,Fee Schedule,100% of CMS OPPS Rate,5078.72,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,140.59,14,,,percent of total billed charges,14% of total billed charges,140.59,24179.33,
"49323 - Laparoscopy, surgical; w/ drainage of lymophocele to",4241829,CDM,960,RC,49323,HCPCS,Outpatient,,,1346.37,673.19,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
49323 - PF Laps Surg w/ Drg Lymohocele Prtl Cavity,4311864,CDM,960,RC,49323,HCPCS,Outpatient,,,1507.93,753.97,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
"49324 - Laparoscopy, surgical; with insertion of tunneled intraperitoneal catheter",3572809,CDM,960,RC,49324,HCPCS,Outpatient,,,1044.66,522.33,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
49325-PF LAP REVISION PERM IP CATH,3430020,CDM,510,RC,49325,HCPCS,Outpatient,,,1117.95,558.98,,838.46,75,,,percent of total billed charges,75% of total billed charges,838.46,75,,,percent of total billed charges,75% of total billed charges,4900.27,100,,,Fee Schedule,100% of CMS OPPS Rate,1862.49,102,,,Fee Schedule,102% of WV Medicaid Rate,8085.46,165,,,Fee Schedule,165% of CMS OPPS Rate,5078.72,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,14075.4,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,19303.29,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,24179.33,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1825.97,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,4900.27,100,,,Fee Schedule,100% of CMS OPPS Rate,5078.72,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,156.51,14,,,percent of total billed charges,14% of total billed charges,156.51,24179.33,
"49326 - (PF) Laparoscopy, surgical; with omentopexy (omental tacking procedure)",3635081,CDM,510,RC,49326,HCPCS,Outpatient,,,516.55,258.28,,387.41,75,,,percent of total billed charges,75% of total billed charges,387.41,75,,,percent of total billed charges,75% of total billed charges,165.3,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72.32,14,,,percent of total billed charges,14% of total billed charges,72.32,387.41,
49329 - PF Unlisted Laparoscopy Px Abd Pertoneum & Omentum,4311865,CDM,960,RC,49329,HCPCS,Outpatient,,,1068.48,534.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
"49329-MA AST UNLISTED LAP ABD,PERIT,OMENT",3430021,CDM,510,RC,49329,HCPCS,Outpatient,,,461.21,230.61,,345.91,75,,,percent of total billed charges,75% of total billed charges,345.91,75,,,percent of total billed charges,75% of total billed charges,4900.27,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,8085.46,165,,,Fee Schedule,165% of CMS OPPS Rate,5078.72,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,14075.4,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,19303.29,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,24179.33,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,4900.27,100,,,Fee Schedule,100% of CMS OPPS Rate,5078.72,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,64.57,14,,,percent of total billed charges,14% of total billed charges,64.57,24179.33,
Periotoneal Port Rad inj/sup,3402664,CDM,320,RC,49400,HCPCS,Outpatient,,,377.68,188.84,,283.26,75,,,percent of total billed charges,75% of total billed charges,283.26,75,,,percent of total billed charges,75% of total billed charges,120.86,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.88,14,,,percent of total billed charges,14% of total billed charges,52.88,283.26,
49402- Removal peritoneal FB from peritoneal cavity,3569395,CDM,510,RC,49402,HCPCS,Outpatient,,,2297.42,1148.71,,1723.07,75,,,percent of total billed charges,75% of total billed charges,1723.07,75,,,percent of total billed charges,75% of total billed charges,3329.99,100,,,Fee Schedule,100% of CMS OPPS Rate,1135.46,102,,,Fee Schedule,102% of WV Medicaid Rate,5494.49,165,,,Fee Schedule,165% of CMS OPPS Rate,3451.26,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,9564.96,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,13117.59,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,16431.12,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1113.2,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,3329.99,100,,,Fee Schedule,100% of CMS OPPS Rate,3451.26,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,321.64,14,,,percent of total billed charges,14% of total billed charges,321.64,16431.12,
"49411 - Placement of interstitial device(s) for radiation therapy guidance (eg, fiducial markers, do",3760998,CDM,983,RC,49411,HCPCS,Outpatient,,,1207.59,603.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
49411-Fiducial Placement -Pelvic,3916937,CDM,510,RC,49411,HCPCS,Outpatient,,,1207.59,603.8,,905.69,75,,,percent of total billed charges,75% of total billed charges,905.69,75,,,percent of total billed charges,75% of total billed charges,1260.44,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,2079.73,165,,,Fee Schedule,165% of CMS OPPS Rate,1306.33,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,3620.47,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,4965.18,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6219.4,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,1260.44,100,,,Fee Schedule,100% of CMS OPPS Rate,1306.33,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,169.06,14,,,percent of total billed charges,14% of total billed charges,169.06,6219.4,
49411-INS MARK ABD/PEL FOR RT PERQ Profee,3565265,CDM,983,RC,49411,HCPCS,Outpatient,,,1207.59,603.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
49411-PELVIC FIDUCIAL,3435787,CDM,333,RC,49411,HCPCS,Outpatient,,,1178.65,589.33,,883.99,75,,,percent of total billed charges,75% of total billed charges,883.99,75,,,percent of total billed charges,75% of total billed charges,1260.44,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,2079.73,165,,,Fee Schedule,165% of CMS OPPS Rate,1306.33,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,3620.47,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,4965.18,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6219.4,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,1260.44,100,,,Fee Schedule,100% of CMS OPPS Rate,1306.33,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,165.01,14,,,percent of total billed charges,14% of total billed charges,165.01,6219.4,
49411-PELVIC FIDUCIAL Profee,3565262,CDM,983,RC,49411,HCPCS,Outpatient,,,1207.59,603.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
CT fiducial Marker abd/pelvis,3642894,CDM,350,RC,49411,HCPCS,Outpatient,,,1178.65,589.33,,883.99,75,,,percent of total billed charges,75% of total billed charges,883.99,75,,,percent of total billed charges,75% of total billed charges,1260.44,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,2079.73,165,,,Fee Schedule,165% of CMS OPPS Rate,1306.33,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,3620.47,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,4965.18,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6219.4,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,1260.44,100,,,Fee Schedule,100% of CMS OPPS Rate,1306.33,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,165.01,14,,,percent of total billed charges,14% of total billed charges,165.01,6219.4,
Read,4181188,CDM,972,RC,49411,HCPCS,Outpatient,,,471.46,235.73,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
49419-MA INSERT ABDOM CATH,3430023,CDM,510,RC,49419,HCPCS,Outpatient,,,1133.9,566.95,,850.43,75,,,percent of total billed charges,75% of total billed charges,850.43,75,,,percent of total billed charges,75% of total billed charges,4832.22,100,,,Fee Schedule,100% of CMS OPPS Rate,1912.09,102,,,Fee Schedule,102% of WV Medicaid Rate,7973.16,165,,,Fee Schedule,165% of CMS OPPS Rate,5008.18,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,13879.91,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,19035.18,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,23843.51,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1874.6,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,4832.22,100,,,Fee Schedule,100% of CMS OPPS Rate,5008.18,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,158.75,14,,,percent of total billed charges,14% of total billed charges,158.75,23843.51,
"49421- Insertion of tunneled intraperitoneal catheter for dialysis, open",3621513,CDM,510,RC,49421,HCPCS,Outpatient,,,616.62,308.31,,462.47,75,,,percent of total billed charges,75% of total billed charges,462.47,75,,,percent of total billed charges,75% of total billed charges,3329.99,100,,,Fee Schedule,100% of CMS OPPS Rate,1135.46,102,,,Fee Schedule,102% of WV Medicaid Rate,5494.49,165,,,Fee Schedule,165% of CMS OPPS Rate,3451.26,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,9564.96,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,13117.59,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,16431.12,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1113.2,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,3329.99,100,,,Fee Schedule,100% of CMS OPPS Rate,3451.26,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,86.33,14,,,percent of total billed charges,14% of total billed charges,86.33,16431.12,
49422-MA REMOVE PERM CANNUAL/CATH,3430024,CDM,510,RC,49422,HCPCS,Outpatient,,,600.45,300.23,,450.34,75,,,percent of total billed charges,75% of total billed charges,450.34,75,,,percent of total billed charges,75% of total billed charges,2800.72,100,,,Fee Schedule,100% of CMS OPPS Rate,1102.62,102,,,Fee Schedule,102% of WV Medicaid Rate,4621.2,165,,,Fee Schedule,165% of CMS OPPS Rate,2902.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8044.7,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11032.67,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13819.54,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1081,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2800.72,100,,,Fee Schedule,100% of CMS OPPS Rate,2902.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,84.06,14,,,percent of total billed charges,14% of total billed charges,84.06,13819.54,
49440 - PF Insert Gastrostomy Tube Perq,4311866,CDM,960,RC,49440,HCPCS,Outpatient,,,469.4,234.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
49440-PF Insertion of Gastrostomy Tube,4321622,CDM,981,RC,49440,HCPCS,Outpatient,,,395.38,197.69,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
49441 - PF Insert Duodenostomy/ Jejunostomy Tube Perq,4311867,CDM,960,RC,49441,HCPCS,Outpatient,,,555.25,277.63,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
49442 - PF Insert Cecostomy/ Other Colonic Tube Perq,4311868,CDM,960,RC,49442,HCPCS,Outpatient,,,471.01,235.51,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
49446 - PF Convert Gastrostomy-Gastro-Jejunostomy Tube Perq,4311869,CDM,960,RC,49446,HCPCS,Outpatient,,,340.75,170.38,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
"49446- Conv gastrostomy tube to GJ tube, perct",3569401,CDM,510,RC,49446,HCPCS,Outpatient,,,2001.46,1000.73,,1501.1,75,,,percent of total billed charges,75% of total billed charges,1501.1,75,,,percent of total billed charges,75% of total billed charges,1637.37,100,,,Fee Schedule,100% of CMS OPPS Rate,557.09,102,,,Fee Schedule,102% of WV Medicaid Rate,2701.67,165,,,Fee Schedule,165% of CMS OPPS Rate,1697,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4703.14,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,6450,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,8079.28,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,546.17,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1637.37,100,,,Fee Schedule,100% of CMS OPPS Rate,1697,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,280.2,14,,,percent of total billed charges,14% of total billed charges,280.2,8079.28,
49450 - PF Replace Gastrostomy/ Cecostomy Tube Perq,4311875,CDM,960,RC,49450,HCPCS,Outpatient,,,155.81,77.91,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
49450-PF REPLACE GASTROSTOMY/CECOSTOMY TUBE PERCUTANEOUS,4321475,CDM,981,RC,49450,HCPCS,Outpatient,,,131.24,65.62,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
49451 - PF Replace Duodenostomy/ Jejunostomy Tube Perq,4311876,CDM,960,RC,49451,HCPCS,Outpatient,,,206.15,103.08,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
"49451 - Replacement of duodenostomy or jejunostomy tube, percutaneous, under fluoroscopic guidance i",3783266,CDM,510,RC,49451,HCPCS,Outpatient,,,1602.89,801.45,,1202.17,75,,,percent of total billed charges,75% of total billed charges,1202.17,75,,,percent of total billed charges,75% of total billed charges,776.11,100,,,Fee Schedule,100% of CMS OPPS Rate,330.28,102,,,Fee Schedule,102% of WV Medicaid Rate,1280.58,165,,,Fee Schedule,165% of CMS OPPS Rate,804.37,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,2229.28,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,3057.28,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,3829.56,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,323.8,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,776.11,100,,,Fee Schedule,100% of CMS OPPS Rate,804.37,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,224.4,14,,,percent of total billed charges,14% of total billed charges,224.4,3829.56,
49452 - PF Replace Gastro-Jejunostomy Tube Perq,4311877,CDM,960,RC,49452,HCPCS,Outpatient,,,318.48,159.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
49452 - Replace G-J Tube Perc,4189307,CDM,960,RC,49452,HCPCS,Outpatient,,,1739.44,869.72,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
49460 - PF Obstructive Material Rmvl From GI Tube,4311878,CDM,960,RC,49460,HCPCS,Outpatient,,,115.75,57.88,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
49505 - PF Rpr 1st Inguin Hrna Age 5 yrs/> Reducible,4311879,CDM,960,RC,49505,HCPCS,Outpatient,,,1241.1,620.55,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
"49505- Repair initial inguinal hernia, age 5 years or older; reducible",3566793,CDM,510,RC,49505,HCPCS,Outpatient,,,1402.5,701.25,,1051.88,75,,,percent of total billed charges,75% of total billed charges,1051.88,75,,,percent of total billed charges,75% of total billed charges,3329.99,100,,,Fee Schedule,100% of CMS OPPS Rate,1135.46,102,,,Fee Schedule,102% of WV Medicaid Rate,5494.49,165,,,Fee Schedule,165% of CMS OPPS Rate,3451.26,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,9564.96,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,13117.59,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,16431.12,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1113.2,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,3329.99,100,,,Fee Schedule,100% of CMS OPPS Rate,3451.26,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,196.35,14,,,percent of total billed charges,14% of total billed charges,196.35,16431.12,
49507 - PF Rpr 1st Inguin Hrna Age 5 yrs/> Incarcerated,4311880,CDM,960,RC,49507,HCPCS,Outpatient,,,1397.6,698.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
"49507- Repair initial inguinal hernia, age 5 years or older; incarcerated or strangulated",3566794,CDM,510,RC,49507,HCPCS,Outpatient,,,1576.72,788.36,,1182.54,75,,,percent of total billed charges,75% of total billed charges,1182.54,75,,,percent of total billed charges,75% of total billed charges,3329.99,100,,,Fee Schedule,100% of CMS OPPS Rate,1135.46,102,,,Fee Schedule,102% of WV Medicaid Rate,5494.49,165,,,Fee Schedule,165% of CMS OPPS Rate,3451.26,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,9564.96,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,13117.59,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,16431.12,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1113.2,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,3329.99,100,,,Fee Schedule,100% of CMS OPPS Rate,3451.26,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,220.74,14,,,percent of total billed charges,14% of total billed charges,220.74,16431.12,
49520 - PF Rpr Recrt Inguinal Hrna Any Age Reducible,4311881,CDM,960,RC,49520,HCPCS,Outpatient,,,1507.65,753.83,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
"49520- Repair recurrent inguinal hernia, any age; reducible",3622240,CDM,510,RC,49520,HCPCS,Outpatient,,,1706.37,853.19,,1279.78,75,,,percent of total billed charges,75% of total billed charges,1279.78,75,,,percent of total billed charges,75% of total billed charges,3329.99,100,,,Fee Schedule,100% of CMS OPPS Rate,1135.46,102,,,Fee Schedule,102% of WV Medicaid Rate,5494.49,165,,,Fee Schedule,165% of CMS OPPS Rate,3451.26,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,9564.96,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,13117.59,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,16431.12,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1113.2,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,3329.99,100,,,Fee Schedule,100% of CMS OPPS Rate,3451.26,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,238.89,14,,,percent of total billed charges,14% of total billed charges,238.89,16431.12,
"49521 - (50) Repair recurrent inguinal hernia, any age; incarcerated or strangulated",3699536,CDM,510,RC,49521,HCPCS,Outpatient,,,1931.01,965.51,,1448.26,75,,,percent of total billed charges,75% of total billed charges,1448.26,75,,,percent of total billed charges,75% of total billed charges,3329.99,100,,,Fee Schedule,100% of CMS OPPS Rate,1135.46,102,,,Fee Schedule,102% of WV Medicaid Rate,5494.49,165,,,Fee Schedule,165% of CMS OPPS Rate,3451.26,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,9564.96,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,13117.59,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,16431.12,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1113.2,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,3329.99,100,,,Fee Schedule,100% of CMS OPPS Rate,3451.26,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,270.34,14,,,percent of total billed charges,14% of total billed charges,270.34,16431.12,
"49521 - (PF) Repair recurrent inguinal hernia, any age; incarcerated or strangulated",3635082,CDM,510,RC,49521,HCPCS,Outpatient,,,1931.01,965.51,,1448.26,75,,,percent of total billed charges,75% of total billed charges,1448.26,75,,,percent of total billed charges,75% of total billed charges,3329.99,100,,,Fee Schedule,100% of CMS OPPS Rate,1135.46,102,,,Fee Schedule,102% of WV Medicaid Rate,5494.49,165,,,Fee Schedule,165% of CMS OPPS Rate,3451.26,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,9564.96,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,13117.59,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,16431.12,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1113.2,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,3329.99,100,,,Fee Schedule,100% of CMS OPPS Rate,3451.26,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,270.34,14,,,percent of total billed charges,14% of total billed charges,270.34,16431.12,
49521 - PF Rpr Recrt Inguin Hrna Any Age Incarcerated,4311882,CDM,960,RC,49521,HCPCS,Outpatient,,,1709.19,854.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
49525 - PF Rpr Inguin Hrna Sliding Any Age,4311883,CDM,960,RC,49525,HCPCS,Outpatient,,,1365.09,682.55,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
49550 - PF 1st Fem Hrna Hany Age Reducible,4311884,CDM,960,RC,49550,HCPCS,Outpatient,,,1375.37,687.69,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
49550 - RPR Rem Hernia Init Reduc,4189308,CDM,960,RC,49550,HCPCS,Outpatient,,,1383.2,691.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
49553 - PF Rpr 1st Fem Hrna Any Age Incarcerated,4311885,CDM,960,RC,49553,HCPCS,Outpatient,,,1506.2,753.1,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
49553 - RPR 1ST FEM HERNIA ANY AGE INCARCERATED,3997189,CDM,960,RC,49553,HCPCS,Outpatient,,,1702.61,851.31,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
49555 - PF Rpr Recrt Fem Hrna Reducible,4311886,CDM,960,RC,49555,HCPCS,Outpatient,,,1440.19,720.1,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
49557 - PF Rpr Recrt Fem Hrna Incarcerated,4311887,CDM,960,RC,49557,HCPCS,Outpatient,,,1726.92,863.46,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
49591 - PF Rpr AA Hrna 1st < 3 cm Reducible,4311888,CDM,960,RC,49591,HCPCS,Outpatient,,,820.31,410.16,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
49591- RPR AA HERNIA 1ST < 3 CM REDUCIBLE,4199249,CDM,983,RC,49591,HCPCS,Outpatient,,,800.31,400.16,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
49591-PF Rpr AA Hrn 1st <3 cm RDC,4322111,CDM,960,RC,49591,HCPCS,Outpatient,,,678.44,339.22,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
49592 - PF Rpr AA Hrna 1st < 3 cm NCRC8/ Strangulated,4311889,CDM,960,RC,49592,HCPCS,Outpatient,,,1145.15,572.58,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
49592- RPR AA HERNIA 1ST < 3 CM NCRC8/STRANGULATED,4199250,CDM,983,RC,49592,HCPCS,Outpatient,,,1117.23,558.62,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
49593 - PF Rpr AA Hrna 1st 3-10 cm Reducible,4311890,CDM,960,RC,49593,HCPCS,Outpatient,,,1379.17,689.59,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
49593- RPR AA HERNIA 1ST 3-10 CM REDUCIBLE,4199251,CDM,983,RC,49593,HCPCS,Outpatient,,,1344.53,672.27,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
49593-PF Rpr AA Hrn 1st 3-10 RDC,4322112,CDM,960,RC,49593,HCPCS,Outpatient,,,1139.82,569.91,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
49594 - PF Rpr AA Hrna 1st 3-10 cm NCRC8/ Strangulated,4311891,CDM,960,RC,49594,HCPCS,Outpatient,,,1798.72,899.36,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
49594- RPR AA HERNIA 1ST 3-10 CM NCRC8/STRANGULATED,4199252,CDM,983,RC,49594,HCPCS,Outpatient,,,1754.87,877.44,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
49595 - PF Rpr AA Hrna 1st > 10 cm Reducible,4311892,CDM,960,RC,49595,HCPCS,Outpatient,,,1855.27,927.64,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
49595- RPR AA HERNIA 1ST > 10 CM REDUCIBLE,4199253,CDM,983,RC,49595,HCPCS,Outpatient,,,1810.02,905.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
49595-PF Rpr AA Hrn 1st >10 cm RDC,4322113,CDM,960,RC,49595,HCPCS,Outpatient,,,1534.72,767.36,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
49596 - PF Rpr AA Hrna 1st > 10 cm NCRC8/ Strangulated,4311893,CDM,960,RC,49596,HCPCS,Outpatient,,,2464.89,1232.45,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
49596- RPR AA HERNIA 1ST > 10 CM NCRC8/STRANGULATED,4199254,CDM,983,RC,49596,HCPCS,Outpatient,,,2404.77,1202.39,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
49600 - PF Rpr Small Omphalocele w/ Primary Closure,4311894,CDM,960,RC,49600,HCPCS,Outpatient,,,1750.31,875.16,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
49605 - PF Rpr Lg Omphalocele/ Gastroschisis w/ wo Prosth,4311895,CDM,960,RC,49605,HCPCS,Outpatient,,,11811.07,5905.54,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
49606 - PF Prp Lg Omphalocele/ Gastroschisis Rmvl Prosth,4311896,CDM,960,RC,49606,HCPCS,Outpatient,,,2718.76,1359.38,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
49610 - PF Rpr Omphalocele Gross Typ Opration 1st Stg,4311897,CDM,960,RC,49610,HCPCS,Outpatient,,,1654.48,827.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
49611 - PF Rpr Omphalocele Gross Typ Opration 2nd Stg,4311898,CDM,960,RC,49611,HCPCS,Outpatient,,,1453.13,726.57,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
49613 - PF Rpr AA Hrna Recr < 3 cm Reducible,4311899,CDM,960,RC,49613,HCPCS,Outpatient,,,1011.21,505.61,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
49613 - RPR AA HERNIA RECR < 3 CM REDUCIBLE,4199261,CDM,983,RC,49613,HCPCS,Outpatient,,,986.54,493.27,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
49613- RPR AA HERNIA RECR < 3 CM REDUCIBLE,4199255,CDM,983,RC,49613,HCPCS,Outpatient,,,986.54,493.27,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
49613-PF Rpr AA Hrn RCR <3 RDC,4322114,CDM,960,RC,49613,HCPCS,Outpatient,,,836.18,418.09,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
49614 - PF Rpr AA Hrna Recr < 3 cm NCRC8/ Strangulated,4311900,CDM,960,RC,49614,HCPCS,Outpatient,,,1376.29,688.15,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
49614- RPR AA HERNIA RECR < 3 CM NCRC8/STRANGULATED,4199256,CDM,983,RC,49614,HCPCS,Outpatient,,,1341.73,670.87,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
49615 - PF Rpr AA Hrna Recr 3-10 cm Reducible,4311901,CDM,960,RC,49615,HCPCS,Outpatient,,,1539.18,769.59,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
49615 - RPR AA HERNIA RECR 3-10 CM REDUCIBLE,4199262,CDM,983,RC,49615,HCPCS,Outpatient,,,1501.64,750.82,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
49615- RPR AA HERNIA RECR 3-10 CM REDUCIBLE,4199257,CDM,983,RC,49615,HCPCS,Outpatient,,,1501.64,750.82,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
49615-PF Rpr AA Hrn RCR 3-10 RDC,4322115,CDM,960,RC,49615,HCPCS,Outpatient,,,1270.2,635.1,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
49616 - PF Rpr AA Hrna Recr 3-10 cm NCRC8/ Strangulated,4311902,CDM,960,RC,49616,HCPCS,Outpatient,,,2070.78,1035.39,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
49616- RPR AA HERNIA RECR 3-10 CM NCRC8/STRANGULATED,4199258,CDM,983,RC,49616,HCPCS,Outpatient,,,2020.29,1010.15,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
49617 - PF Rpr AA Hrna Recr > 10 cm Reducible,4311903,CDM,960,RC,49617,HCPCS,Outpatient,,,2065.37,1032.69,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
49617 - RPR AA HERNIA RECR > 10 CM REDUCIBLE,4199263,CDM,983,RC,49617,HCPCS,Outpatient,,,2077.53,1038.77,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
49617- RPR AA HERNIA RECR > 10 CM REDUCIBLE,4199259,CDM,983,RC,49617,HCPCS,Outpatient,,,2077.53,1038.77,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
49617-PF Rpr AA Hrn RCR >10 RDC,4322116,CDM,960,RC,49617,HCPCS,Outpatient,,,1759.12,879.56,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
49618 - PF Rpr AA Hrna Recr > 10 cm NCRC8/ Strangulated,4311904,CDM,960,RC,49618,HCPCS,Outpatient,,,2988.97,1494.49,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
49618- RPR AA HERNIA RECR > 10 CM NCRC8/STRANGULATED,4199260,CDM,983,RC,49618,HCPCS,Outpatient,,,2916.06,1458.03,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
49621 - RPR PARASTOMAL HERNIA 1ST/RECR REDUCIBLE,4249119,CDM,983,RC,49621,HCPCS,Outpatient,,,1986.6,993.3,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
49622PF Rpr Parastomal Hrna 1st/Rec NCRC/Strangulated,4281206,CDM,960,RC,49622,HCPCS,Outpatient,,,1962.31,981.16,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
49623 - PF Rmvl NonInfct Mesh/Prosth AA/Parastomal Hra Rpr PF,4305373,CDM,960,RC,49623,HCPCS,Outpatient,,,424.04,212.02,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
"49650 - PF - Laparoscopy, surgical; repair initial inguinal hernia",3640923,CDM,510,RC,49650,HCPCS,Outpatient,,,1154.79,577.4,,866.09,75,,,percent of total billed charges,75% of total billed charges,866.09,75,,,percent of total billed charges,75% of total billed charges,4900.27,100,,,Fee Schedule,100% of CMS OPPS Rate,1862.49,102,,,Fee Schedule,102% of WV Medicaid Rate,8085.46,165,,,Fee Schedule,165% of CMS OPPS Rate,5078.72,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,14075.4,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,19303.29,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,24179.33,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1825.97,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,4900.27,100,,,Fee Schedule,100% of CMS OPPS Rate,5078.72,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,161.67,14,,,percent of total billed charges,14% of total billed charges,161.67,24179.33,
49650 - PF Laparoscopy Surg Rpr Init Inguinal Hrna,4311905,CDM,960,RC,49650,HCPCS,Outpatient,,,1022.18,511.09,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
"49651 - Laparoscopy, surgical; repair recurrent inguinal hernia",3572810,CDM,960,RC,49651,HCPCS,Outpatient,,,1509.83,754.92,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
49651 - PF Laps Surg Rpr Recurrent Inguinal Hrna,4311906,CDM,960,RC,49651,HCPCS,Outpatient,,,1337.31,668.66,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
49659 - Laparo Proc Hernia Repair,4189309,CDM,960,RC,49659,HCPCS,Outpatient,,,2611.84,1305.92,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
49659 - PF Unlisted Laps Px Hrnap Herniorrhaphy Herniotomy,4311907,CDM,960,RC,49659,HCPCS,Outpatient,,,1068.48,534.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
49905-PF OMENTAL FLAP INTRA-ABD,3430038,CDM,510,RC,49905,HCPCS,Outpatient,,,954.24,477.12,,715.68,75,,,percent of total billed charges,75% of total billed charges,715.68,75,,,percent of total billed charges,75% of total billed charges,954.24,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,954.24,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,954.24,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,954.24,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,954.24,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,954.24,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,954.24,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,954.24,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,133.59,14,,,percent of total billed charges,14% of total billed charges,133.59,954.24,
"49999 - PF Unlisted procedure, abdomen, peritoneum and omentum",3641213,CDM,510,RC,49999,HCPCS,Outpatient,,,3723.06,1861.53,,2792.3,75,,,percent of total billed charges,75% of total billed charges,2792.3,75,,,percent of total billed charges,75% of total billed charges,776.11,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1280.58,165,,,Fee Schedule,165% of CMS OPPS Rate,804.37,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,2229.28,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,3057.28,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,3829.56,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,776.11,100,,,Fee Schedule,100% of CMS OPPS Rate,804.37,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,521.23,14,,,percent of total billed charges,14% of total billed charges,521.23,3829.56,
49999 - PF Unlisted Px Abd Peritoneum & Omentum,4311908,CDM,960,RC,49999,HCPCS,Outpatient,,,1068.48,534.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
49999-PF UNLISTED PROCEDURE ABDOMEN PERITONEUM & OMENTUM,4321621,CDM,981,RC,49999,HCPCS,Outpatient,,,3512.32,1756.16,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
"50080 - Percutaneous nephrostolithotomy or pyelostolithotomy, with or without dilation, endoscopy, l",3572811,CDM,510,RC,50080,HCPCS,Outpatient,,,2266.36,1133.18,,1699.77,75,,,percent of total billed charges,75% of total billed charges,1699.77,75,,,percent of total billed charges,75% of total billed charges,8045.5,100,,,Fee Schedule,100% of CMS OPPS Rate,3275.92,102,,,Fee Schedule,102% of WV Medicaid Rate,13275.07,165,,,Fee Schedule,165% of CMS OPPS Rate,8338.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,23109.59,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,31692.97,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,39698.66,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,3211.69,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,8045.5,100,,,Fee Schedule,100% of CMS OPPS Rate,8338.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,317.29,14,,,percent of total billed charges,14% of total billed charges,317.29,39698.66,
50080PF - Percutaneous nephrostolithotomy or pyelostolithoto,4263691,CDM,975,RC,50080,HCPCS,Outpatient,,,1610.46,805.23,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
50081PF-Percutaneous/rmv kidney stone,4263689,CDM,975,RC,50081,HCPCS,Outpatient,,,2607.68,1303.84,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
CT add Needle Bx Renal,645130,CDM,360,RC,50200,HCPCS,Outpatient,,,1239.99,620,,929.99,75,,,percent of total billed charges,75% of total billed charges,929.99,75,,,percent of total billed charges,75% of total billed charges,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,479.67,102,,,Fee Schedule,102% of WV Medicaid Rate,2326.19,165,,,Fee Schedule,165% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4049.52,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5553.61,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6956.46,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,470.26,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,173.6,14,,,percent of total billed charges,14% of total billed charges,173.6,6956.46,
Read,4181206,CDM,972,RC,50200,HCPCS,Outpatient,,,496,248,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
50220 - Nephrectomy w/PRTL Ureterectomy w/Open Rib Resc,3899049,CDM,983,RC,50220,HCPCS,Outpatient,,,2775.57,1387.79,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
50230PF- Nephrect/rad/lymphadenec/vc thromb,4263690,CDM,975,RC,50230,HCPCS,Outpatient,,,2975.08,1487.54,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
50234PF Nephrectomy w/Total Ureterectomy and Bladder Cuff Same Incision,4263108,CDM,975,RC,50234,HCPCS,Outpatient,,,3025.56,1512.78,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
50384 - PF Removal Indwelling Ureteral Stent Prq,4301623,CDM,960,RC,50384,HCPCS,Outpatient,,,472.89,236.45,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
50386 - PF Remove Int Dwell Ureteral Stent Transurethral,4301620,CDM,960,RC,50386,HCPCS,Outpatient,,,334.03,167.02,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
"50389 - (50) Removal of nephrostomy tube, requiring fluoroscopic guidance (eg, with concurrent indwe",3699539,CDM,510,RC,50389,HCPCS,Outpatient,,,1042.44,521.22,,781.83,75,,,percent of total billed charges,75% of total billed charges,781.83,75,,,percent of total billed charges,75% of total billed charges,587.91,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,970.07,165,,,Fee Schedule,165% of CMS OPPS Rate,609.33,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1688.73,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2315.95,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,2900.97,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,587.91,100,,,Fee Schedule,100% of CMS OPPS Rate,609.33,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,145.94,14,,,percent of total billed charges,14% of total billed charges,145.94,2900.97,
"50389 - PF Removal of nephrostomy tube, requiring fluoroscopic guidance (eg, with concurrent indwell",3699538,CDM,510,RC,50389,HCPCS,Outpatient,,,1042.44,521.22,,781.83,75,,,percent of total billed charges,75% of total billed charges,781.83,75,,,percent of total billed charges,75% of total billed charges,587.91,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,970.07,165,,,Fee Schedule,165% of CMS OPPS Rate,609.33,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1688.73,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2315.95,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,2900.97,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,587.91,100,,,Fee Schedule,100% of CMS OPPS Rate,609.33,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,145.94,14,,,percent of total billed charges,14% of total billed charges,145.94,2900.97,
CT add Renal drainage/asp,654538,CDM,360,RC,50390,HCPCS,Outpatient,,,245.5,122.75,,184.13,75,,,percent of total billed charges,75% of total billed charges,184.13,75,,,percent of total billed charges,75% of total billed charges,610.13,100,,,Fee Schedule,100% of CMS OPPS Rate,254,102,,,Fee Schedule,102% of WV Medicaid Rate,1006.72,165,,,Fee Schedule,165% of CMS OPPS Rate,632.35,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1752.53,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2403.46,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,3010.58,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,249.02,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,610.13,100,,,Fee Schedule,100% of CMS OPPS Rate,632.35,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,34.37,14,,,percent of total billed charges,14% of total billed charges,34.37,3010.58,
DR Nephrostogram Injection Procedure,646389,CDM,361,RC,50430,HCPCS,Outpatient,,,1519.38,759.69,,1139.54,75,,,percent of total billed charges,75% of total billed charges,1139.54,75,,,percent of total billed charges,75% of total billed charges,587.91,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,970.07,165,,,Fee Schedule,165% of CMS OPPS Rate,609.33,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1688.73,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2315.95,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,2900.97,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,587.91,100,,,Fee Schedule,100% of CMS OPPS Rate,609.33,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,212.71,14,,,percent of total billed charges,14% of total billed charges,212.71,2900.97,
"50432 - PF Placement of nephrostomy catheter, percutaneous, including diagnostic nephrostogram and/o",3641210,CDM,510,RC,50432,HCPCS,Outpatient,,,2274.93,1137.47,,1706.2,75,,,percent of total billed charges,75% of total billed charges,1706.2,75,,,percent of total billed charges,75% of total billed charges,1743.88,100,,,Fee Schedule,100% of CMS OPPS Rate,643.69,102,,,Fee Schedule,102% of WV Medicaid Rate,2877.42,165,,,Fee Schedule,165% of CMS OPPS Rate,1807.39,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,5009.09,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,6869.58,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,8604.84,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,631.07,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1743.88,100,,,Fee Schedule,100% of CMS OPPS Rate,1807.39,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,318.49,14,,,percent of total billed charges,14% of total billed charges,318.49,8604.84,
50432-IR INTRODUCTION OF NEPHRO CATH BI,3431933,CDM,360,RC,50432,HCPCS,Outpatient,,,2274.93,1137.47,,1706.2,75,,,percent of total billed charges,75% of total billed charges,1706.2,75,,,percent of total billed charges,75% of total billed charges,1743.88,100,,,Fee Schedule,100% of CMS OPPS Rate,643.69,102,,,Fee Schedule,102% of WV Medicaid Rate,2877.42,165,,,Fee Schedule,165% of CMS OPPS Rate,1807.39,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,5009.09,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,6869.58,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,8604.84,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,631.07,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1743.88,100,,,Fee Schedule,100% of CMS OPPS Rate,1807.39,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,318.49,14,,,percent of total billed charges,14% of total billed charges,318.49,8604.84,
50432-IR INTRODUCTION OF NEPHRO CATH LT,3431934,CDM,360,RC,50432,HCPCS,Outpatient,,,2274.93,1137.47,,1706.2,75,,,percent of total billed charges,75% of total billed charges,1706.2,75,,,percent of total billed charges,75% of total billed charges,1743.88,100,,,Fee Schedule,100% of CMS OPPS Rate,643.69,102,,,Fee Schedule,102% of WV Medicaid Rate,2877.42,165,,,Fee Schedule,165% of CMS OPPS Rate,1807.39,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,5009.09,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,6869.58,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,8604.84,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,631.07,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1743.88,100,,,Fee Schedule,100% of CMS OPPS Rate,1807.39,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,318.49,14,,,percent of total billed charges,14% of total billed charges,318.49,8604.84,
50432-IR INTRODUCTION OF NEPHRO CATH RT,3431935,CDM,360,RC,50432,HCPCS,Outpatient,,,2274.93,1137.47,,1706.2,75,,,percent of total billed charges,75% of total billed charges,1706.2,75,,,percent of total billed charges,75% of total billed charges,1743.88,100,,,Fee Schedule,100% of CMS OPPS Rate,643.69,102,,,Fee Schedule,102% of WV Medicaid Rate,2877.42,165,,,Fee Schedule,165% of CMS OPPS Rate,1807.39,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,5009.09,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,6869.58,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,8604.84,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,631.07,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1743.88,100,,,Fee Schedule,100% of CMS OPPS Rate,1807.39,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,318.49,14,,,percent of total billed charges,14% of total billed charges,318.49,8604.84,
50432-IR NEPHROSTOMY PERCUTANEOUS LT,3431936,CDM,360,RC,50432,HCPCS,Outpatient,,,2274.93,1137.47,,1706.2,75,,,percent of total billed charges,75% of total billed charges,1706.2,75,,,percent of total billed charges,75% of total billed charges,1743.88,100,,,Fee Schedule,100% of CMS OPPS Rate,643.69,102,,,Fee Schedule,102% of WV Medicaid Rate,2877.42,165,,,Fee Schedule,165% of CMS OPPS Rate,1807.39,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,5009.09,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,6869.58,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,8604.84,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,631.07,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1743.88,100,,,Fee Schedule,100% of CMS OPPS Rate,1807.39,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,318.49,14,,,percent of total billed charges,14% of total billed charges,318.49,8604.84,
50432-IR NEPHROSTOMY PERCUTANEOUS RT,3431937,CDM,360,RC,50432,HCPCS,Outpatient,,,2274.93,1137.47,,1706.2,75,,,percent of total billed charges,75% of total billed charges,1706.2,75,,,percent of total billed charges,75% of total billed charges,1743.88,100,,,Fee Schedule,100% of CMS OPPS Rate,643.69,102,,,Fee Schedule,102% of WV Medicaid Rate,2877.42,165,,,Fee Schedule,165% of CMS OPPS Rate,1807.39,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,5009.09,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,6869.58,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,8604.84,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,631.07,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1743.88,100,,,Fee Schedule,100% of CMS OPPS Rate,1807.39,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,318.49,14,,,percent of total billed charges,14% of total billed charges,318.49,8604.84,
50432-IR- Nephrostomy Tube Insertion Bilateral,4061203,CDM,481,RC,50432,HCPCS,Outpatient,,,2274.93,1137.47,,1706.2,75,,,percent of total billed charges,75% of total billed charges,1706.2,75,,,percent of total billed charges,75% of total billed charges,1743.88,100,,,Fee Schedule,100% of CMS OPPS Rate,643.69,102,,,Fee Schedule,102% of WV Medicaid Rate,2877.42,165,,,Fee Schedule,165% of CMS OPPS Rate,1807.39,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,5009.09,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,6869.58,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,8604.84,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,631.07,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1743.88,100,,,Fee Schedule,100% of CMS OPPS Rate,1807.39,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,318.49,14,,,percent of total billed charges,14% of total billed charges,318.49,8604.84,
50432-PF IR INTRODUCTION OF NEPHRO CATH BI,3580889,CDM,960,RC,50432,HCPCS,Outpatient,,,2274.93,1137.47,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
50432-PF IR INTRODUCTION OF NEPHRO CATH LT,3580890,CDM,960,RC,50432,HCPCS,Outpatient,,,2274.93,1137.47,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
50432-PF IR INTRODUCTION OF NEPHRO CATH RT,3580891,CDM,960,RC,50432,HCPCS,Outpatient,,,2274.93,1137.47,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
50432-PF IR NEPHROSTOMY PERCUTANEOUS LT,3580892,CDM,960,RC,50432,HCPCS,Outpatient,,,2274.93,1137.47,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
50432-PF IR NEPHROSTOMY PERCUTANEOUS RT,3580893,CDM,960,RC,50432,HCPCS,Outpatient,,,2274.93,1137.47,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
50432-PF IR Nephrostomy Tube Insertion Bilateral,4061206,CDM,960,RC,50432,HCPCS,Outpatient,,,2274.93,1137.47,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
50432-PF PLMT NEPHROSTOMY CATH PRQ NEW ACCESS RS&I,4321476,CDM,981,RC,50432,HCPCS,Outpatient,,,397.52,198.76,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
CT Nephrostomy Percutaneous Bilat,3349765,CDM,360,RC,50432,HCPCS,Outpatient,,,2184.02,1092.01,,1638.02,75,,,percent of total billed charges,75% of total billed charges,1638.02,75,,,percent of total billed charges,75% of total billed charges,1743.88,100,,,Fee Schedule,100% of CMS OPPS Rate,643.69,102,,,Fee Schedule,102% of WV Medicaid Rate,2877.42,165,,,Fee Schedule,165% of CMS OPPS Rate,1807.39,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,5009.09,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,6869.58,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,8604.84,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,631.07,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1743.88,100,,,Fee Schedule,100% of CMS OPPS Rate,1807.39,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,305.76,14,,,percent of total billed charges,14% of total billed charges,305.76,8604.84,
CT Nephrostomy Percutaneous LT,3349767,CDM,360,RC,50432,HCPCS,Outpatient,,,2184.02,1092.01,,1638.02,75,,,percent of total billed charges,75% of total billed charges,1638.02,75,,,percent of total billed charges,75% of total billed charges,1743.88,100,,,Fee Schedule,100% of CMS OPPS Rate,643.69,102,,,Fee Schedule,102% of WV Medicaid Rate,2877.42,165,,,Fee Schedule,165% of CMS OPPS Rate,1807.39,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,5009.09,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,6869.58,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,8604.84,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,631.07,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1743.88,100,,,Fee Schedule,100% of CMS OPPS Rate,1807.39,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,305.76,14,,,percent of total billed charges,14% of total billed charges,305.76,8604.84,
CT Nephrostomy Percutaneous RT,3349769,CDM,360,RC,50432,HCPCS,Outpatient,,,2184.02,1092.01,,1638.02,75,,,percent of total billed charges,75% of total billed charges,1638.02,75,,,percent of total billed charges,75% of total billed charges,1743.88,100,,,Fee Schedule,100% of CMS OPPS Rate,643.69,102,,,Fee Schedule,102% of WV Medicaid Rate,2877.42,165,,,Fee Schedule,165% of CMS OPPS Rate,1807.39,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,5009.09,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,6869.58,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,8604.84,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,631.07,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1743.88,100,,,Fee Schedule,100% of CMS OPPS Rate,1807.39,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,305.76,14,,,percent of total billed charges,14% of total billed charges,305.76,8604.84,
IR Introduction of Nephro Catheter Bilat,603513,CDM,360,RC,50432,HCPCS,Outpatient,,,2184.02,1092.01,,1638.02,75,,,percent of total billed charges,75% of total billed charges,1638.02,75,,,percent of total billed charges,75% of total billed charges,1743.88,100,,,Fee Schedule,100% of CMS OPPS Rate,643.69,102,,,Fee Schedule,102% of WV Medicaid Rate,2877.42,165,,,Fee Schedule,165% of CMS OPPS Rate,1807.39,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,5009.09,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,6869.58,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,8604.84,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,631.07,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1743.88,100,,,Fee Schedule,100% of CMS OPPS Rate,1807.39,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,305.76,14,,,percent of total billed charges,14% of total billed charges,305.76,8604.84,
IR Introduction of Nephro Catheter Lt,603503,CDM,360,RC,50432,HCPCS,Outpatient,,,2184.02,1092.01,,1638.02,75,,,percent of total billed charges,75% of total billed charges,1638.02,75,,,percent of total billed charges,75% of total billed charges,1743.88,100,,,Fee Schedule,100% of CMS OPPS Rate,643.69,102,,,Fee Schedule,102% of WV Medicaid Rate,2877.42,165,,,Fee Schedule,165% of CMS OPPS Rate,1807.39,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,5009.09,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,6869.58,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,8604.84,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,631.07,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1743.88,100,,,Fee Schedule,100% of CMS OPPS Rate,1807.39,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,305.76,14,,,percent of total billed charges,14% of total billed charges,305.76,8604.84,
IR Introduction of Nephro Catheter Rt,603508,CDM,360,RC,50432,HCPCS,Outpatient,,,2184.02,1092.01,,1638.02,75,,,percent of total billed charges,75% of total billed charges,1638.02,75,,,percent of total billed charges,75% of total billed charges,1743.88,100,,,Fee Schedule,100% of CMS OPPS Rate,643.69,102,,,Fee Schedule,102% of WV Medicaid Rate,2877.42,165,,,Fee Schedule,165% of CMS OPPS Rate,1807.39,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,5009.09,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,6869.58,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,8604.84,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,631.07,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1743.88,100,,,Fee Schedule,100% of CMS OPPS Rate,1807.39,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,305.76,14,,,percent of total billed charges,14% of total billed charges,305.76,8604.84,
IR Ureteral Stent Placement Lt,603505,CDM,360,RC,50432,HCPCS,Outpatient,,,2184.02,1092.01,,1638.02,75,,,percent of total billed charges,75% of total billed charges,1638.02,75,,,percent of total billed charges,75% of total billed charges,1743.88,100,,,Fee Schedule,100% of CMS OPPS Rate,643.69,102,,,Fee Schedule,102% of WV Medicaid Rate,2877.42,165,,,Fee Schedule,165% of CMS OPPS Rate,1807.39,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,5009.09,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,6869.58,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,8604.84,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,631.07,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1743.88,100,,,Fee Schedule,100% of CMS OPPS Rate,1807.39,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,305.76,14,,,percent of total billed charges,14% of total billed charges,305.76,8604.84,
Read,596947,CDM,972,RC,50432,HCPCS,Outpatient,,,873.61,436.81,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
Read,596950,CDM,972,RC,50432,HCPCS,Outpatient,,,873.61,436.81,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
Read,596953,CDM,972,RC,50432,HCPCS,Outpatient,,,873.61,436.81,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
Read,4181214,CDM,972,RC,50432,HCPCS,Outpatient,,,873.61,436.81,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
Read,4181216,CDM,972,RC,50432,HCPCS,Outpatient,,,873.61,436.81,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
Read,4181218,CDM,972,RC,50432,HCPCS,Outpatient,,,873.61,436.81,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
"50433-PF Placement of nephroureteral catheter, new access",4271250,CDM,960,RC,50433,HCPCS,Outpatient,,,2178.02,1089.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
"50433-Placement of nephroureteral catheter, new access",4271249,CDM,481,RC,50433,HCPCS,Outpatient,,,2178.02,1089.01,,1633.52,75,,,percent of total billed charges,75% of total billed charges,1633.52,75,,,percent of total billed charges,75% of total billed charges,3013.34,100,,,Fee Schedule,100% of CMS OPPS Rate,1126.95,102,,,Fee Schedule,102% of WV Medicaid Rate,4972.01,165,,,Fee Schedule,165% of CMS OPPS Rate,3123.07,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8655.42,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11870.22,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,14868.65,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1104.85,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,3013.34,100,,,Fee Schedule,100% of CMS OPPS Rate,3123.07,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,304.92,14,,,percent of total billed charges,14% of total billed charges,304.92,14868.65,
"Placement of nephroureteral catheter, new access",4271251,CDM,761,RC,50433,HCPCS,Outpatient,,,2178.02,1089.01,,1633.52,75,,,percent of total billed charges,75% of total billed charges,1633.52,75,,,percent of total billed charges,75% of total billed charges,3013.34,100,,,Fee Schedule,100% of CMS OPPS Rate,1126.95,102,,,Fee Schedule,102% of WV Medicaid Rate,4972.01,165,,,Fee Schedule,165% of CMS OPPS Rate,3123.07,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8655.42,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11870.22,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,14868.65,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1104.85,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,3013.34,100,,,Fee Schedule,100% of CMS OPPS Rate,3123.07,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,304.92,14,,,percent of total billed charges,14% of total billed charges,304.92,14868.65,
50435-IR NEPHROSTOMY TUBE CHANGE BILAT,3431938,CDM,481,RC,50435,HCPCS,Outpatient,,,192.7,96.35,,144.53,75,,,percent of total billed charges,75% of total billed charges,144.53,75,,,percent of total billed charges,75% of total billed charges,1743.88,100,,,Fee Schedule,100% of CMS OPPS Rate,643.69,102,,,Fee Schedule,102% of WV Medicaid Rate,2877.42,165,,,Fee Schedule,165% of CMS OPPS Rate,1807.39,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,5009.09,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,6869.58,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,8604.84,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,631.07,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1743.88,100,,,Fee Schedule,100% of CMS OPPS Rate,1807.39,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,26.98,14,,,percent of total billed charges,14% of total billed charges,26.98,8604.84,
50435-IR- Nephrostomy Tube Change Left,4061204,CDM,481,RC,50435,HCPCS,Outpatient,,,192.7,96.35,,144.53,75,,,percent of total billed charges,75% of total billed charges,144.53,75,,,percent of total billed charges,75% of total billed charges,1743.88,100,,,Fee Schedule,100% of CMS OPPS Rate,643.69,102,,,Fee Schedule,102% of WV Medicaid Rate,2877.42,165,,,Fee Schedule,165% of CMS OPPS Rate,1807.39,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,5009.09,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,6869.58,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,8604.84,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,631.07,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1743.88,100,,,Fee Schedule,100% of CMS OPPS Rate,1807.39,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,26.98,14,,,percent of total billed charges,14% of total billed charges,26.98,8604.84,
50435-Nephrostomy Tube Change RT,3560655,CDM,481,RC,50435,HCPCS,Outpatient,,,192.7,96.35,,144.53,75,,,percent of total billed charges,75% of total billed charges,144.53,75,,,percent of total billed charges,75% of total billed charges,1743.88,100,,,Fee Schedule,100% of CMS OPPS Rate,643.69,102,,,Fee Schedule,102% of WV Medicaid Rate,2877.42,165,,,Fee Schedule,165% of CMS OPPS Rate,1807.39,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,5009.09,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,6869.58,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,8604.84,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,631.07,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1743.88,100,,,Fee Schedule,100% of CMS OPPS Rate,1807.39,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,26.98,14,,,percent of total billed charges,14% of total billed charges,26.98,8604.84,
50435-PF EXCHANGE NEPHROSTOMY CATHETER PRQ W/IMG GID RS&I,4321620,CDM,981,RC,50435,HCPCS,Outpatient,,,192.7,96.35,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
50435-PF IR NEPHROSTOMY TUBE CHANGE BILAT,3580894,CDM,960,RC,50435,HCPCS,Outpatient,,,192.7,96.35,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
50435-PF IR Nephrostomy Tube Change Left,4061207,CDM,960,RC,50435,HCPCS,Outpatient,,,192.7,96.35,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
50435-PF Nephrostomy Tube Change RT,3580895,CDM,960,RC,50435,HCPCS,Outpatient,,,192.7,96.35,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
CT Nephrostomy Tube Change Bilat,3349761,CDM,761,RC,50435,HCPCS,Outpatient,,,192.7,96.35,,144.53,75,,,percent of total billed charges,75% of total billed charges,144.53,75,,,percent of total billed charges,75% of total billed charges,1743.88,100,,,Fee Schedule,100% of CMS OPPS Rate,643.69,102,,,Fee Schedule,102% of WV Medicaid Rate,2877.42,165,,,Fee Schedule,165% of CMS OPPS Rate,1807.39,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,5009.09,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,6869.58,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,8604.84,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,631.07,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1743.88,100,,,Fee Schedule,100% of CMS OPPS Rate,1807.39,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,26.98,14,,,percent of total billed charges,14% of total billed charges,26.98,8604.84,
CT Nephrostomy Tube Change LT,3349763,CDM,761,RC,50435,HCPCS,Outpatient,,,192.7,96.35,,144.53,75,,,percent of total billed charges,75% of total billed charges,144.53,75,,,percent of total billed charges,75% of total billed charges,1743.88,100,,,Fee Schedule,100% of CMS OPPS Rate,643.69,102,,,Fee Schedule,102% of WV Medicaid Rate,2877.42,165,,,Fee Schedule,165% of CMS OPPS Rate,1807.39,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,5009.09,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,6869.58,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,8604.84,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,631.07,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1743.88,100,,,Fee Schedule,100% of CMS OPPS Rate,1807.39,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,26.98,14,,,percent of total billed charges,14% of total billed charges,26.98,8604.84,
CT Nephrostomy Tube Change RT,3349759,CDM,761,RC,50435,HCPCS,Outpatient,,,192.7,96.35,,144.53,75,,,percent of total billed charges,75% of total billed charges,144.53,75,,,percent of total billed charges,75% of total billed charges,1743.88,100,,,Fee Schedule,100% of CMS OPPS Rate,643.69,102,,,Fee Schedule,102% of WV Medicaid Rate,2877.42,165,,,Fee Schedule,165% of CMS OPPS Rate,1807.39,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,5009.09,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,6869.58,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,8604.84,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,631.07,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1743.88,100,,,Fee Schedule,100% of CMS OPPS Rate,1807.39,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,26.98,14,,,percent of total billed charges,14% of total billed charges,26.98,8604.84,
Read,630444,CDM,972,RC,50435,HCPCS,Outpatient,,,192.7,96.35,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
Read,630446,CDM,972,RC,50435,HCPCS,Outpatient,,,192.7,96.35,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
Read,630448,CDM,972,RC,50435,HCPCS,Outpatient,,,192.7,96.35,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
Read,4181220,CDM,972,RC,50435,HCPCS,Outpatient,,,192.7,96.35,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
Read,4181222,CDM,972,RC,50435,HCPCS,Outpatient,,,192.7,96.35,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
Read,4181224,CDM,972,RC,50435,HCPCS,Outpatient,,,192.7,96.35,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
50541PF Lap Surgical Ablation of Renal Cysts,4263109,CDM,975,RC,50541,HCPCS,Outpatient,,,2126.56,1063.28,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
50543PF Lap Surgical Partial Nephrectomy,4263110,CDM,975,RC,50543,HCPCS,Outpatient,,,3445.68,1722.84,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
50544PF Laparoscopy Surgical Pyeloplasty,4263111,CDM,975,RC,50544,HCPCS,Outpatient,,,2878.35,1439.18,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
50545PF Lap Surgical Radical Nephrectomy,4263112,CDM,975,RC,50545,HCPCS,Outpatient,,,3093.11,1546.56,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
50546PF Lap Surgical Nephrectomy w/Partial Ureterectomy,4263113,CDM,975,RC,50546,HCPCS,Outpatient,,,2792.12,1396.06,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
50548PF Lap Surgical Nephrectomy w/Total Ureterectomy,4263114,CDM,975,RC,50548,HCPCS,Outpatient,,,3112.01,1556.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
50549PF Unlisted Lap Procedure Renal,4263115,CDM,975,RC,50549,HCPCS,Outpatient,,,3988.99,1994.5,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
50555PF Renal endoscopy/biopsy,4263116,CDM,975,RC,50555,HCPCS,Outpatient,,,788.13,394.07,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
50590PF Lithotripsy Extracorporeal Shock Wave,4263117,CDM,975,RC,50590,HCPCS,Outpatient,,,1314.99,657.5,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
"50605 - Ureterotomy for insertion of indwelling stent, all types",3760902,CDM,983,RC,50605,HCPCS,Outpatient,,,2689.8,1344.9,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
50693: IR Nephroureteral Stent Placement,3654904,CDM,481,RC,50693,HCPCS,Outpatient,,,2490.76,1245.38,,1868.07,75,,,percent of total billed charges,75% of total billed charges,1868.07,75,,,percent of total billed charges,75% of total billed charges,3013.34,100,,,Fee Schedule,100% of CMS OPPS Rate,1126.95,102,,,Fee Schedule,102% of WV Medicaid Rate,4972.01,165,,,Fee Schedule,165% of CMS OPPS Rate,3123.07,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8655.42,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11870.22,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,14868.65,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1104.85,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,3013.34,100,,,Fee Schedule,100% of CMS OPPS Rate,3123.07,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,348.71,14,,,percent of total billed charges,14% of total billed charges,348.71,14868.65,
50693-IR PF Nephroureteral Stent Placement,3654906,CDM,960,RC,50693,HCPCS,Outpatient,,,2490.76,1245.38,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
Read,4183196,CDM,972,RC,50693,HCPCS,Outpatient,,,954.05,477.03,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
50694 - PLMT URTRL STNT PRQ NEW ACESS W/O SEP NFROS CATH,4037566,CDM,983,RC,50694,HCPCS,Outpatient,,,2798.94,1399.47,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
50715 - Ureterolysis w/wo RPSG Ureter Retroperitoneal Fibrosis,4169590,CDM,983,RC,50715,HCPCS,Outpatient,,,2838.02,1419.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
50760PF Ureteroureterostomy,4263118,CDM,975,RC,50760,HCPCS,Outpatient,,,2650.4,1325.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
50780-REIMPLANT URETER IN BLADDER,3430053,CDM,510,RC,50780,HCPCS,Outpatient,,,2916.75,1458.38,,2187.56,75,,,percent of total billed charges,75% of total billed charges,2187.56,75,,,percent of total billed charges,75% of total billed charges,2916.75,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,2916.75,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2916.75,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2916.75,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2916.75,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2916.75,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,2916.75,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2916.75,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,408.35,14,,,percent of total billed charges,14% of total billed charges,408.35,2916.75,
50945 - PF Laparoscopy Urtrolithotomy,4327331,CDM,960,RC,50945,HCPCS,Outpatient,,,1858.56,929.28,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
50949PF Unlisted Laparoscopy Procedure Ureter,4263119,CDM,975,RC,50949,HCPCS,Outpatient,,,3988.99,1994.5,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
51040PF Cystostomy/Cystotomy w/Drainage,4263120,CDM,975,RC,51040,HCPCS,Outpatient,,,666.09,333.05,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
51100-PF Aspiration of Bladder; by Needle,4321619,CDM,981,RC,51100,HCPCS,Outpatient,,,77.18,38.59,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
51102-PF ASPIRATION BLADDER INSERT SUPRAPUBIC CATHETER,4321477,CDM,981,RC,51102,HCPCS,Outpatient,,,279.84,139.92,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
51102PF Aspiration of Bladder w/Insertion Suprapubic Catheter,4263121,CDM,975,RC,51102,HCPCS,Outpatient,,,538.44,269.22,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
51500PF Excision Urachal Cyst/Sinus w/wo Umbilical Hernia Repair,4263122,CDM,975,RC,51500,HCPCS,Outpatient,,,1470.94,735.47,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
"51550 - Cystectomy, partial; simple",4169593,CDM,983,RC,51550,HCPCS,Outpatient,,,2254.97,1127.49,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
51555PF Cystectomy Partial Complicated,4263123,CDM,975,RC,51555,HCPCS,Outpatient,,,2919.96,1459.98,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
51575PF Cystectomy w/Bilat Pelvic Lymphadenectomy w/External Iliac/Hypogastric/Obturator Nodes,4263124,CDM,975,RC,51575,HCPCS,Outpatient,,,4215.77,2107.89,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
51600PF Injection Procedure Cystography or Voiding Urethrocystography,4263125,CDM,975,RC,51600,HCPCS,Outpatient,,,102.46,51.23,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
51610PF Injection Procedure for Retrograde Urethrocystography,4263126,CDM,975,RC,51610,HCPCS,Outpatient,,,146.52,73.26,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
51700PF Bladder Irrigation Simple Lavage/Instillation,4263127,CDM,975,RC,51700,HCPCS,Outpatient,,,70.95,35.48,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
51700-PF BLDR IRRIGATION SMPL LAVAGE &/INSTLJ,4321618,CDM,981,RC,51700,HCPCS,Outpatient,,,59.76,29.88,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
AMB alprostidil Admin Charge:Admin alprostadil Charge 51700,3444221,CDM,510,RC,51700,HCPCS,Outpatient,,,70.95,35.48,,53.21,75,,,percent of total billed charges,75% of total billed charges,53.21,75,,,percent of total billed charges,75% of total billed charges,202.01,100,,,Fee Schedule,100% of CMS OPPS Rate,43.68,102,,,Fee Schedule,102% of WV Medicaid Rate,333.31,165,,,Fee Schedule,165% of CMS OPPS Rate,209.36,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,580.25,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,795.77,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,996.78,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,42.82,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,202.01,100,,,Fee Schedule,100% of CMS OPPS Rate,209.36,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,9.93,14,,,percent of total billed charges,14% of total billed charges,9.93,996.78,
AMB Bladder Irrigation Charge:Bladder Irrigation- 51700,3444232,CDM,510,RC,51700,HCPCS,Outpatient,,,70.95,35.48,,53.21,75,,,percent of total billed charges,75% of total billed charges,53.21,75,,,percent of total billed charges,75% of total billed charges,202.01,100,,,Fee Schedule,100% of CMS OPPS Rate,43.68,102,,,Fee Schedule,102% of WV Medicaid Rate,333.31,165,,,Fee Schedule,165% of CMS OPPS Rate,209.36,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,580.25,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,795.77,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,996.78,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,42.82,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,202.01,100,,,Fee Schedule,100% of CMS OPPS Rate,209.36,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,9.93,14,,,percent of total billed charges,14% of total billed charges,9.93,996.78,
51701PF Insertion Non-Indwelling Bladder Catheter,4263128,CDM,975,RC,51701,HCPCS,Outpatient,,,59.82,29.91,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
51701-PF INSJ NON-NDWELLG BLADDER CATHETER,4321617,CDM,981,RC,51701,HCPCS,Outpatient,,,50.38,25.19,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
51702PF Insertion Temporary Indwelling Bladder Catheter Simple,4263129,CDM,975,RC,51702,HCPCS,Outpatient,,,58.79,29.4,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
51702-PF INSJ NON-NDWELLG BLADDER CATHETER,4321616,CDM,981,RC,51702,HCPCS,Outpatient,,,49.52,24.76,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
51703PF Insertion Temporary Indwelling Bladder Catheter Complicated,4263130,CDM,975,RC,51703,HCPCS,Outpatient,,,178.12,89.06,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
51703-PF INSJ TEMP NDWELLG BLADDER CATHETER COMPLICATED,4321615,CDM,981,RC,51703,HCPCS,Outpatient,,,150.04,75.02,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
CATH TEMP DWELL COMPLICATED,3428403,CDM,761,RC,51703,HCPCS,Outpatient,,,178.12,89.06,,133.59,75,,,percent of total billed charges,75% of total billed charges,133.59,75,,,percent of total billed charges,75% of total billed charges,136.72,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,225.58,165,,,Fee Schedule,165% of CMS OPPS Rate,141.69,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,392.72,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,538.59,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,674.64,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,136.72,100,,,Fee Schedule,100% of CMS OPPS Rate,141.69,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,24.94,14,,,percent of total billed charges,14% of total billed charges,24.94,674.64,
Cath Temp Dwell Simple,3428404,CDM,761,RC,51703,HCPCS,Outpatient,,,178.12,89.06,,133.59,75,,,percent of total billed charges,75% of total billed charges,133.59,75,,,percent of total billed charges,75% of total billed charges,136.72,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,225.58,165,,,Fee Schedule,165% of CMS OPPS Rate,141.69,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,392.72,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,538.59,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,674.64,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,136.72,100,,,Fee Schedule,100% of CMS OPPS Rate,141.69,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,24.94,14,,,percent of total billed charges,14% of total billed charges,24.94,674.64,
51705PF Change Cystostomy Tube Simple,4263131,CDM,975,RC,51705,HCPCS,Outpatient,,,118.91,59.46,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
51705-PF CHANGE CYSTOSTOMY TUBE SIMPLE,4321614,CDM,981,RC,51705,HCPCS,Outpatient,,,118.91,59.46,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
51710PF Change Cystostomy Tube Complicated,4263132,CDM,975,RC,51710,HCPCS,Outpatient,,,184.4,92.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
51715PF Endoscopic Injection Implant Material Submucosal Tissues Urethra/Bladder Neck,4263133,CDM,975,RC,51715,HCPCS,Outpatient,,,465.55,232.78,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
51720PF Bladder Instillation Anticarcinogenic Agentc,4263134,CDM,975,RC,51720,HCPCS,Outpatient,,,102.67,51.34,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
Clinic Cystometrogram Simple,3550630,CDM,510,RC,51725,HCPCS,Outpatient,,,497.91,248.96,,373.43,75,,,percent of total billed charges,75% of total billed charges,373.43,75,,,percent of total billed charges,75% of total billed charges,202.01,100,,,Fee Schedule,100% of CMS OPPS Rate,108.62,102,,,Fee Schedule,102% of WV Medicaid Rate,333.31,165,,,Fee Schedule,165% of CMS OPPS Rate,209.36,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,580.25,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,795.77,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,996.78,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,106.49,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,202.01,100,,,Fee Schedule,100% of CMS OPPS Rate,209.36,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,69.71,14,,,percent of total billed charges,14% of total billed charges,69.71,996.78,
51726PF Complex Cystometrogram,4263135,CDM,975,RC,51726,HCPCS,Outpatient,,,651.01,325.51,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
Clinic Cystometrogram Complex,3550631,CDM,510,RC,51726,HCPCS,Outpatient,,,651.01,325.51,,488.26,75,,,percent of total billed charges,75% of total billed charges,488.26,75,,,percent of total billed charges,75% of total billed charges,202.01,100,,,Fee Schedule,100% of CMS OPPS Rate,108.62,102,,,Fee Schedule,102% of WV Medicaid Rate,333.31,165,,,Fee Schedule,165% of CMS OPPS Rate,209.36,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,580.25,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,795.77,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,996.78,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,106.49,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,202.01,100,,,Fee Schedule,100% of CMS OPPS Rate,209.36,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,91.14,14,,,percent of total billed charges,14% of total billed charges,91.14,996.78,
51728PF Complex Cystometrogram w/Voiding Pressure Studies Any Technique,4263136,CDM,975,RC,51728,HCPCS,Outpatient,,,787.63,393.82,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
51729PF Complex Cystometrogram w/Voiding Pressure and Urethral Pressure Profile Studies,4263137,CDM,975,RC,51729,HCPCS,Outpatient,,,838.74,419.37,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
51741PF Complex Uroflowmetry,4263138,CDM,975,RC,51741,HCPCS,Outpatient,,,31.96,15.98,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
51797PF Addon Voiding Pressure Studies Intra-Abdominal,4263139,CDM,975,RC,51797,HCPCS,Outpatient,,,411.58,205.79,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
51798-PF MEAS POST-VOIDING RESIDUAL URINE&/BLADDER CAP,4321613,CDM,981,RC,51798,HCPCS,Outpatient,,,18.92,9.46,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
51798PF Measurement Post-Voiding Residual Urine/Bladder Capacity Ultrasound Non-Imaging,4263140,CDM,975,RC,51798,HCPCS,Outpatient,,,22.46,11.23,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
51800 - CSTOPLASTY/CSTOURTP PLSTC ANY,3997196,CDM,960,RC,51800,HCPCS,Outpatient,,,2709.94,1354.97,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
51845- Abdomino-vag vesical neck suspens,3431682,CDM,360,RC,51845,HCPCS,Outpatient,,,1518.84,759.42,,1139.13,75,,,percent of total billed charges,75% of total billed charges,1139.13,75,,,percent of total billed charges,75% of total billed charges,4357.75,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,7190.32,165,,,Fee Schedule,165% of CMS OPPS Rate,4516.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,12517.1,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,17166.21,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,21502.42,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,4357.75,100,,,Fee Schedule,100% of CMS OPPS Rate,4516.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,212.64,14,,,percent of total billed charges,14% of total billed charges,212.64,21502.42,
51860-MA AST REPAIR OF BLADDER WD,3430084,CDM,510,RC,51860,HCPCS,Outpatient,,,1959.81,979.91,,1469.86,75,,,percent of total billed charges,75% of total billed charges,1469.86,75,,,percent of total billed charges,75% of total billed charges,8045.5,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,13275.07,165,,,Fee Schedule,165% of CMS OPPS Rate,8338.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,23109.59,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,31692.97,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,39698.66,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,8045.5,100,,,Fee Schedule,100% of CMS OPPS Rate,8338.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,274.37,14,,,percent of total billed charges,14% of total billed charges,274.37,39698.66,
51860-PF REPAIR OF BLADDER WOUND,3430085,CDM,510,RC,51860,HCPCS,Outpatient,,,1959.81,979.91,,1469.86,75,,,percent of total billed charges,75% of total billed charges,1469.86,75,,,percent of total billed charges,75% of total billed charges,8045.5,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,13275.07,165,,,Fee Schedule,165% of CMS OPPS Rate,8338.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,23109.59,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,31692.97,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,39698.66,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,8045.5,100,,,Fee Schedule,100% of CMS OPPS Rate,8338.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,274.37,14,,,percent of total billed charges,14% of total billed charges,274.37,39698.66,
"51865PF Cystorrhaphy, suture of bladder wound, injury or rup",4272098,CDM,975,RC,51865,HCPCS,Outpatient,,,2080.93,1040.47,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
51800PF Cystoplasty/Cystourethroplasty Plastic,4263141,CDM,975,RC,51880,HCPCS,Outpatient,,,1073.11,536.56,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
"51900 - Closure of vesicovaginal fistula, abdominal approach",3783524,CDM,510,RC,51900,HCPCS,Outpatient,,,2148.28,1074.14,,1611.21,75,,,percent of total billed charges,75% of total billed charges,1611.21,75,,,percent of total billed charges,75% of total billed charges,2148.28,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,2148.28,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2148.28,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2148.28,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2148.28,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2148.28,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,2148.28,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2148.28,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,300.76,14,,,percent of total billed charges,14% of total billed charges,300.76,2148.28,
51900-MA REPAIR BLADDER/VAGINA LESION,3430088,CDM,510,RC,51900,HCPCS,Outpatient,,,2148.28,1074.14,,1611.21,75,,,percent of total billed charges,75% of total billed charges,1611.21,75,,,percent of total billed charges,75% of total billed charges,2148.28,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,2148.28,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2148.28,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2148.28,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2148.28,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2148.28,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,2148.28,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2148.28,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,300.76,14,,,percent of total billed charges,14% of total billed charges,300.76,2148.28,
"51999 - PF Unlisted Laparoscipy Procedure, Bladder",4309238,CDM,960,RC,51999,HCPCS,Outpatient,,,1699.84,849.92,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
52000PF Cystourethroscopy,4263142,CDM,975,RC,52000,HCPCS,Outpatient,,,186.75,93.38,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
Clinic Cystoscopy,3550628,CDM,510,RC,52000,HCPCS,Outpatient,,,186.75,93.38,,140.06,75,,,percent of total billed charges,75% of total billed charges,140.06,75,,,percent of total billed charges,75% of total billed charges,587.91,100,,,Fee Schedule,100% of CMS OPPS Rate,234.83,102,,,Fee Schedule,102% of WV Medicaid Rate,970.06,165,,,Fee Schedule,165% of CMS OPPS Rate,609.32,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1688.72,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2315.94,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,2900.97,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,230.23,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,587.91,100,,,Fee Schedule,100% of CMS OPPS Rate,609.32,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,26.15,14,,,percent of total billed charges,14% of total billed charges,26.15,2900.97,
52001PF Cystourethroscopy w/Irrigation and Evacuation Multiple Obstructing Clots,4263143,CDM,975,RC,52001,HCPCS,Outpatient,,,662.38,331.19,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
52005- Cystourethroscop/cath/exc rad serv,3435968,CDM,510,RC,52005,HCPCS,Outpatient,,,723.54,361.77,,542.66,75,,,percent of total billed charges,75% of total billed charges,542.66,75,,,percent of total billed charges,75% of total billed charges,1743.88,100,,,Fee Schedule,100% of CMS OPPS Rate,643.69,102,,,Fee Schedule,102% of WV Medicaid Rate,2877.42,165,,,Fee Schedule,165% of CMS OPPS Rate,1807.39,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,5009.09,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,6869.58,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,8604.84,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,631.07,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1743.88,100,,,Fee Schedule,100% of CMS OPPS Rate,1807.39,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,101.3,14,,,percent of total billed charges,14% of total billed charges,101.3,8604.84,
52005-PF CYSTO BLADDER W/URETERAL CATHETERIZATION,4321478,CDM,981,RC,52005,HCPCS,Outpatient,,,255.48,127.74,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
52005PF Cystourethroscopy w/Ureteral Catheterization w/wo Irrigation/Instillation,4263144,CDM,975,RC,52005,HCPCS,Outpatient,,,303.31,151.66,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
52204- Cystourethroscopy with biopsy,3430089,CDM,510,RC,52204,HCPCS,Outpatient,,,324.06,162.03,,243.05,75,,,percent of total billed charges,75% of total billed charges,243.05,75,,,percent of total billed charges,75% of total billed charges,1743.88,100,,,Fee Schedule,100% of CMS OPPS Rate,643.69,102,,,Fee Schedule,102% of WV Medicaid Rate,2877.42,165,,,Fee Schedule,165% of CMS OPPS Rate,1807.39,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,5009.09,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,6869.58,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,8604.84,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,631.07,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1743.88,100,,,Fee Schedule,100% of CMS OPPS Rate,1807.39,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,45.37,14,,,percent of total billed charges,14% of total billed charges,45.37,8604.84,
"52214 - Cystourethroscopy, with fulguration (including cryosurgery or laser surgery) of trigone, bla",3572812,CDM,983,RC,52214,HCPCS,Outpatient,,,1875.47,937.74,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
52214PF Cystourethroscopy w/Destruction of Lesions,4263145,CDM,975,RC,52214,HCPCS,Outpatient,,,407.44,203.72,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
52224PF Cystourethroscopy w/Removal Small Lesion Less Than 0.5cm w/wo Bx,4263146,CDM,975,RC,52224,HCPCS,Outpatient,,,471.95,235.98,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
52234PF Cystourethroscopy w/Fulguration/Resection Small Tumor 0.5cm-2.0cm,4263147,CDM,975,RC,52234,HCPCS,Outpatient,,,566.85,283.43,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
52235PF Cystourethroscopy w/Fulguration/Resection Medium Tumor 2.0cm-5.0cm,4263148,CDM,975,RC,52235,HCPCS,Outpatient,,,665.16,332.58,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
52240PF Cystourethroscopy w/Fulguration/Resection Large Tumor Greater Than 5.0cm,4263149,CDM,975,RC,52240,HCPCS,Outpatient,,,904.82,452.41,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
52260PF Cystourethroscopy w/Dilation Bladder General/Conduction Anesthesia,4263150,CDM,975,RC,52260,HCPCS,Outpatient,,,487.32,243.66,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
52276PF Cystourethroscopy w/Direct Vision Internal Urethrotomy,4263151,CDM,975,RC,52276,HCPCS,Outpatient,,,608.99,304.5,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
52281-PF CYSTO CALIBRATION DILAT URTL STRIX/STENOSIS,4321479,CDM,981,RC,52281,HCPCS,Outpatient,,,294.82,147.41,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
52281PF Cystourethroscopy w/Calibration/Dilation Urethral Stricture/Stenosis Male/Female,4263152,CDM,960,RC,52281,HCPCS,Outpatient,,,312.51,156.26,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
52284 - PF Optilume/cystourethroscopoy for stricture,4339430,CDM,960,RC,52284,HCPCS,Outpatient,,,314.08,157.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
52287PF Cystourethroscopy w/Injection Chemodenervation Bladder,4263153,CDM,975,RC,52287,HCPCS,Outpatient,,,392.66,196.33,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
"52300 - Cystourethroscopy; with resection or fulguration of orthotopic ureterocele(s), unilateral or",3760999,CDM,983,RC,52300,HCPCS,Outpatient,,,728.25,364.13,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
52310-PF CYSTO W/SIMPLE REMOVAL STONE & STENT,4321612,CDM,981,RC,52310,HCPCS,Outpatient,,,294.5,147.25,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
52310PF Cystourethroscopy w/Removal FB/Calculus/Ureteral Stent Urethra/Bladder Simple,4263154,CDM,975,RC,52310,HCPCS,Outpatient,,,349.63,174.82,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
Clinic Cystoscopy w/stent removal,3550633,CDM,510,RC,52310,HCPCS,Outpatient,,,349.63,174.82,,262.22,75,,,percent of total billed charges,75% of total billed charges,262.22,75,,,percent of total billed charges,75% of total billed charges,1743.88,100,,,Fee Schedule,100% of CMS OPPS Rate,643.69,102,,,Fee Schedule,102% of WV Medicaid Rate,2877.42,165,,,Fee Schedule,165% of CMS OPPS Rate,1807.39,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,5009.09,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,6869.58,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,8604.84,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,631.07,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1743.88,100,,,Fee Schedule,100% of CMS OPPS Rate,1807.39,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,48.95,14,,,percent of total billed charges,14% of total billed charges,48.95,8604.84,
52317PF Litholapaxy Crushing/Fragmentation and Removal Calculus Simple/Small Less Than 2.5cm,4263155,CDM,975,RC,52317,HCPCS,Outpatient,,,800.98,400.49,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
52318PF Litholapaxy Crushing/Fragmentation and Removal Calculus Comp/Large Greater Than 2.5cm,4263156,CDM,975,RC,52318,HCPCS,Outpatient,,,1094.27,547.14,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
"52330 - Cystourethroscopy (including ureteral catheterization); with manipulation, without removal o",3572813,CDM,983,RC,52330,HCPCS,Outpatient,,,1532.65,766.33,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
52330PF Cystourethroscopy w/Manipulation w/o Removal Ureteral Calculus,4263157,CDM,975,RC,52330,HCPCS,Outpatient,,,607.37,303.69,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
52332PF Cystourethroscopy w/Insertion Indwelling Ureteral Stent,4263158,CDM,975,RC,52332,HCPCS,Outpatient,,,358.04,179.02,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
"52341- Cystourethroscopy; with treatment of ureteral stricture (eg, balloon dilation, laser, electro",3621519,CDM,510,RC,52341,HCPCS,Outpatient,,,739,369.5,,554.25,75,,,percent of total billed charges,75% of total billed charges,554.25,75,,,percent of total billed charges,75% of total billed charges,3013.34,100,,,Fee Schedule,100% of CMS OPPS Rate,1126.95,102,,,Fee Schedule,102% of WV Medicaid Rate,4972.01,165,,,Fee Schedule,165% of CMS OPPS Rate,3123.07,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8655.42,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11870.22,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,14868.65,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1104.85,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,3013.34,100,,,Fee Schedule,100% of CMS OPPS Rate,3123.07,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,103.46,14,,,percent of total billed charges,14% of total billed charges,103.46,14868.65,
52344PF Cystourethroscopy w/Ureteroscopy w/Tx Ureteral Stricture,4263159,CDM,975,RC,52344,HCPCS,Outpatient,,,850.4,425.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
"52345 Cystourethroscopy with ureteroscopy; with treatment of ureteropelvic junction stricture (eg, b",3621659,CDM,510,RC,52345,HCPCS,Outpatient,,,1028.58,514.29,,771.44,75,,,percent of total billed charges,75% of total billed charges,771.44,75,,,percent of total billed charges,75% of total billed charges,3013.34,100,,,Fee Schedule,100% of CMS OPPS Rate,1126.95,102,,,Fee Schedule,102% of WV Medicaid Rate,4972.01,165,,,Fee Schedule,165% of CMS OPPS Rate,3123.07,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8655.42,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11870.22,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,14868.65,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1104.85,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,3013.34,100,,,Fee Schedule,100% of CMS OPPS Rate,3123.07,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,144,14,,,percent of total billed charges,14% of total billed charges,144,14868.65,
52351PF Cystourethroscopy w/Ureteroscopy/Pyeloscopy Diagnostic,4263160,CDM,975,RC,52351,HCPCS,Outpatient,,,696.98,348.49,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
52352PF Cystourethroscopy w/Ureteroscopy/Pyeloscopy w/Removal/Manipulation Calculus,4263161,CDM,975,RC,52352,HCPCS,Outpatient,,,816.98,408.49,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
52353PF Cystourethroscopy w/Ureteroscopy/Pyeloscopy w/Lithotripsy,4263162,CDM,975,RC,52353,HCPCS,Outpatient,,,904.82,452.41,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
52354PF Cystourethroscopy w/Ureteroscopy/Pyeloscopy w/Bx/Fulguration Renal Pelvic Lesion,4263163,CDM,975,RC,52354,HCPCS,Outpatient,,,961.9,480.95,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
52355 - PF Cystourethroscopy w/Ureteroscopy/Pyeloscopy w/Resection Ureteral/Renal Pelvic Tumor,4327196,CDM,960,RC,52355,HCPCS,Outpatient,,,892.34,446.17,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
"52356 - (50) Cystourethroscopy, with ureteroscopy and/or pyeloscopy; with lithotripsy including inse",3699540,CDM,510,RC,52356,HCPCS,Outpatient,,,959.14,479.57,,719.36,75,,,percent of total billed charges,75% of total billed charges,719.36,75,,,percent of total billed charges,75% of total billed charges,4420.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1665.85,102,,,Fee Schedule,102% of WV Medicaid Rate,7294.36,165,,,Fee Schedule,165% of CMS OPPS Rate,4581.8,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,12698.22,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,17414.59,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,21813.56,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1633.19,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,4420.83,100,,,Fee Schedule,100% of CMS OPPS Rate,4581.8,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,134.28,14,,,percent of total billed charges,14% of total billed charges,134.28,21813.56,
52356PF Cystourethroscopy w/Ureteroscopy w/Lithotripsy w/Insert Indwelling Ureteral Stent,4263165,CDM,975,RC,52356,HCPCS,Outpatient,,,959.14,479.57,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
"52400 - PF Cystourethroscopy with incision, fulguration, or resection of congenital posterior urethr",3699541,CDM,510,RC,52400,HCPCS,Outpatient,,,1246.03,623.02,,934.52,75,,,percent of total billed charges,75% of total billed charges,934.52,75,,,percent of total billed charges,75% of total billed charges,3013.34,100,,,Fee Schedule,100% of CMS OPPS Rate,1126.95,102,,,Fee Schedule,102% of WV Medicaid Rate,4972.01,165,,,Fee Schedule,165% of CMS OPPS Rate,3123.07,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8655.42,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11870.22,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,14868.65,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1104.85,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,3013.34,100,,,Fee Schedule,100% of CMS OPPS Rate,3123.07,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,174.44,14,,,percent of total billed charges,14% of total billed charges,174.44,14868.65,
"52400PF Cystourethroscopy with incision, fulguration, or res",4272095,CDM,975,RC,52400,HCPCS,Outpatient,,,1103.08,551.54,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
52441PF Cystourethro w/Implant,4263166,CDM,975,RC,52441,HCPCS,Outpatient,,,483.9,241.95,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
52442PF Cystourethro w/Addl Implant,4263167,CDM,975,RC,52442,HCPCS,Outpatient,,,117.7,58.85,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
52450 - PF Transurethral Incision Prostate,4301621,CDM,960,RC,52450,HCPCS,Outpatient,,,971.62,485.81,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
52500 - Revision of bladder neck,4241830,CDM,960,RC,52500,HCPCS,Outpatient,,,1010.35,505.18,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
52601PF Transurethral Electrosurgical Resection Prostate w/Control Postop Bleed Complete,4263168,CDM,975,RC,52601,HCPCS,Outpatient,,,1684.18,842.09,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
52630 - PF TrnsUrthrl Rsctn Rsdl/Rgrwth Obstr Prstate Tiss,4349187,CDM,960,RC,52630,HCPCS,Outpatient,,,772.26,386.13,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
52648PF Laser Vaporization Prostate w/Control Postoperative Bleeding Complete,4263169,CDM,975,RC,52648,HCPCS,Outpatient,,,1598.61,799.31,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
53020PF Meatotomy/Cutting of Meatus Except Infant,4263164,CDM,975,RC,53020,HCPCS,Outpatient,,,1088.11,544.06,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
53200 Biopsy of urethra,3621304,CDM,510,RC,53200,HCPCS,Outpatient,,,410.55,205.28,,307.91,75,,,percent of total billed charges,75% of total billed charges,307.91,75,,,percent of total billed charges,75% of total billed charges,1743.88,100,,,Fee Schedule,100% of CMS OPPS Rate,643.69,102,,,Fee Schedule,102% of WV Medicaid Rate,2877.42,165,,,Fee Schedule,165% of CMS OPPS Rate,1807.39,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,5009.09,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,6869.58,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,8604.84,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,631.07,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1743.88,100,,,Fee Schedule,100% of CMS OPPS Rate,1807.39,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,57.48,14,,,percent of total billed charges,14% of total billed charges,57.48,8604.84,
53200-PF BIOPSY URETHRA,4321480,CDM,981,RC,53200,HCPCS,Outpatient,,,276.98,138.49,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
53220PF Excision/Fulguration Carcinoma Urethra,4263170,CDM,975,RC,53220,HCPCS,Outpatient,,,1041.53,520.77,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
53265 - Excision or fulgration; urethral caruncle,4241831,CDM,960,RC,53265,HCPCS,Outpatient,,,467.31,233.66,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
"53450 - Urethromeatoplasty, with mucosal advancement",3997201,CDM,960,RC,53450,HCPCS,Outpatient,,,1060.73,530.37,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
"53505 - PF Urethrorrhaphy, suture of urethral wound or injury; penile",3641188,CDM,510,RC,53505,HCPCS,Outpatient,,,1263.34,631.67,,947.51,75,,,percent of total billed charges,75% of total billed charges,947.51,75,,,percent of total billed charges,75% of total billed charges,4420.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1665.85,102,,,Fee Schedule,102% of WV Medicaid Rate,7294.36,165,,,Fee Schedule,165% of CMS OPPS Rate,4581.8,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,12698.22,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,17414.59,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,21813.56,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1633.19,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,4420.83,100,,,Fee Schedule,100% of CMS OPPS Rate,4581.8,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,176.87,14,,,percent of total billed charges,14% of total billed charges,176.87,21813.56,
"53510 - Urethrorrhaphy, suture of urethral wound or injury; perineal",3783527,CDM,510,RC,53510,HCPCS,Outpatient,,,1647.05,823.53,,1235.29,75,,,percent of total billed charges,75% of total billed charges,1235.29,75,,,percent of total billed charges,75% of total billed charges,4420.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1665.85,102,,,Fee Schedule,102% of WV Medicaid Rate,7294.36,165,,,Fee Schedule,165% of CMS OPPS Rate,4581.8,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,12698.22,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,17414.59,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,21813.56,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1633.19,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,4420.83,100,,,Fee Schedule,100% of CMS OPPS Rate,4581.8,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,230.59,14,,,percent of total billed charges,14% of total billed charges,230.59,21813.56,
53600-PF DILAT URETHRAL STRIX DILATOR MALE 1ST,4321611,CDM,981,RC,53600,HCPCS,Outpatient,,,126.32,63.16,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
53600PF Dilation Urethral Stricture Passage of Sound/Urethral Dilator Male Initial,4263171,CDM,975,RC,53600,HCPCS,Outpatient,,,149.97,74.99,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
53605PF Dilation Urethral Stricture/Vesical Neck Passage Urethral Dilator Male w/Anesthesia,4263172,CDM,975,RC,53605,HCPCS,Outpatient,,,150.75,75.38,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
53620-PF DILAT URETHRAL STRIX FILIFORM & FOLLWR MALE 1ST,4321610,CDM,981,RC,53620,HCPCS,Outpatient,,,169.22,84.61,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
53620PF Dilation Urethral Stricture Passage Filiform and Follower Male Initial,4263173,CDM,975,RC,53620,HCPCS,Outpatient,,,200.9,100.45,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
53621PF Dilation Urethral Stricture Passage Filiform and Follower Male Subsequent,4263174,CDM,975,RC,53621,HCPCS,Outpatient,,,166.78,83.39,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
53660PF Dilation Female Urethra Suppository/Instillation Initial,4263175,CDM,975,RC,53660,HCPCS,Outpatient,,,96.38,48.19,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
53661PF Dilation Female Urethra w/Suppository/Instillation Subsequent,4263176,CDM,975,RC,53661,HCPCS,Outpatient,,,94.4,47.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
"53899 - Unlisted procedure, urinary system",3899055,CDM,983,RC,53899,HCPCS,Outpatient,,,2389.88,1194.94,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
54001 - Slitting Prepuce Dorsal/Lat SPX XCP Newborn,3899058,CDM,983,RC,54001,HCPCS,Outpatient,,,500.6,250.3,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
54001PF Slitting Prepuce Dorsal/Lateral Except Newborn,4265108,CDM,960,RC,54001,HCPCS,Outpatient,,,321.92,160.96,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
54055PF Destruction Lesion Penis Simple Electrodesiccation,4265109,CDM,960,RC,54055,HCPCS,Outpatient,,,217.54,108.77,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
54056PF Cryosurgery/penis lesion (s),4265110,CDM,960,RC,54056,HCPCS,Outpatient,,,219.19,109.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
54057 - Laser Surg Penis Lesion(s),4189310,CDM,960,RC,54057,HCPCS,Outpatient,,,313.65,156.83,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
54060PF Destruction Lesion Penis Simple Surgical Excision,4265111,CDM,960,RC,54060,HCPCS,Outpatient,,,298.98,149.49,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
54065 - Dstr lesion penis extensive,4241824,CDM,510,RC,54065,HCPCS,Outpatient,,,442.68,221.34,,332.01,75,,,percent of total billed charges,75% of total billed charges,332.01,75,,,percent of total billed charges,75% of total billed charges,1622.59,100,,,Fee Schedule,100% of CMS OPPS Rate,699.11,102,,,Fee Schedule,102% of WV Medicaid Rate,2677.27,165,,,Fee Schedule,165% of CMS OPPS Rate,1681.67,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4660.68,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,6391.75,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,8006.31,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,685.4,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1622.59,100,,,Fee Schedule,100% of CMS OPPS Rate,1681.67,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,61.98,14,,,percent of total billed charges,14% of total billed charges,61.98,8006.31,
54100PF Bx Penis Separate Procedure,4265112,CDM,960,RC,54100,HCPCS,Outpatient,,,242.27,121.14,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
54120PF Amputation Penis Partial,4265113,CDM,960,RC,54120,HCPCS,Outpatient,,,1459.43,729.72,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
54150PF Circumcision w/Clamp/Other Device w/Regional Dorsal,4267330,CDM,960,RC,54150,HCPCS,Outpatient,,,226.78,113.39,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
Circumcision,634068,CDM,723,RC,54150,HCPCS,Outpatient,,,375.91,187.96,,281.93,75,,,percent of total billed charges,75% of total billed charges,281.93,75,,,percent of total billed charges,75% of total billed charges,1743.88,100,,,Fee Schedule,100% of CMS OPPS Rate,643.69,102,,,Fee Schedule,102% of WV Medicaid Rate,2877.42,165,,,Fee Schedule,165% of CMS OPPS Rate,1807.39,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,5009.09,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,6869.58,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,8604.84,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,631.07,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1743.88,100,,,Fee Schedule,100% of CMS OPPS Rate,1807.39,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,52.63,14,,,percent of total billed charges,14% of total billed charges,52.63,8604.84,
Circumcision procedure date/time,636296,CDM,723,RC,54150,HCPCS,Outpatient,,,381.66,190.83,,286.25,75,,,percent of total billed charges,75% of total billed charges,286.25,75,,,percent of total billed charges,75% of total billed charges,1743.88,100,,,Fee Schedule,100% of CMS OPPS Rate,643.69,102,,,Fee Schedule,102% of WV Medicaid Rate,2877.42,165,,,Fee Schedule,165% of CMS OPPS Rate,1807.39,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,5009.09,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,6869.58,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,8604.84,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,631.07,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1743.88,100,,,Fee Schedule,100% of CMS OPPS Rate,1807.39,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,53.43,14,,,percent of total billed charges,14% of total billed charges,53.43,8604.84,
54160PF Circumcision Surg Exc Other Than Clamp/Device/Dorsal,4267335,CDM,960,RC,54160,HCPCS,Outpatient,,,335.86,167.93,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
54161PF Circumcision Surg Exc Other Than Clamp/Device/Dorsal,4267336,CDM,960,RC,54161,HCPCS,Outpatient,,,454.58,227.29,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
54162PF Lysis/Excision Penile Post-Circumcision Adhesions,4265114,CDM,960,RC,54162,HCPCS,Outpatient,,,461.49,230.75,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
54163PF Repair Incomplete Circumcision,4265115,CDM,960,RC,54163,HCPCS,Outpatient,,,499.55,249.78,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
54164PF Frenulotomy of Penis,4265116,CDM,960,RC,54164,HCPCS,Outpatient,,,440.76,220.38,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
54200PF Injection Procedure Peyronie Disease,4267337,CDM,960,RC,54200,HCPCS,Outpatient,,,194.91,97.46,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
AMB Injection Procedure -> Initial Admin: 54200,3561577,CDM,510,RC,54200,HCPCS,Outpatient,,,286.73,143.37,,215.05,75,,,percent of total billed charges,75% of total billed charges,215.05,75,,,percent of total billed charges,75% of total billed charges,202.01,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,333.31,165,,,Fee Schedule,165% of CMS OPPS Rate,209.36,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,580.25,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,795.77,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,996.78,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,202.01,100,,,Fee Schedule,100% of CMS OPPS Rate,209.36,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,40.14,14,,,percent of total billed charges,14% of total billed charges,40.14,996.78,
AMB Injection Procedure -> Subsequent Admin: 54200-58,3561578,CDM,510,RC,54200,HCPCS,Outpatient,,,286.73,143.37,,215.05,75,,,percent of total billed charges,75% of total billed charges,215.05,75,,,percent of total billed charges,75% of total billed charges,202.01,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,333.31,165,,,Fee Schedule,165% of CMS OPPS Rate,209.36,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,580.25,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,795.77,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,996.78,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,202.01,100,,,Fee Schedule,100% of CMS OPPS Rate,209.36,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,40.14,14,,,percent of total billed charges,14% of total billed charges,40.14,996.78,
54220PF Irrigation Corpora Cavernosa Priapism,4265117,CDM,960,RC,54220,HCPCS,Outpatient,,,311.97,155.99,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
54220-PF Irrigation Corpora Cavernosa Priapism,4321609,CDM,981,RC,54220,HCPCS,Outpatient,,,262.78,131.39,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
Irrigation/Aspiration/Injection Treatment for Priapism,3428472,CDM,981,RC,54220,HCPCS,Outpatient,,,558.03,279.02,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
54230 - PF Injection Corpora Cavernosography,4333234,CDM,960,RC,54230,HCPCS,Outpatient,,,151.4,75.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
54235PF Injection Corpora Cavernosa w/Pharmacologic Agent,4265118,CDM,960,RC,54235,HCPCS,Outpatient,,,170.5,85.25,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
54360 Plastic operation on penis to correct angulation,3622376,CDM,510,RC,54360,HCPCS,Outpatient,,,1881.45,940.73,,1411.09,75,,,percent of total billed charges,75% of total billed charges,1411.09,75,,,percent of total billed charges,75% of total billed charges,3013.34,100,,,Fee Schedule,100% of CMS OPPS Rate,1126.95,102,,,Fee Schedule,102% of WV Medicaid Rate,4972.01,165,,,Fee Schedule,165% of CMS OPPS Rate,3123.07,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8655.42,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11870.22,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,14868.65,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1104.85,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,3013.34,100,,,Fee Schedule,100% of CMS OPPS Rate,3123.07,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,263.4,14,,,percent of total billed charges,14% of total billed charges,263.4,14868.65,
54400PF Insertion Penile Prosthesis Non-Inflatable Semi-Rigi,4265119,CDM,960,RC,54400,HCPCS,Outpatient,,,1228.39,614.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
54405PF Insertion Multi-Component Inflatable Penile Prosthes,4265120,CDM,960,RC,54405,HCPCS,Outpatient,,,1870.43,935.22,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
"54406 - (PF) Removal of all components of a multi-component, inflatable penile prosthesis without",3635228,CDM,510,RC,54406,HCPCS,Outpatient,,,1907.19,953.6,,1430.39,75,,,percent of total billed charges,75% of total billed charges,1430.39,75,,,percent of total billed charges,75% of total billed charges,3013.34,100,,,Fee Schedule,100% of CMS OPPS Rate,1126.95,102,,,Fee Schedule,102% of WV Medicaid Rate,4972.02,165,,,Fee Schedule,165% of CMS OPPS Rate,3123.07,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8655.42,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11870.22,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,14868.65,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1104.85,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,3013.34,100,,,Fee Schedule,100% of CMS OPPS Rate,3123.07,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,267.01,14,,,percent of total billed charges,14% of total billed charges,267.01,14868.65,
"54408 - PF - Repair of component(s) of a multi-component, inflatable penile prosthesis",3640924,CDM,510,RC,54408,HCPCS,Outpatient,,,2061.67,1030.84,,1546.25,75,,,percent of total billed charges,75% of total billed charges,1546.25,75,,,percent of total billed charges,75% of total billed charges,4420.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1665.85,102,,,Fee Schedule,102% of WV Medicaid Rate,7294.36,165,,,Fee Schedule,165% of CMS OPPS Rate,4581.8,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,12698.22,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,17414.59,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,21813.56,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1633.19,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,4420.83,100,,,Fee Schedule,100% of CMS OPPS Rate,4581.8,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.63,14,,,percent of total billed charges,14% of total billed charges,288.63,21813.56,
54410 - Rmvl & Rplcmt Infaltable Penile Prosth Same Sess,4169596,CDM,983,RC,54410,HCPCS,Outpatient,,,2008.55,1004.28,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
54415 - PF Rmvl Non-Nfltbl/Nfltbl Penile Prosth w/o Rplcmnt,4128290,CDM,960,RC,54415,HCPCS,Outpatient,,,1017.7,508.85,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
54417 - PF Remove/Replace Non-Inflatable/Inflatable Penile Prosthesis Infected Field Same Session,4333237,CDM,960,RC,54417,HCPCS,Outpatient,,,1721.1,860.55,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
"54435 Corpora cavernosa-glans penis fistulization (eg, biopsy needle, Winter procedure, rongeur, or",3621664,CDM,510,RC,54435,HCPCS,Outpatient,,,1071.52,535.76,,803.64,75,,,percent of total billed charges,75% of total billed charges,803.64,75,,,percent of total billed charges,75% of total billed charges,3013.34,100,,,Fee Schedule,100% of CMS OPPS Rate,1126.95,102,,,Fee Schedule,102% of WV Medicaid Rate,4972.01,165,,,Fee Schedule,165% of CMS OPPS Rate,3123.07,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8655.42,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11870.22,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,14868.65,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1104.85,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,3013.34,100,,,Fee Schedule,100% of CMS OPPS Rate,3123.07,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,150.01,14,,,percent of total billed charges,14% of total billed charges,150.01,14868.65,
54437 - PF Repair of traumatic corporeal tear(s),4333235,CDM,960,RC,54437,HCPCS,Outpatient,,,1296.46,648.23,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
54440 - Plastic operation penis injury,4241832,CDM,960,RC,54440,HCPCS,Outpatient,,,4059.8,2029.9,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
54450 - PF Foreskin manipulation including lysis of preputial adhesions and stretching,3699545,CDM,510,RC,54450,HCPCS,Outpatient,,,175.51,87.76,,131.63,75,,,percent of total billed charges,75% of total billed charges,131.63,75,,,percent of total billed charges,75% of total billed charges,202.01,100,,,Fee Schedule,100% of CMS OPPS Rate,108.62,102,,,Fee Schedule,102% of WV Medicaid Rate,333.31,165,,,Fee Schedule,165% of CMS OPPS Rate,209.36,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,580.25,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,795.77,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,996.78,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,106.49,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,202.01,100,,,Fee Schedule,100% of CMS OPPS Rate,209.36,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,24.57,14,,,percent of total billed charges,14% of total billed charges,24.57,996.78,
54450-PF FORESKN MANJ W/LSS PREPUTIAL ADS&STRETCHING,4321481,CDM,981,RC,54450,HCPCS,Outpatient,,,112.4,56.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
54512 Excision of extraparenchymal lesion of testis,3622072,CDM,510,RC,54512,HCPCS,Outpatient,,,1399.81,699.91,,1049.86,75,,,percent of total billed charges,75% of total billed charges,1049.86,75,,,percent of total billed charges,75% of total billed charges,3013.34,100,,,Fee Schedule,100% of CMS OPPS Rate,1126.95,102,,,Fee Schedule,102% of WV Medicaid Rate,4972.01,165,,,Fee Schedule,165% of CMS OPPS Rate,3123.07,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8655.42,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11870.22,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,14868.65,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1104.85,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,3013.34,100,,,Fee Schedule,100% of CMS OPPS Rate,3123.07,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,195.97,14,,,percent of total billed charges,14% of total billed charges,195.97,14868.65,
54520PF Orchiectomy Simple w/woTesticular Prosthesis Scrotal,4265121,CDM,960,RC,54520,HCPCS,Outpatient,,,755.54,377.77,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
"54522 - (50) Orchiectomy, partial",3715148,CDM,510,RC,54522,HCPCS,Outpatient,,,1531.53,765.77,,1148.65,75,,,percent of total billed charges,75% of total billed charges,1148.65,75,,,percent of total billed charges,75% of total billed charges,3013.34,100,,,Fee Schedule,100% of CMS OPPS Rate,1126.95,102,,,Fee Schedule,102% of WV Medicaid Rate,4972.01,165,,,Fee Schedule,165% of CMS OPPS Rate,3123.07,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8655.42,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11870.22,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,14868.65,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1104.85,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,3013.34,100,,,Fee Schedule,100% of CMS OPPS Rate,3123.07,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,214.41,14,,,percent of total billed charges,14% of total billed charges,214.41,14868.65,
"54522 - PF Orchiectomy, partial",3715145,CDM,510,RC,54522,HCPCS,Outpatient,,,1531.53,765.77,,1148.65,75,,,percent of total billed charges,75% of total billed charges,1148.65,75,,,percent of total billed charges,75% of total billed charges,3013.34,100,,,Fee Schedule,100% of CMS OPPS Rate,1126.95,102,,,Fee Schedule,102% of WV Medicaid Rate,4972.01,165,,,Fee Schedule,165% of CMS OPPS Rate,3123.07,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8655.42,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11870.22,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,14868.65,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1104.85,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,3013.34,100,,,Fee Schedule,100% of CMS OPPS Rate,3123.07,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,214.41,14,,,percent of total billed charges,14% of total billed charges,214.41,14868.65,
54530PF Orchiectomy Radical Tumor Inguinal Approach,4281200,CDM,960,RC,54530,HCPCS,Outpatient,,,1047.7,523.85,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
"54535 - Orchiectomy, radical, for tumor; with abdominal exploration",4037641,CDM,983,RC,54535,HCPCS,Outpatient,,,1939.85,969.93,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
54600 - PF Rdct Torsion Testis w/wo Fix Clat Testis,4301624,CDM,960,RC,54600,HCPCS,Outpatient,,,931.89,465.95,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
54640PF Orchiopexy Inguinal/Scrotal Approach,4265122,CDM,960,RC,54640,HCPCS,Outpatient,,,1002.04,501.02,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
54690 - PF Laparoscopy Surgical Orchiectomy,4315549,CDM,960,RC,54690,HCPCS,Outpatient,,,1352.81,676.41,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
54699PF Unlisted laparoscopy proc/testis,4265123,CDM,960,RC,54699,HCPCS,Outpatient,,,489.41,244.71,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
54700-PF I&D EPIDIDYMIS TSTIS&/SCROTAL SPACE,4321608,CDM,981,RC,54700,HCPCS,Outpatient,,,412.24,206.12,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
54700PF Incision/Drainage Epididymis/Testis/Scrotal Space,4265124,CDM,960,RC,54700,HCPCS,Outpatient,,,489.41,244.71,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
54840PF Excision Spermatocele w/wo Epididymectomy,4265125,CDM,960,RC,54840,HCPCS,Outpatient,,,742.81,371.41,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
54860 - PF Epididymectomy; unilateral,3715149,CDM,510,RC,54860,HCPCS,Outpatient,,,1088.33,544.17,,816.25,75,,,percent of total billed charges,75% of total billed charges,816.25,75,,,percent of total billed charges,75% of total billed charges,3013.34,100,,,Fee Schedule,100% of CMS OPPS Rate,1126.95,102,,,Fee Schedule,102% of WV Medicaid Rate,4972.01,165,,,Fee Schedule,165% of CMS OPPS Rate,3123.07,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8655.42,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11870.22,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,14868.65,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1104.85,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,3013.34,100,,,Fee Schedule,100% of CMS OPPS Rate,3123.07,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,152.37,14,,,percent of total billed charges,14% of total billed charges,152.37,14868.65,
55000PF Bx Testis Needle Separate Procedure,4265126,CDM,960,RC,55000,HCPCS,Outpatient,,,194.3,97.15,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
55040PF Excision Hydrocele Unilateral,4265127,CDM,960,RC,55040,HCPCS,Outpatient,,,777.33,388.67,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
55041PF Excision Hydrocele Bilateral,4265128,CDM,960,RC,55041,HCPCS,Outpatient,,,1178.87,589.44,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
55100PF Drainage of scrotal wall abscess,4267405,CDM,960,RC,55100,HCPCS,Outpatient,,,383.64,191.82,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
55100-PF DRAINAGE SCROTAL WALL ABSCESS,4321482,CDM,981,RC,55100,HCPCS,Outpatient,,,323.14,161.57,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
55110 - PF Scrotal exploration,3700900,CDM,510,RC,55110,HCPCS,Outpatient,,,1011.21,505.61,,758.41,75,,,percent of total billed charges,75% of total billed charges,758.41,75,,,percent of total billed charges,75% of total billed charges,3013.34,100,,,Fee Schedule,100% of CMS OPPS Rate,1126.95,102,,,Fee Schedule,102% of WV Medicaid Rate,4972.01,165,,,Fee Schedule,165% of CMS OPPS Rate,3123.07,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8655.42,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11870.22,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,14868.65,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1104.85,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,3013.34,100,,,Fee Schedule,100% of CMS OPPS Rate,3123.07,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,141.57,14,,,percent of total billed charges,14% of total billed charges,141.57,14868.65,
55150 - PF Resection of scrotum,3715150,CDM,510,RC,55150,HCPCS,Outpatient,,,1287.33,643.67,,965.5,75,,,percent of total billed charges,75% of total billed charges,965.5,75,,,percent of total billed charges,75% of total billed charges,3013.34,100,,,Fee Schedule,100% of CMS OPPS Rate,1126.95,102,,,Fee Schedule,102% of WV Medicaid Rate,4972.01,165,,,Fee Schedule,165% of CMS OPPS Rate,3123.07,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8655.42,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11870.22,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,14868.65,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1104.85,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,3013.34,100,,,Fee Schedule,100% of CMS OPPS Rate,3123.07,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,180.23,14,,,percent of total billed charges,14% of total billed charges,180.23,14868.65,
"55200 - PF Vasotomy, cannulization with or without incision of vas, unilateral or bilateral (separat",3715237,CDM,510,RC,55200,HCPCS,Outpatient,,,981.55,490.78,,736.16,75,,,percent of total billed charges,75% of total billed charges,736.16,75,,,percent of total billed charges,75% of total billed charges,3013.34,100,,,Fee Schedule,100% of CMS OPPS Rate,1126.95,102,,,Fee Schedule,102% of WV Medicaid Rate,4972.01,165,,,Fee Schedule,165% of CMS OPPS Rate,3123.07,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8655.42,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11870.22,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,14868.65,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1104.85,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,3013.34,100,,,Fee Schedule,100% of CMS OPPS Rate,3123.07,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,137.42,14,,,percent of total billed charges,14% of total billed charges,137.42,14868.65,
55250PF Vasectomy Unilateral/Bilateral Separate Procedure w/,4265129,CDM,960,RC,55250,HCPCS,Outpatient,,,521.56,260.78,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
55400PF Vasovasostomy/Vasovasorrhaphy,4265130,CDM,960,RC,55400,HCPCS,Outpatient,,,1153.04,576.52,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
55500PF Excision Hydrocele Spermatic Cord Unilateral Separat,4265143,CDM,960,RC,55500,HCPCS,Outpatient,,,908.02,454.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
55520PF Excision Lesion Spermatic Cord,4265132,CDM,960,RC,55520,HCPCS,Outpatient,,,1078.43,539.22,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
55530- Exc varicocele/ligate spermat vein,3431674,CDM,510,RC,55530,HCPCS,Outpatient,,,917.6,458.8,,688.2,75,,,percent of total billed charges,75% of total billed charges,688.2,75,,,percent of total billed charges,75% of total billed charges,3013.34,100,,,Fee Schedule,100% of CMS OPPS Rate,1126.95,102,,,Fee Schedule,102% of WV Medicaid Rate,4972.01,165,,,Fee Schedule,165% of CMS OPPS Rate,3123.07,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8655.42,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11870.22,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,14868.65,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1104.85,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,3013.34,100,,,Fee Schedule,100% of CMS OPPS Rate,3123.07,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,128.46,14,,,percent of total billed charges,14% of total billed charges,128.46,14868.65,
55530PF Exc variocele/ligate spermat vein,4265133,CDM,960,RC,55530,HCPCS,Outpatient,,,811.07,405.54,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
55700PF Bx Prostate Needle/Punch Single/Multiple Any Approac,4265134,CDM,960,RC,55700,HCPCS,Outpatient,,,301.59,150.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
Read,3575337,CDM,972,RC,55700,HCPCS,Outpatient,,,301.59,150.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
US add Needle Bx Prostate,645154,CDM,320,RC,55700,HCPCS,Outpatient,,,599.2,299.6,,449.4,75,,,percent of total billed charges,75% of total billed charges,449.4,75,,,percent of total billed charges,75% of total billed charges,1743.88,100,,,Fee Schedule,100% of CMS OPPS Rate,643.69,102,,,Fee Schedule,102% of WV Medicaid Rate,2877.42,165,,,Fee Schedule,165% of CMS OPPS Rate,1807.39,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,5009.09,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,6869.58,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,8604.84,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,631.07,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1743.88,100,,,Fee Schedule,100% of CMS OPPS Rate,1807.39,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,83.89,14,,,percent of total billed charges,14% of total billed charges,83.89,8604.84,
"55706- Biopsies, prostate, needle, transperineal, stereotactic template guided saturation sampling,",3569411,CDM,510,RC,55706,HCPCS,Outpatient,,,974.28,487.14,,730.71,75,,,percent of total billed charges,75% of total billed charges,730.71,75,,,percent of total billed charges,75% of total billed charges,3013.34,100,,,Fee Schedule,100% of CMS OPPS Rate,1126.95,102,,,Fee Schedule,102% of WV Medicaid Rate,4972.01,165,,,Fee Schedule,165% of CMS OPPS Rate,3123.07,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8655.42,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11870.22,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,14868.65,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1104.85,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,3013.34,100,,,Fee Schedule,100% of CMS OPPS Rate,3123.07,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,136.4,14,,,percent of total billed charges,14% of total billed charges,136.4,14868.65,
55706PF Bx Prostate Needle Transperineal Stereotactic Guided,4265142,CDM,960,RC,55706,HCPCS,Outpatient,,,864.07,432.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
"55725 Prostatotomy, external drainage of prostatic abscess, any approach; complicated",3622080,CDM,510,RC,55725,HCPCS,Outpatient,,,1546.74,773.37,,1160.06,75,,,percent of total billed charges,75% of total billed charges,1160.06,75,,,percent of total billed charges,75% of total billed charges,3013.34,100,,,Fee Schedule,100% of CMS OPPS Rate,1126.95,102,,,Fee Schedule,102% of WV Medicaid Rate,4972.01,165,,,Fee Schedule,165% of CMS OPPS Rate,3123.07,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8655.42,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11870.22,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,14868.65,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1104.85,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,3013.34,100,,,Fee Schedule,100% of CMS OPPS Rate,3123.07,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,216.54,14,,,percent of total billed charges,14% of total billed charges,216.54,14868.65,
55821PF Prostatectomy Suprapubic Subtotal 1 or 2 Stages,4265135,CDM,960,RC,55821,HCPCS,Outpatient,,,1940.02,970.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
55845PF Prostatectomy Retropubic Radical w/wo Nerve Sparing,4265136,CDM,960,RC,55845,HCPCS,Outpatient,,,3150.19,1575.1,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
55866PF Laparoscopy Surgical Prostatectomy Retropubic Radica,4265137,CDM,960,RC,55866,HCPCS,Outpatient,,,2774.91,1387.46,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
55867 - PF Laparoscopy Surgical Prostatectomy Simple Subtotal Includes Robot Assist,4327195,CDM,960,RC,55867,HCPCS,Outpatient,,,2011.74,1005.87,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
55874PF Transperineal Placement Biodegradable Material Peri-,4265141,CDM,960,RC,55874,HCPCS,Outpatient,,,378.14,189.07,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
55875PF Transperineal needle/cath/prostate/interstit radioel,4265138,CDM,960,RC,55875,HCPCS,Outpatient,,,1789.94,894.97,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
55876PF Placement Interstitial Device Radiation Therapy Guid,4265139,CDM,960,RC,55876,HCPCS,Outpatient,,,116.64,58.32,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
55876-PROSTATE FIDUCIAL,3565264,CDM,360,RC,55876,HCPCS,Outpatient,,,377.76,188.88,,283.32,75,,,percent of total billed charges,75% of total billed charges,283.32,75,,,percent of total billed charges,75% of total billed charges,1260.44,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,2079.73,165,,,Fee Schedule,165% of CMS OPPS Rate,1306.33,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,3620.47,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,4965.18,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6219.4,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,1260.44,100,,,Fee Schedule,100% of CMS OPPS Rate,1306.33,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,52.89,14,,,percent of total billed charges,14% of total billed charges,52.89,6219.4,
55876-PROSTATE FIDUCIAL Profee,3565261,CDM,983,RC,55876,HCPCS,Outpatient,,,382.3,191.15,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
Read,3575343,CDM,972,RC,55876,HCPCS,Outpatient,,,233.28,116.64,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
"55899 - PF Unlisted procedure, male genital system",3641214,CDM,510,RC,55899,HCPCS,Outpatient,,,5318.66,2659.33,,3989,75,,,percent of total billed charges,75% of total billed charges,3989,75,,,percent of total billed charges,75% of total billed charges,202.01,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,333.31,165,,,Fee Schedule,165% of CMS OPPS Rate,209.36,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,580.25,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,795.77,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,996.78,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,202.01,100,,,Fee Schedule,100% of CMS OPPS Rate,209.36,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,744.61,14,,,percent of total billed charges,14% of total billed charges,202.01,3989,
55899PF Unlisted Procedure Male Genital System,4265140,CDM,960,RC,55899,HCPCS,Outpatient,,,3343.24,1671.62,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
56405- Vulva/perineal abscess/ I & D,3431352,CDM,360,RC,56405,HCPCS,Outpatient,,,380.26,190.13,,285.2,75,,,percent of total billed charges,75% of total billed charges,285.2,75,,,percent of total billed charges,75% of total billed charges,274.47,100,,,Fee Schedule,100% of CMS OPPS Rate,74.52,102,,,Fee Schedule,102% of WV Medicaid Rate,452.9,165,,,Fee Schedule,165% of CMS OPPS Rate,284.48,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,788.43,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1081.27,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1354.41,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,73.06,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,274.47,100,,,Fee Schedule,100% of CMS OPPS Rate,284.48,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,53.24,14,,,percent of total billed charges,14% of total billed charges,53.24,1354.41,
56405-PF I&D VULVA/PERINEAL ABSCESS,4321607,CDM,981,RC,56405,HCPCS,Outpatient,,,244.26,122.13,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
56420- Bartholin's gland abscess/I & D,3431353,CDM,510,RC,56420,HCPCS,Outpatient,,,256.2,128.1,,192.15,75,,,percent of total billed charges,75% of total billed charges,192.15,75,,,percent of total billed charges,75% of total billed charges,167.47,100,,,Fee Schedule,100% of CMS OPPS Rate,69.54,102,,,Fee Schedule,102% of WV Medicaid Rate,276.31,165,,,Fee Schedule,165% of CMS OPPS Rate,173.56,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,481.04,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,659.7,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,826.34,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,68.18,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,167.47,100,,,Fee Schedule,100% of CMS OPPS Rate,173.56,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,35.87,14,,,percent of total billed charges,14% of total billed charges,35.87,826.34,
56420-PF I&D OF BARTHOLINS GLAND ABSCESS,4321606,CDM,981,RC,56420,HCPCS,Outpatient,,,215.8,107.9,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
56420PF Incision/Drainage Bartholin's Gland Abscess,4265144,CDM,960,RC,56420,HCPCS,Outpatient,,,256.2,128.1,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
56440PF Bartholin gland cyst/marsupializat,4165145,CDM,960,RC,56440,HCPCS,Outpatient,,,423.64,211.82,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
56441-MA LYSIS OF LABIAL LESION(S),3430121,CDM,510,RC,56441,HCPCS,Outpatient,,,473.56,236.78,,355.17,75,,,percent of total billed charges,75% of total billed charges,355.17,75,,,percent of total billed charges,75% of total billed charges,2658.26,100,,,Fee Schedule,100% of CMS OPPS Rate,1048.68,102,,,Fee Schedule,102% of WV Medicaid Rate,4386.13,165,,,Fee Schedule,165% of CMS OPPS Rate,2755.05,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,7635.49,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,10471.46,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13116.58,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1028.12,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2658.26,100,,,Fee Schedule,100% of CMS OPPS Rate,2755.05,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,66.3,14,,,percent of total billed charges,14% of total billed charges,66.3,13116.58,
"56501-MA DESTROY, VULVA LESIONS",3430122,CDM,510,RC,56501,HCPCS,Outpatient,,,265.32,132.66,,198.99,75,,,percent of total billed charges,75% of total billed charges,198.99,75,,,percent of total billed charges,75% of total billed charges,1622.59,100,,,Fee Schedule,100% of CMS OPPS Rate,109.48,102,,,Fee Schedule,102% of WV Medicaid Rate,2677.27,165,,,Fee Schedule,165% of CMS OPPS Rate,1681.67,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4660.68,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,6391.75,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,8006.31,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,107.33,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1622.59,100,,,Fee Schedule,100% of CMS OPPS Rate,1681.67,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,37.14,14,,,percent of total billed charges,14% of total billed charges,37.14,8006.31,
56515- Lesion destruction/vulva/extensive,3431356,CDM,510,RC,56515,HCPCS,Outpatient,,,716.79,358.4,,537.59,75,,,percent of total billed charges,75% of total billed charges,537.59,75,,,percent of total billed charges,75% of total billed charges,1622.59,100,,,Fee Schedule,100% of CMS OPPS Rate,699.11,102,,,Fee Schedule,102% of WV Medicaid Rate,2677.27,165,,,Fee Schedule,165% of CMS OPPS Rate,1681.67,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4660.68,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,6391.75,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,8006.31,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,685.4,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1622.59,100,,,Fee Schedule,100% of CMS OPPS Rate,1681.67,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,100.35,14,,,percent of total billed charges,14% of total billed charges,100.35,8006.31,
56605- BX vulva or perineum/1 lesion,3431357,CDM,360,RC,56605,HCPCS,Outpatient,,,248.99,124.5,,186.74,75,,,percent of total billed charges,75% of total billed charges,186.74,75,,,percent of total billed charges,75% of total billed charges,661.37,100,,,Fee Schedule,100% of CMS OPPS Rate,44.22,102,,,Fee Schedule,102% of WV Medicaid Rate,1091.26,165,,,Fee Schedule,165% of CMS OPPS Rate,685.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1899.71,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2605.3,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,3263.41,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,43.35,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,661.37,100,,,Fee Schedule,100% of CMS OPPS Rate,685.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,34.86,14,,,percent of total billed charges,14% of total billed charges,34.86,3263.41,
56606- Bx vulva or perineum/ea add lesion,3431358,CDM,360,RC,56606,HCPCS,Outpatient,,,100.02,50.01,,75.02,75,,,percent of total billed charges,75% of total billed charges,75.02,75,,,percent of total billed charges,75% of total billed charges,32.01,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14,14,,,percent of total billed charges,14% of total billed charges,14,75.02,
56620- Vulvectomy/simple/partial,3431359,CDM,510,RC,56620,HCPCS,Outpatient,,,1519.81,759.91,,1139.86,75,,,percent of total billed charges,75% of total billed charges,1139.86,75,,,percent of total billed charges,75% of total billed charges,2658.26,100,,,Fee Schedule,100% of CMS OPPS Rate,1048.68,102,,,Fee Schedule,102% of WV Medicaid Rate,4386.13,165,,,Fee Schedule,165% of CMS OPPS Rate,2755.05,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,7635.49,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,10471.46,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13116.58,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1028.12,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2658.26,100,,,Fee Schedule,100% of CMS OPPS Rate,2755.05,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,212.77,14,,,percent of total billed charges,14% of total billed charges,212.77,13116.58,
56625-PF COMPLETE REMOVAL OF VULVA,3430126,CDM,510,RC,56625,HCPCS,Outpatient,,,1749.47,874.74,,1312.1,75,,,percent of total billed charges,75% of total billed charges,1312.1,75,,,percent of total billed charges,75% of total billed charges,2658.26,100,,,Fee Schedule,100% of CMS OPPS Rate,1048.68,102,,,Fee Schedule,102% of WV Medicaid Rate,4386.13,165,,,Fee Schedule,165% of CMS OPPS Rate,2755.05,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,7635.49,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,10471.46,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13116.58,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1028.12,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2658.26,100,,,Fee Schedule,100% of CMS OPPS Rate,2755.05,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,244.93,14,,,percent of total billed charges,14% of total billed charges,244.93,13116.58,
56630-MA AST EXTENSIVE VULVA SURGERY,3430127,CDM,510,RC,56630,HCPCS,Outpatient,,,2526.02,1263.01,,1894.52,75,,,percent of total billed charges,75% of total billed charges,1894.52,75,,,percent of total billed charges,75% of total billed charges,2526.02,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,2526.02,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2526.02,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2526.02,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2526.02,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2526.02,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,2526.02,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2526.02,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,353.64,14,,,percent of total billed charges,14% of total billed charges,353.64,2526.02,
56630-PF EXTENSIVE VULVA SURG,3430128,CDM,510,RC,56630,HCPCS,Outpatient,,,2526.02,1263.01,,1894.52,75,,,percent of total billed charges,75% of total billed charges,1894.52,75,,,percent of total billed charges,75% of total billed charges,2526.02,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,2526.02,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2526.02,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2526.02,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2526.02,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2526.02,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,2526.02,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2526.02,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,353.64,14,,,percent of total billed charges,14% of total billed charges,353.64,2526.02,
MA AST EXTENSIVE VULVA SURGERY,3527846,CDM,960,RC,56630,HCPCS,Outpatient,,,2526.02,1263.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
"56631 - PF Vulvectomy, radical, partial; with unilateral inguinofemoral lymphadenectomy",3641189,CDM,510,RC,56631,HCPCS,Outpatient,,,3125.22,1562.61,,2343.92,75,,,percent of total billed charges,75% of total billed charges,2343.92,75,,,percent of total billed charges,75% of total billed charges,3125.22,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,3125.22,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3125.22,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3125.22,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3125.22,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3125.22,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,3125.22,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3125.22,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,437.53,14,,,percent of total billed charges,14% of total billed charges,437.53,3125.22,
MA EXTENSIVE VULVA SURGERY,3527835,CDM,960,RC,56631,HCPCS,Outpatient,,,3125.22,1562.61,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
56632 - PF EXTENSIVE VULVA SURGERY,3430130,CDM,510,RC,56632,HCPCS,Outpatient,,,3765.84,1882.92,,2824.38,75,,,percent of total billed charges,75% of total billed charges,2824.38,75,,,percent of total billed charges,75% of total billed charges,3765.84,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,3765.84,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3765.84,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3765.84,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3765.84,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3765.84,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,3765.84,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3765.84,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,527.22,14,,,percent of total billed charges,14% of total billed charges,527.22,3765.84,
56633-PF EXTENSIVE VULVA SURGERY,3430132,CDM,510,RC,56633,HCPCS,Outpatient,,,3243.18,1621.59,,2432.39,75,,,percent of total billed charges,75% of total billed charges,2432.39,75,,,percent of total billed charges,75% of total billed charges,3243.18,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,3243.18,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3243.18,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3243.18,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3243.18,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3243.18,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,3243.18,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3243.18,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,454.05,14,,,percent of total billed charges,14% of total billed charges,454.05,3243.18,
"56634 - PF Vulvectomy, radical, complete; with unilateral inguinofemoral lymphadenectomy",3696903,CDM,510,RC,56634,HCPCS,Outpatient,,,3408.96,1704.48,,2556.72,75,,,percent of total billed charges,75% of total billed charges,2556.72,75,,,percent of total billed charges,75% of total billed charges,3408.96,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,3408.96,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3408.96,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3408.96,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3408.96,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3408.96,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,3408.96,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3408.96,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,477.25,14,,,percent of total billed charges,14% of total billed charges,477.25,3408.96,
"56637 - PF Vulvectomy, radical, complete; with bilateral inguinofemoral lymphadenectomy",3696906,CDM,510,RC,56637,HCPCS,Outpatient,,,4002.16,2001.08,,3001.62,75,,,percent of total billed charges,75% of total billed charges,3001.62,75,,,percent of total billed charges,75% of total billed charges,4002.16,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,4002.16,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4002.16,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4002.16,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4002.16,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4002.16,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,4002.16,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4002.16,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,560.3,14,,,percent of total billed charges,14% of total billed charges,560.3,4002.16,
56637-MA AST EXTENSIVE VULVA SURGERY,3430133,CDM,510,RC,56637,HCPCS,Outpatient,,,4002.16,2001.08,,3001.62,75,,,percent of total billed charges,75% of total billed charges,3001.62,75,,,percent of total billed charges,75% of total billed charges,4002.16,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,4002.16,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4002.16,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4002.16,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4002.16,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4002.16,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,4002.16,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4002.16,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,560.3,14,,,percent of total billed charges,14% of total billed charges,560.3,4002.16,
56637-PF EXTENSIVE VULVA SURGERY,3430134,CDM,510,RC,56637,HCPCS,Outpatient,,,4002.16,2001.08,,3001.62,75,,,percent of total billed charges,75% of total billed charges,3001.62,75,,,percent of total billed charges,75% of total billed charges,4002.16,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,4002.16,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4002.16,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4002.16,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4002.16,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4002.16,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,4002.16,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4002.16,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,560.3,14,,,percent of total billed charges,14% of total billed charges,560.3,4002.16,
56700- Part hymenectomy/revi hymenal ring,3431360,CDM,510,RC,56700,HCPCS,Outpatient,,,530.49,265.25,,397.87,75,,,percent of total billed charges,75% of total billed charges,397.87,75,,,percent of total billed charges,75% of total billed charges,2658.26,100,,,Fee Schedule,100% of CMS OPPS Rate,1048.68,102,,,Fee Schedule,102% of WV Medicaid Rate,4386.13,165,,,Fee Schedule,165% of CMS OPPS Rate,2755.05,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,7635.49,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,10471.46,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13116.58,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1028.12,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2658.26,100,,,Fee Schedule,100% of CMS OPPS Rate,2755.05,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,74.27,14,,,percent of total billed charges,14% of total billed charges,74.27,13116.58,
56740-MA REMOVE VAGINA GLAND LESION,3430137,CDM,510,RC,56740,HCPCS,Outpatient,,,835.46,417.73,,626.6,75,,,percent of total billed charges,75% of total billed charges,626.6,75,,,percent of total billed charges,75% of total billed charges,2658.26,100,,,Fee Schedule,100% of CMS OPPS Rate,1048.68,102,,,Fee Schedule,102% of WV Medicaid Rate,4386.13,165,,,Fee Schedule,165% of CMS OPPS Rate,2755.05,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,7635.49,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,10471.46,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13116.58,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1028.12,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2658.26,100,,,Fee Schedule,100% of CMS OPPS Rate,2755.05,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,116.96,14,,,percent of total billed charges,14% of total billed charges,116.96,13116.58,
56740-PF EXC BARTHOLINS GLAND/CYST,4321605,CDM,981,RC,56740,HCPCS,Outpatient,,,621.42,310.71,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
56800- Plastic repair/introitus,3431361,CDM,510,RC,56800,HCPCS,Outpatient,,,665.34,332.67,,499.01,75,,,percent of total billed charges,75% of total billed charges,499.01,75,,,percent of total billed charges,75% of total billed charges,2658.26,100,,,Fee Schedule,100% of CMS OPPS Rate,1048.68,102,,,Fee Schedule,102% of WV Medicaid Rate,4386.13,165,,,Fee Schedule,165% of CMS OPPS Rate,2755.05,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,7635.49,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,10471.46,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13116.58,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1028.12,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2658.26,100,,,Fee Schedule,100% of CMS OPPS Rate,2755.05,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,93.15,14,,,percent of total billed charges,14% of total billed charges,93.15,13116.58,
56810- Perineoplasy/non-OB,3431362,CDM,510,RC,56810,HCPCS,Outpatient,,,716.93,358.47,,537.7,75,,,percent of total billed charges,75% of total billed charges,537.7,75,,,percent of total billed charges,75% of total billed charges,2658.26,100,,,Fee Schedule,100% of CMS OPPS Rate,1048.68,102,,,Fee Schedule,102% of WV Medicaid Rate,4386.13,165,,,Fee Schedule,165% of CMS OPPS Rate,2755.05,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,7635.49,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,10471.46,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13116.58,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1028.12,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2658.26,100,,,Fee Schedule,100% of CMS OPPS Rate,2755.05,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,100.37,14,,,percent of total billed charges,14% of total billed charges,100.37,13116.58,
56820 Exam of vulva w/scope,3428323,CDM,983,RC,56820,HCPCS,Outpatient,,,322.74,161.37,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
56821 Exam/biopsy of vulva w/scope,3428324,CDM,983,RC,56821,HCPCS,Outpatient,,,433.02,216.51,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
MA EXPLORATION OF VAGINA,3527839,CDM,960,RC,57000,HCPCS,Outpatient,,,532.02,266.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
57022 - I&D Vaginal Hematoma Obstetrical/Postpartum,4113117,CDM,983,RC,57022,HCPCS,Outpatient,,,425.99,213,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
57023 - I&D VAGINAL HEMATOMA NON-OBSTETRICAL,3997202,CDM,960,RC,57023,HCPCS,Outpatient,,,848.67,424.34,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
57061-MA DESTROY VAG LESIONS,3430142,CDM,510,RC,57061,HCPCS,Outpatient,,,229.09,114.55,,171.82,75,,,percent of total billed charges,75% of total billed charges,171.82,75,,,percent of total billed charges,75% of total billed charges,2658.26,100,,,Fee Schedule,100% of CMS OPPS Rate,97.45,102,,,Fee Schedule,102% of WV Medicaid Rate,4386.13,165,,,Fee Schedule,165% of CMS OPPS Rate,2755.05,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,7635.49,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,10471.46,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13116.58,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,95.54,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2658.26,100,,,Fee Schedule,100% of CMS OPPS Rate,2755.05,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,32.07,14,,,percent of total billed charges,14% of total billed charges,32.07,13116.58,
57065-MA DESTROY VAG LESIONS COMPLEX,3430143,CDM,510,RC,57065,HCPCS,Outpatient,,,636.95,318.48,,477.71,75,,,percent of total billed charges,75% of total billed charges,477.71,75,,,percent of total billed charges,75% of total billed charges,2658.26,100,,,Fee Schedule,100% of CMS OPPS Rate,1048.68,102,,,Fee Schedule,102% of WV Medicaid Rate,4386.13,165,,,Fee Schedule,165% of CMS OPPS Rate,2755.05,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,7635.49,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,10471.46,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13116.58,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1028.12,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2658.26,100,,,Fee Schedule,100% of CMS OPPS Rate,2755.05,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,89.17,14,,,percent of total billed charges,14% of total billed charges,89.17,13116.58,
57100PF Bx Vaginal Mucosa Simple Separate Procedure,4265146,CDM,960,RC,57100,HCPCS,Outpatient,,,153.95,76.98,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
57105PF Bx Vaginal Mucosa Extensive Requiring Suture,4265147,CDM,960,RC,57105,HCPCS,Outpatient,,,333.58,166.79,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
57106- Vaginectomy/part rmv vaginal wall,3431365,CDM,510,RC,57106,HCPCS,Outpatient,,,1404.47,702.24,,1053.35,75,,,percent of total billed charges,75% of total billed charges,1053.35,75,,,percent of total billed charges,75% of total billed charges,2658.26,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,4386.13,165,,,Fee Schedule,165% of CMS OPPS Rate,2755.05,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,7635.49,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,10471.46,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13116.58,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,2658.26,100,,,Fee Schedule,100% of CMS OPPS Rate,2755.05,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,196.63,14,,,percent of total billed charges,14% of total billed charges,196.63,13116.58,
"57107-PF REMOVE VAGINA TISSUE, PART",3430147,CDM,510,RC,57107,HCPCS,Outpatient,,,3859.8,1929.9,,2894.85,75,,,percent of total billed charges,75% of total billed charges,2894.85,75,,,percent of total billed charges,75% of total billed charges,2658.26,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,4386.13,165,,,Fee Schedule,165% of CMS OPPS Rate,2755.05,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,7635.49,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,10471.46,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13116.58,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,2658.26,100,,,Fee Schedule,100% of CMS OPPS Rate,2755.05,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,540.37,14,,,percent of total billed charges,14% of total billed charges,540.37,13116.58,
"57110 - PF  Vaginectomy, complete removal vaginal wall",4301616,CDM,960,RC,57110,HCPCS,Outpatient,,,1903.59,951.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
MA REMOVE VAGINAL TISSUE,3527857,CDM,960,RC,57111,HCPCS,Outpatient,,,4568.92,2284.46,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
57130- Excision/vaginal septum,3431366,CDM,510,RC,57130,HCPCS,Outpatient,,,595.82,297.91,,446.87,75,,,percent of total billed charges,75% of total billed charges,446.87,75,,,percent of total billed charges,75% of total billed charges,2658.26,100,,,Fee Schedule,100% of CMS OPPS Rate,1048.68,102,,,Fee Schedule,102% of WV Medicaid Rate,4386.13,165,,,Fee Schedule,165% of CMS OPPS Rate,2755.05,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,7635.49,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,10471.46,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13116.58,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1028.12,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2658.26,100,,,Fee Schedule,100% of CMS OPPS Rate,2755.05,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,83.41,14,,,percent of total billed charges,14% of total billed charges,83.41,13116.58,
57135-MA REMOVE VAGINA LESION,3430152,CDM,510,RC,57135,HCPCS,Outpatient,,,637.46,318.73,,478.1,75,,,percent of total billed charges,75% of total billed charges,478.1,75,,,percent of total billed charges,75% of total billed charges,2658.26,100,,,Fee Schedule,100% of CMS OPPS Rate,1048.68,102,,,Fee Schedule,102% of WV Medicaid Rate,4386.13,165,,,Fee Schedule,165% of CMS OPPS Rate,2755.05,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,7635.49,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,10471.46,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13116.58,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1028.12,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2658.26,100,,,Fee Schedule,100% of CMS OPPS Rate,2755.05,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,89.24,14,,,percent of total billed charges,14% of total billed charges,89.24,13116.58,
57155 - Insertion of uterine tandem and/or vaginal ovoids for clinical brachytherapy,3800930,CDM,983,RC,57155,HCPCS,Outpatient,,,997.96,498.98,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
57156 - Insertion of a vaginal radiation afterloading appara,3938956,CDM,510,RC,57156,HCPCS,Outpatient,,,572.82,286.41,,429.62,75,,,percent of total billed charges,75% of total billed charges,429.62,75,,,percent of total billed charges,75% of total billed charges,274.47,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,452.9,165,,,Fee Schedule,165% of CMS OPPS Rate,284.48,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,788.43,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1081.27,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1354.41,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,274.47,100,,,Fee Schedule,100% of CMS OPPS Rate,284.48,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,80.19,14,,,percent of total billed charges,14% of total billed charges,80.19,1354.41,
57156- Vaginal insert/clin brachytherapy,3431367,CDM,510,RC,57156,HCPCS,Outpatient,,,572.82,286.41,,429.62,75,,,percent of total billed charges,75% of total billed charges,429.62,75,,,percent of total billed charges,75% of total billed charges,274.47,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,452.9,165,,,Fee Schedule,165% of CMS OPPS Rate,284.48,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,788.43,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1081.27,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1354.41,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,274.47,100,,,Fee Schedule,100% of CMS OPPS Rate,284.48,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,80.19,14,,,percent of total billed charges,14% of total billed charges,80.19,1354.41,
57156-Ins Vag Brachytx Device,4169512,CDM,360,RC,57156,HCPCS,Outpatient,,,571.64,285.82,,428.73,75,,,percent of total billed charges,75% of total billed charges,428.73,75,,,percent of total billed charges,75% of total billed charges,274.47,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,452.9,165,,,Fee Schedule,165% of CMS OPPS Rate,284.48,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,788.43,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1081.27,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1354.41,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,274.47,100,,,Fee Schedule,100% of CMS OPPS Rate,284.48,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,80.03,14,,,percent of total billed charges,14% of total billed charges,80.03,1354.41,
57156-Ins Vag Brachytx Device - Pro Fee,4169513,CDM,983,RC,57156,HCPCS,Outpatient,,,347.18,173.59,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
57160- Insert/pessary/other support devic,3431368,CDM,510,RC,57160,HCPCS,Outpatient,,,190.67,95.34,,143,75,,,percent of total billed charges,75% of total billed charges,143,75,,,percent of total billed charges,75% of total billed charges,167.47,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,276.31,165,,,Fee Schedule,165% of CMS OPPS Rate,173.56,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,481.04,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,659.7,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,826.34,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,167.47,100,,,Fee Schedule,100% of CMS OPPS Rate,173.56,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,26.69,14,,,percent of total billed charges,14% of total billed charges,26.69,826.34,
57170- Fitting of diaphragm/cap,3431369,CDM,510,RC,57170,HCPCS,Outpatient,,,201.04,100.52,,150.78,75,,,percent of total billed charges,75% of total billed charges,150.78,75,,,percent of total billed charges,75% of total billed charges,167.47,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,276.31,165,,,Fee Schedule,165% of CMS OPPS Rate,173.56,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,481.04,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,659.7,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,826.34,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,167.47,100,,,Fee Schedule,100% of CMS OPPS Rate,173.56,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,28.15,14,,,percent of total billed charges,14% of total billed charges,28.15,826.34,
57180- Vag hem/non OB/hemostat agent/pac,3431370,CDM,510,RC,57180,HCPCS,Outpatient,,,506.84,253.42,,380.13,75,,,percent of total billed charges,75% of total billed charges,380.13,75,,,percent of total billed charges,75% of total billed charges,167.47,100,,,Fee Schedule,100% of CMS OPPS Rate,69.54,102,,,Fee Schedule,102% of WV Medicaid Rate,276.31,165,,,Fee Schedule,165% of CMS OPPS Rate,173.56,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,481.04,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,659.7,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,826.34,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,68.18,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,167.47,100,,,Fee Schedule,100% of CMS OPPS Rate,173.56,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,70.96,14,,,percent of total billed charges,14% of total billed charges,68.18,826.34,
57200- Colporrhapy/vag injury sut/non OB,3431371,CDM,510,RC,57200,HCPCS,Outpatient,,,866.27,433.14,,649.7,75,,,percent of total billed charges,75% of total billed charges,649.7,75,,,percent of total billed charges,75% of total billed charges,2658.26,100,,,Fee Schedule,100% of CMS OPPS Rate,1048.68,102,,,Fee Schedule,102% of WV Medicaid Rate,4386.13,165,,,Fee Schedule,165% of CMS OPPS Rate,2755.05,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,7635.49,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,10471.46,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13116.58,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1028.12,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2658.26,100,,,Fee Schedule,100% of CMS OPPS Rate,2755.05,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,121.28,14,,,percent of total billed charges,14% of total billed charges,121.28,13116.58,
"57210 - PF Colpoperineorrhaphy, suture of injury of vagina and/or perineum (nonobstetrical)",3699547,CDM,510,RC,57210,HCPCS,Outpatient,,,1034.67,517.34,,776,75,,,percent of total billed charges,75% of total billed charges,776,75,,,percent of total billed charges,75% of total billed charges,2658.26,100,,,Fee Schedule,100% of CMS OPPS Rate,1048.68,102,,,Fee Schedule,102% of WV Medicaid Rate,4386.13,165,,,Fee Schedule,165% of CMS OPPS Rate,2755.05,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,7635.49,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,10471.46,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13116.58,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1028.12,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2658.26,100,,,Fee Schedule,100% of CMS OPPS Rate,2755.05,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,144.85,14,,,percent of total billed charges,14% of total billed charges,144.85,13116.58,
57220- Urethral sphincter op/vag approach,3431373,CDM,510,RC,57220,HCPCS,Outpatient,,,907.1,453.55,,680.33,75,,,percent of total billed charges,75% of total billed charges,680.33,75,,,percent of total billed charges,75% of total billed charges,4357.75,100,,,Fee Schedule,100% of CMS OPPS Rate,1505.68,102,,,Fee Schedule,102% of WV Medicaid Rate,7190.32,165,,,Fee Schedule,165% of CMS OPPS Rate,4516.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,12517.1,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,17166.21,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,21502.42,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1476.16,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,4357.75,100,,,Fee Schedule,100% of CMS OPPS Rate,4516.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,126.99,14,,,percent of total billed charges,14% of total billed charges,126.99,21502.42,
"57240 Anterior colporrhaphy, repair of cystocele with or without repair of urethrocele, including cy",3622085,CDM,510,RC,57240,HCPCS,Outpatient,,,1620.01,810.01,,1215.01,75,,,percent of total billed charges,75% of total billed charges,1215.01,75,,,percent of total billed charges,75% of total billed charges,4357.75,100,,,Fee Schedule,100% of CMS OPPS Rate,1505.68,102,,,Fee Schedule,102% of WV Medicaid Rate,7190.32,165,,,Fee Schedule,165% of CMS OPPS Rate,4516.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,12517.1,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,17166.21,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,21502.42,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1476.16,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,4357.75,100,,,Fee Schedule,100% of CMS OPPS Rate,4516.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,226.8,14,,,percent of total billed charges,14% of total billed charges,226.8,21502.42,
"57240PF Anterior colporrhaphy, repair of cystocele with or w",4272096,CDM,975,RC,57240,HCPCS,Outpatient,,,1437.77,718.89,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
57250PF Posterior Colporrhaphy Repair Rectocele w/wo Perineo,4165148,CDM,960,RC,57250,HCPCS,Outpatient,,,1445.97,722.99,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
57260PF Combined Anteroposterior Colporrhaphy w/wo Cystouret,4265149,CDM,960,RC,57260,HCPCS,Outpatient,,,1833.99,917,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
57265- Ant/post colporrhap/enterocele rpr,3431684,CDM,761,RC,57265,HCPCS,Outpatient,,,2320.64,1160.32,,1740.48,75,,,percent of total billed charges,75% of total billed charges,1740.48,75,,,percent of total billed charges,75% of total billed charges,4357.75,100,,,Fee Schedule,100% of CMS OPPS Rate,1505.68,102,,,Fee Schedule,102% of WV Medicaid Rate,7190.32,165,,,Fee Schedule,165% of CMS OPPS Rate,4516.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,12517.1,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,17166.21,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,21502.42,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1476.16,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,4357.75,100,,,Fee Schedule,100% of CMS OPPS Rate,4516.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,324.89,14,,,percent of total billed charges,14% of total billed charges,324.89,21502.42,
57267PF Addon Insertion Mesh/Other Prosthesis Repair Pelvic,4265150,CDM,960,RC,57267,HCPCS,Outpatient,,,593.98,296.99,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
57268- PF REPAIR OF BOWEL BULGE,4133416,CDM,960,RC,57268,HCPCS,Outpatient,,,1330.54,665.27,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
57280 - Colpopexy abdominal approach,4241833,CDM,960,RC,57280,HCPCS,Outpatient,,,2028.37,1014.19,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
57282PF Colpopexy Vaginal Extra-peritoneal Approach,4265151,CDM,960,RC,57282,HCPCS,Outpatient,,,1630.16,815.08,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
57283PF Colpopexy/vaginal/intra-peritioneal,4265152,CDM,960,RC,57283,HCPCS,Outpatient,,,1645.92,822.96,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
57284- Paravaginal defect repair/open abd,3431685,CDM,761,RC,57284,HCPCS,Outpatient,,,2211.82,1105.91,,1658.87,75,,,percent of total billed charges,75% of total billed charges,1658.87,75,,,percent of total billed charges,75% of total billed charges,4357.75,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,7190.32,165,,,Fee Schedule,165% of CMS OPPS Rate,4516.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,12517.1,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,17166.21,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,21502.42,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,4357.75,100,,,Fee Schedule,100% of CMS OPPS Rate,4516.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,309.65,14,,,percent of total billed charges,14% of total billed charges,309.65,21502.42,
57287PF Removal/Revision Sling for Stress Incontinence,4265153,CDM,960,RC,57287,HCPCS,Outpatient,,,1719.18,859.59,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
57288PF Sling Operation for Stress Incontinence,4265154,CDM,960,RC,57288,HCPCS,Outpatient,,,1734.76,867.38,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
57292 - Construction artificial vagina w/ graft,4241834,CDM,960,RC,57292,HCPCS,Outpatient,,,1746.35,873.18,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
57295 - REVJ/RMVL PROSTHETIC VAGINAL GRAFT VAGINAL APP,3997204,CDM,960,RC,57295,HCPCS,Outpatient,,,1320.38,660.19,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
57296 - Revision (including removal) of prosthetic vaginal graft; open abdominal approach,3783272,CDM,510,RC,57296,HCPCS,Outpatient,,,2555.53,1277.77,,1916.65,75,,,percent of total billed charges,75% of total billed charges,1916.65,75,,,percent of total billed charges,75% of total billed charges,2555.53,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,2555.53,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2555.53,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2555.53,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2555.53,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2555.53,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,2555.53,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2555.53,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,357.77,14,,,percent of total billed charges,14% of total billed charges,357.77,2555.53,
57300-PF REPAIR RECTUM-VAG FISTULA,3430183,CDM,510,RC,57300,HCPCS,Outpatient,,,1610.33,805.17,,1207.75,75,,,percent of total billed charges,75% of total billed charges,1207.75,75,,,percent of total billed charges,75% of total billed charges,2658.26,100,,,Fee Schedule,100% of CMS OPPS Rate,1048.68,102,,,Fee Schedule,102% of WV Medicaid Rate,4386.13,165,,,Fee Schedule,165% of CMS OPPS Rate,2755.05,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,7635.49,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,10471.46,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13116.58,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1028.12,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2658.26,100,,,Fee Schedule,100% of CMS OPPS Rate,2755.05,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,225.45,14,,,percent of total billed charges,14% of total billed charges,225.45,13116.58,
MA REPAIR RECTUM-VAG FISTULA,3527855,CDM,960,RC,57300,HCPCS,Outpatient,,,1610.33,805.17,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
57305- PF REPAIR RECTUM-VAGINA FISTULA,4133421,CDM,960,RC,57305,HCPCS,Outpatient,,,2623.99,1312,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
57320PF Closure Vesicovaginal Fistula Vaginal Approach,4265155,CDM,960,RC,57320,HCPCS,Outpatient,,,1326.1,663.05,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
57330 - Repair Bladder-Vagina Lesion,4189311,CDM,960,RC,57330,HCPCS,Outpatient,,,1793.44,896.72,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
MA DILATION OF VAGINA,3527858,CDM,960,RC,57400,HCPCS,Outpatient,,,345.41,172.71,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
57410PF Pelvic Examination Under Anesthesia,4265156,CDM,960,RC,57410,HCPCS,Outpatient,,,245.82,122.91,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
57415PF Remove Vaginal Foreign Body,4267372,CDM,960,RC,57415,HCPCS,Outpatient,,,405.12,202.56,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
57420- Colposcopy/vagina/cervix,3431385,CDM,360,RC,57420,HCPCS,Outpatient,,,339.84,169.92,,254.88,75,,,percent of total billed charges,75% of total billed charges,254.88,75,,,percent of total billed charges,75% of total billed charges,274.47,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,452.9,165,,,Fee Schedule,165% of CMS OPPS Rate,284.48,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,788.43,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1081.27,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1354.41,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,274.47,100,,,Fee Schedule,100% of CMS OPPS Rate,284.48,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,47.58,14,,,percent of total billed charges,14% of total billed charges,47.58,1354.41,
57421- Colposcopy/cervix/bx vagina/cervix,3431386,CDM,360,RC,57421,HCPCS,Outpatient,,,458.2,229.1,,343.65,75,,,percent of total billed charges,75% of total billed charges,343.65,75,,,percent of total billed charges,75% of total billed charges,661.37,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1091.26,165,,,Fee Schedule,165% of CMS OPPS Rate,685.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1899.71,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2605.3,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,3263.41,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,661.37,100,,,Fee Schedule,100% of CMS OPPS Rate,685.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,64.15,14,,,percent of total billed charges,14% of total billed charges,64.15,3263.41,
"57423 - PF Paravaginal defect repair (including repair of cystocele, if performed), laparoscopic app",3715240,CDM,510,RC,57423,HCPCS,Outpatient,,,2469.27,1234.64,,1851.95,75,,,percent of total billed charges,75% of total billed charges,1851.95,75,,,percent of total billed charges,75% of total billed charges,8543.54,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,14096.88,165,,,Fee Schedule,165% of CMS OPPS Rate,8854.68,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,24540.24,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,33654.98,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,42156.28,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,8543.54,100,,,Fee Schedule,100% of CMS OPPS Rate,8854.68,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,345.7,14,,,percent of total billed charges,14% of total billed charges,345.7,42156.28,
57423PF Paravaginal defect repair (including repair of cysto,4272097,CDM,975,RC,57423,HCPCS,Outpatient,,,2187.82,1093.91,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
"57425-PF LAPAROSCOPY, SURG COLPOPEXY",3430189,CDM,510,RC,57425,HCPCS,Outpatient,,,2587.48,1293.74,,1940.61,75,,,percent of total billed charges,75% of total billed charges,1940.61,75,,,percent of total billed charges,75% of total billed charges,8543.54,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,14096.88,165,,,Fee Schedule,165% of CMS OPPS Rate,8854.68,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,24540.24,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,33654.98,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,42156.28,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,8543.54,100,,,Fee Schedule,100% of CMS OPPS Rate,8854.68,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,362.25,14,,,percent of total billed charges,14% of total billed charges,362.25,42156.28,
57426 - REVISION PROSTHETIC VAGINAL GRAFT LAPAROSCOPIC,4037690,CDM,983,RC,57426,HCPCS,Outpatient,,,2303.51,1151.76,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
57452- Colposcopy/cervix/up/adjacent vag,3431387,CDM,360,RC,57452,HCPCS,Outpatient,,,326.38,163.19,,244.79,75,,,percent of total billed charges,75% of total billed charges,244.79,75,,,percent of total billed charges,75% of total billed charges,167.47,100,,,Fee Schedule,100% of CMS OPPS Rate,55.96,102,,,Fee Schedule,102% of WV Medicaid Rate,276.31,165,,,Fee Schedule,165% of CMS OPPS Rate,173.56,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,481.04,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,659.7,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,826.34,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,54.86,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,167.47,100,,,Fee Schedule,100% of CMS OPPS Rate,173.56,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,45.69,14,,,percent of total billed charges,14% of total billed charges,45.69,826.34,
57454- Colposcopy/cervix/biopsy/curettage,3431388,CDM,510,RC,57454,HCPCS,Outpatient,,,312.35,156.18,,234.26,75,,,percent of total billed charges,75% of total billed charges,234.26,75,,,percent of total billed charges,75% of total billed charges,274.47,100,,,Fee Schedule,100% of CMS OPPS Rate,64.15,102,,,Fee Schedule,102% of WV Medicaid Rate,452.9,165,,,Fee Schedule,165% of CMS OPPS Rate,284.48,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,788.43,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1081.27,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1354.41,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,62.89,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,274.47,100,,,Fee Schedule,100% of CMS OPPS Rate,284.48,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,43.73,14,,,percent of total billed charges,14% of total billed charges,43.73,1354.41,
57455- Colposcopy/cervix/biopsy,3431389,CDM,360,RC,57455,HCPCS,Outpatient,,,418.18,209.09,,313.64,75,,,percent of total billed charges,75% of total billed charges,313.64,75,,,percent of total billed charges,75% of total billed charges,274.47,100,,,Fee Schedule,100% of CMS OPPS Rate,69.06,102,,,Fee Schedule,102% of WV Medicaid Rate,452.9,165,,,Fee Schedule,165% of CMS OPPS Rate,284.48,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,788.43,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1081.27,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1354.41,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,67.71,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,274.47,100,,,Fee Schedule,100% of CMS OPPS Rate,284.48,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,58.55,14,,,percent of total billed charges,14% of total billed charges,58.55,1354.41,
57456- Colposcopy/cervix/endocerv curettage,3431390,CDM,360,RC,57456,HCPCS,Outpatient,,,391.74,195.87,,293.81,75,,,percent of total billed charges,75% of total billed charges,293.81,75,,,percent of total billed charges,75% of total billed charges,274.47,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,452.9,165,,,Fee Schedule,165% of CMS OPPS Rate,284.48,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,788.43,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1081.27,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1354.41,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,274.47,100,,,Fee Schedule,100% of CMS OPPS Rate,284.48,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,54.84,14,,,percent of total billed charges,14% of total billed charges,54.84,1354.41,
57460- Colposcopy/cervix/LEEP,3431391,CDM,510,RC,57460,HCPCS,Outpatient,,,806.42,403.21,,604.82,75,,,percent of total billed charges,75% of total billed charges,604.82,75,,,percent of total billed charges,75% of total billed charges,2658.26,100,,,Fee Schedule,100% of CMS OPPS Rate,171.98,102,,,Fee Schedule,102% of WV Medicaid Rate,4386.13,165,,,Fee Schedule,165% of CMS OPPS Rate,2755.05,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,7635.49,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,10471.46,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13116.58,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,168.61,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2658.26,100,,,Fee Schedule,100% of CMS OPPS Rate,2755.05,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,112.9,14,,,percent of total billed charges,14% of total billed charges,112.9,13116.58,
57461- Colposcopy/cervix/ conization,3431392,CDM,510,RC,57461,HCPCS,Outpatient,,,905.65,452.83,,679.24,75,,,percent of total billed charges,75% of total billed charges,679.24,75,,,percent of total billed charges,75% of total billed charges,2658.26,100,,,Fee Schedule,100% of CMS OPPS Rate,182.64,102,,,Fee Schedule,102% of WV Medicaid Rate,4386.13,165,,,Fee Schedule,165% of CMS OPPS Rate,2755.05,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,7635.49,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,10471.46,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13116.58,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,179.06,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2658.26,100,,,Fee Schedule,100% of CMS OPPS Rate,2755.05,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,126.79,14,,,percent of total billed charges,14% of total billed charges,126.79,13116.58,
57500- Biopsy/cervix/single/multiple,3431393,CDM,514,RC,57500,HCPCS,Outpatient,,,393.05,196.53,,294.79,75,,,percent of total billed charges,75% of total billed charges,294.79,75,,,percent of total billed charges,75% of total billed charges,661.37,100,,,Fee Schedule,100% of CMS OPPS Rate,90.09,102,,,Fee Schedule,102% of WV Medicaid Rate,1091.26,165,,,Fee Schedule,165% of CMS OPPS Rate,685.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1899.71,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2605.3,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,3263.41,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,88.32,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,661.37,100,,,Fee Schedule,100% of CMS OPPS Rate,685.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,55.03,14,,,percent of total billed charges,14% of total billed charges,55.03,3263.41,
57500PF Bx Cervix Single/Multiple/Local Excision Lesion w/wo,4265157,CDM,960,RC,57500,HCPCS,Outpatient,,,174.04,87.02,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
57505- Endocervical curettage,3431394,CDM,360,RC,57505,HCPCS,Outpatient,,,393.72,196.86,,295.29,75,,,percent of total billed charges,75% of total billed charges,295.29,75,,,percent of total billed charges,75% of total billed charges,661.37,100,,,Fee Schedule,100% of CMS OPPS Rate,90.63,102,,,Fee Schedule,102% of WV Medicaid Rate,1091.26,165,,,Fee Schedule,165% of CMS OPPS Rate,685.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1899.71,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2605.3,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,3263.41,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,88.85,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,661.37,100,,,Fee Schedule,100% of CMS OPPS Rate,685.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,55.12,14,,,percent of total billed charges,14% of total billed charges,55.12,3263.41,
57511- Cautery/cervix/cryocautery,3431395,CDM,510,RC,57511,HCPCS,Outpatient,,,513.99,257,,385.49,75,,,percent of total billed charges,75% of total billed charges,385.49,75,,,percent of total billed charges,75% of total billed charges,274.47,100,,,Fee Schedule,100% of CMS OPPS Rate,103.47,102,,,Fee Schedule,102% of WV Medicaid Rate,452.9,165,,,Fee Schedule,165% of CMS OPPS Rate,284.48,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,788.43,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1081.27,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1354.41,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,101.44,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,274.47,100,,,Fee Schedule,100% of CMS OPPS Rate,284.48,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,71.96,14,,,percent of total billed charges,14% of total billed charges,71.96,1354.41,
57520 - Conization/Cervix/Cold Knife/Laser,4133230,CDM,960,RC,57520,HCPCS,Outpatient,,,912.15,456.08,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
57520- Conization/cervix/cold knife/laser,3431686,CDM,761,RC,57520,HCPCS,Outpatient,,,912.15,456.08,,684.11,75,,,percent of total billed charges,75% of total billed charges,684.11,75,,,percent of total billed charges,75% of total billed charges,2658.26,100,,,Fee Schedule,100% of CMS OPPS Rate,1048.68,102,,,Fee Schedule,102% of WV Medicaid Rate,4386.13,165,,,Fee Schedule,165% of CMS OPPS Rate,2755.05,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,7635.49,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,10471.46,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13116.58,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1028.12,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2658.26,100,,,Fee Schedule,100% of CMS OPPS Rate,2755.05,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,127.7,14,,,percent of total billed charges,14% of total billed charges,127.7,13116.58,
57522- Conization/cerv/loop electrode exc,3431396,CDM,510,RC,57522,HCPCS,Outpatient,,,786.86,393.43,,590.15,75,,,percent of total billed charges,75% of total billed charges,590.15,75,,,percent of total billed charges,75% of total billed charges,2658.26,100,,,Fee Schedule,100% of CMS OPPS Rate,1048.68,102,,,Fee Schedule,102% of WV Medicaid Rate,4386.13,165,,,Fee Schedule,165% of CMS OPPS Rate,2755.05,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,7635.49,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,10471.46,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13116.58,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1028.12,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2658.26,100,,,Fee Schedule,100% of CMS OPPS Rate,2755.05,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,110.16,14,,,percent of total billed charges,14% of total billed charges,110.16,13116.58,
57530-PF REMOVAL OF CERVIX,3430191,CDM,510,RC,57530,HCPCS,Outpatient,,,977.78,488.89,,733.34,75,,,percent of total billed charges,75% of total billed charges,733.34,75,,,percent of total billed charges,75% of total billed charges,4357.75,100,,,Fee Schedule,100% of CMS OPPS Rate,1505.68,102,,,Fee Schedule,102% of WV Medicaid Rate,7190.32,165,,,Fee Schedule,165% of CMS OPPS Rate,4516.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,12517.1,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,17166.21,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,21502.42,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1476.16,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,4357.75,100,,,Fee Schedule,100% of CMS OPPS Rate,4516.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,136.89,14,,,percent of total billed charges,14% of total billed charges,136.89,21502.42,
57800- Dilation/cervical canal/instrument,3431397,CDM,510,RC,57800,HCPCS,Outpatient,,,197.8,98.9,,148.35,75,,,percent of total billed charges,75% of total billed charges,148.35,75,,,percent of total billed charges,75% of total billed charges,2658.26,100,,,Fee Schedule,100% of CMS OPPS Rate,39.31,102,,,Fee Schedule,102% of WV Medicaid Rate,4386.13,165,,,Fee Schedule,165% of CMS OPPS Rate,2755.05,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,7635.49,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,10471.46,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13116.58,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,38.54,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2658.26,100,,,Fee Schedule,100% of CMS OPPS Rate,2755.05,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,27.69,14,,,percent of total billed charges,14% of total billed charges,27.69,13116.58,
58100- EMB w/o cervical dilation,3431398,CDM,360,RC,58100,HCPCS,Outpatient,,,264.47,132.24,,198.35,75,,,percent of total billed charges,75% of total billed charges,198.35,75,,,percent of total billed charges,75% of total billed charges,167.47,100,,,Fee Schedule,100% of CMS OPPS Rate,45.32,102,,,Fee Schedule,102% of WV Medicaid Rate,276.31,165,,,Fee Schedule,165% of CMS OPPS Rate,173.56,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,481.04,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,659.7,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,826.34,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,44.43,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,167.47,100,,,Fee Schedule,100% of CMS OPPS Rate,173.56,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,37.03,14,,,percent of total billed charges,14% of total billed charges,37.03,826.34,
58100-PF ENDOMETRIAL BX W/WO ENDOCERVIX BX W/O DILAT SPX,4321483,CDM,981,RC,58100,HCPCS,Outpatient,,,126.28,63.14,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
58110- EMB w/colposcopy,3431399,CDM,510,RC,58110,HCPCS,Outpatient,,,94.93,47.47,,71.2,75,,,percent of total billed charges,75% of total billed charges,71.2,75,,,percent of total billed charges,75% of total billed charges,30.38,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.29,14,,,percent of total billed charges,14% of total billed charges,13.29,71.2,
58120- D&C/diagnostic/therapeutic/non OB,3431400,CDM,510,RC,58120,HCPCS,Outpatient,,,773.17,386.59,,579.88,75,,,percent of total billed charges,75% of total billed charges,579.88,75,,,percent of total billed charges,75% of total billed charges,2658.26,100,,,Fee Schedule,100% of CMS OPPS Rate,1048.68,102,,,Fee Schedule,102% of WV Medicaid Rate,4386.13,165,,,Fee Schedule,165% of CMS OPPS Rate,2755.05,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,7635.49,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,10471.46,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13116.58,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1028.12,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2658.26,100,,,Fee Schedule,100% of CMS OPPS Rate,2755.05,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,108.24,14,,,percent of total billed charges,14% of total billed charges,108.24,13116.58,
58140-PF MYOMECTOMY ABDOM METHOD,3430195,CDM,510,RC,58140,HCPCS,Outpatient,,,2488.94,1244.47,,1866.71,75,,,percent of total billed charges,75% of total billed charges,1866.71,75,,,percent of total billed charges,75% of total billed charges,2488.94,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,2488.94,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2488.94,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2488.94,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2488.94,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2488.94,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,2488.94,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2488.94,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,348.45,14,,,percent of total billed charges,14% of total billed charges,348.45,2488.94,
58145- Myomectomy/1-4 myomas/vag approach,3431401,CDM,510,RC,58145,HCPCS,Outpatient,,,1502.26,751.13,,1126.7,75,,,percent of total billed charges,75% of total billed charges,1126.7,75,,,percent of total billed charges,75% of total billed charges,2658.26,100,,,Fee Schedule,100% of CMS OPPS Rate,1048.68,102,,,Fee Schedule,102% of WV Medicaid Rate,4386.13,165,,,Fee Schedule,165% of CMS OPPS Rate,2755.05,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,7635.49,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,10471.46,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13116.58,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1028.12,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2658.26,100,,,Fee Schedule,100% of CMS OPPS Rate,2755.05,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,210.32,14,,,percent of total billed charges,14% of total billed charges,210.32,13116.58,
58146- Myomectomy/5 or>/abd approach,3431402,CDM,510,RC,58146,HCPCS,Outpatient,,,3086.58,1543.29,,2314.94,75,,,percent of total billed charges,75% of total billed charges,2314.94,75,,,percent of total billed charges,75% of total billed charges,3086.58,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,3086.58,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3086.58,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3086.58,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3086.58,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3086.58,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,3086.58,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3086.58,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,432.12,14,,,percent of total billed charges,14% of total billed charges,432.12,3086.58,
58150- Tot abd hysterect w/w/o tubes/ovar,3431403,CDM,510,RC,58150,HCPCS,Outpatient,,,2688.94,1344.47,,2016.71,75,,,percent of total billed charges,75% of total billed charges,2016.71,75,,,percent of total billed charges,75% of total billed charges,2688.94,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,2688.94,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2688.94,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2688.94,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2688.94,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2688.94,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,2688.94,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2688.94,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,376.45,14,,,percent of total billed charges,14% of total billed charges,376.45,2688.94,
58152- TAH w/MMK,3431687,CDM,510,RC,58152,HCPCS,Outpatient,,,3305.84,1652.92,,2479.38,75,,,percent of total billed charges,75% of total billed charges,2479.38,75,,,percent of total billed charges,75% of total billed charges,3305.84,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,3305.84,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3305.84,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3305.84,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3305.84,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3305.84,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,3305.84,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3305.84,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,462.82,14,,,percent of total billed charges,14% of total billed charges,462.82,3305.84,
"58180 Supracervical abdominal hysterectomy (subtotal hysterectomy), with or without removal of tube(",3622575,CDM,960,RC,58180,HCPCS,Outpatient,,,2553.21,1276.61,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
58200- Abdominal hysterectomy/total,3431688,CDM,510,RC,58200,HCPCS,Outpatient,,,3572.27,1786.14,,2679.2,75,,,percent of total billed charges,75% of total billed charges,2679.2,75,,,percent of total billed charges,75% of total billed charges,3572.27,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,3572.27,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3572.27,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3572.27,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3572.27,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3572.27,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,3572.27,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3572.27,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,500.12,14,,,percent of total billed charges,14% of total billed charges,500.12,3572.27,
58210-PF EXTENSIVE HYSTERECTOMY,3430207,CDM,510,RC,58210,HCPCS,Outpatient,,,4828.2,2414.1,,3621.15,75,,,percent of total billed charges,75% of total billed charges,3621.15,75,,,percent of total billed charges,75% of total billed charges,4828.2,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,4828.2,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4828.2,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4828.2,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4828.2,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4828.2,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,4828.2,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4828.2,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,675.95,14,,,percent of total billed charges,14% of total billed charges,675.95,4828.2,
58240-PF REMOVAL OF PELVIS CONTENTS,3430209,CDM,510,RC,58240,HCPCS,Outpatient,,,7786.17,3893.09,,5839.63,75,,,percent of total billed charges,75% of total billed charges,5839.63,75,,,percent of total billed charges,75% of total billed charges,7786.17,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,7786.17,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,7786.17,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,7786.17,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,7786.17,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,7786.17,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,7786.17,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,7786.17,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1090.06,14,,,percent of total billed charges,14% of total billed charges,1090.06,7786.17,
58260- Vaginal hysterectomy/250 g or<,3431405,CDM,510,RC,58260,HCPCS,Outpatient,,,2230.59,1115.3,,1672.94,75,,,percent of total billed charges,75% of total billed charges,1672.94,75,,,percent of total billed charges,75% of total billed charges,4357.75,100,,,Fee Schedule,100% of CMS OPPS Rate,1505.68,102,,,Fee Schedule,102% of WV Medicaid Rate,7190.32,165,,,Fee Schedule,165% of CMS OPPS Rate,4516.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,12517.1,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,17166.21,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,21502.42,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1476.16,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,4357.75,100,,,Fee Schedule,100% of CMS OPPS Rate,4516.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,312.28,14,,,percent of total billed charges,14% of total billed charges,312.28,21502.42,
58262- Vag hys/<250g/rmv tube/& or ovarie,3431407,CDM,510,RC,58262,HCPCS,Outpatient,,,2468.85,1234.43,,1851.64,75,,,percent of total billed charges,75% of total billed charges,1851.64,75,,,percent of total billed charges,75% of total billed charges,4357.75,100,,,Fee Schedule,100% of CMS OPPS Rate,1505.68,102,,,Fee Schedule,102% of WV Medicaid Rate,7190.32,165,,,Fee Schedule,165% of CMS OPPS Rate,4516.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,12517.1,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,17166.21,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,21502.42,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1476.16,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,4357.75,100,,,Fee Schedule,100% of CMS OPPS Rate,4516.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,345.64,14,,,percent of total billed charges,14% of total billed charges,345.64,21502.42,
58263- Vag hys/<250g/rmv tube/rpr entero,3431408,CDM,510,RC,58263,HCPCS,Outpatient,,,2648.61,1324.31,,1986.46,75,,,percent of total billed charges,75% of total billed charges,1986.46,75,,,percent of total billed charges,75% of total billed charges,4357.75,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,7190.32,165,,,Fee Schedule,165% of CMS OPPS Rate,4516.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,12517.1,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,17166.21,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,21502.42,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,4357.75,100,,,Fee Schedule,100% of CMS OPPS Rate,4516.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,370.81,14,,,percent of total billed charges,14% of total billed charges,370.81,21502.42,
58267- TVH/uterus < 250g w/MMK,3431689,CDM,510,RC,58267,HCPCS,Outpatient,,,2851.87,1425.94,,2138.9,75,,,percent of total billed charges,75% of total billed charges,2138.9,75,,,percent of total billed charges,75% of total billed charges,2851.87,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,2851.87,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2851.87,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2851.87,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2851.87,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2851.87,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,2851.87,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2851.87,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,399.26,14,,,percent of total billed charges,14% of total billed charges,399.26,2851.87,
58270PF Vaginal Hysterectomy Uterus 250g or Less w/Repair En,4265158,CDM,960,RC,58270,HCPCS,Outpatient,,,2114.04,1057.02,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
58290- TVH/uterus > 250g,3431690,CDM,360,RC,58290,HCPCS,Outpatient,,,3075.56,1537.78,,2306.67,75,,,percent of total billed charges,75% of total billed charges,2306.67,75,,,percent of total billed charges,75% of total billed charges,6511.17,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,10743.43,165,,,Fee Schedule,165% of CMS OPPS Rate,6748.28,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,18702.46,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,25648.94,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,32127.9,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,6511.17,100,,,Fee Schedule,100% of CMS OPPS Rate,6748.28,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,430.58,14,,,percent of total billed charges,14% of total billed charges,430.58,32127.9,
58291- TVH/uterus > 250g/salping/ooph,3431691,CDM,360,RC,58291,HCPCS,Outpatient,,,3325.96,1662.98,,2494.47,75,,,percent of total billed charges,75% of total billed charges,2494.47,75,,,percent of total billed charges,75% of total billed charges,4357.75,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,7190.32,165,,,Fee Schedule,165% of CMS OPPS Rate,4516.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,12517.1,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,17166.21,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,21502.42,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,4357.75,100,,,Fee Schedule,100% of CMS OPPS Rate,4516.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,465.63,14,,,percent of total billed charges,14% of total billed charges,465.63,21502.42,
58300- Insertion/intrauterine device,3431410,CDM,360,RC,58300,HCPCS,Outpatient,,,275.39,137.7,,206.54,75,,,percent of total billed charges,75% of total billed charges,206.54,75,,,percent of total billed charges,75% of total billed charges,88.12,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.55,14,,,percent of total billed charges,14% of total billed charges,38.55,206.54,
AMB IUD Admin Charge:Insert Intrauterine Device 58300,3444234,CDM,510,RC,58300,HCPCS,Outpatient,,,275.39,137.7,,206.54,75,,,percent of total billed charges,75% of total billed charges,206.54,75,,,percent of total billed charges,75% of total billed charges,88.12,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.55,14,,,percent of total billed charges,14% of total billed charges,38.55,206.54,
58301- Remove intrauterine device,3431411,CDM,360,RC,58301,HCPCS,Outpatient,,,285,142.5,,213.75,75,,,percent of total billed charges,75% of total billed charges,213.75,75,,,percent of total billed charges,75% of total billed charges,274.49,100,,,Fee Schedule,100% of CMS OPPS Rate,50.5,102,,,Fee Schedule,102% of WV Medicaid Rate,452.91,165,,,Fee Schedule,165% of CMS OPPS Rate,284.48,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,788.43,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1081.27,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1354.41,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,49.51,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,274.49,100,,,Fee Schedule,100% of CMS OPPS Rate,284.48,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,39.9,14,,,percent of total billed charges,14% of total billed charges,39.9,1354.41,
58301-PF REMOVAL INTRAUTERINE DEVICE IUD,4321604,CDM,981,RC,58301,HCPCS,Outpatient,,,132.38,66.19,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
58322- Artificial insemination/intrauterine,3431412,CDM,510,RC,58322,HCPCS,Outpatient,,,235.09,117.55,,176.32,75,,,percent of total billed charges,75% of total billed charges,176.32,75,,,percent of total billed charges,75% of total billed charges,167.47,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,276.31,165,,,Fee Schedule,165% of CMS OPPS Rate,173.56,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,481.04,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,659.7,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,826.34,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,167.47,100,,,Fee Schedule,100% of CMS OPPS Rate,173.56,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,32.91,14,,,percent of total billed charges,14% of total billed charges,32.91,826.34,
58340- Cath/saline/contrast/SIS/hysteosal,3431413,CDM,510,RC,58340,HCPCS,Outpatient,,,118.59,59.3,,88.94,75,,,percent of total billed charges,75% of total billed charges,88.94,75,,,percent of total billed charges,75% of total billed charges,37.95,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.6,14,,,percent of total billed charges,14% of total billed charges,16.6,88.94,
58350- Oviduct chromotubation,3431414,CDM,510,RC,58350,HCPCS,Outpatient,,,389.8,194.9,,292.35,75,,,percent of total billed charges,75% of total billed charges,292.35,75,,,percent of total billed charges,75% of total billed charges,4357.75,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,7190.32,165,,,Fee Schedule,165% of CMS OPPS Rate,4516.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,12517.1,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,17166.21,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,21502.42,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,4357.75,100,,,Fee Schedule,100% of CMS OPPS Rate,4516.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,54.57,14,,,percent of total billed charges,14% of total billed charges,54.57,21502.42,
58520 - HYSTERORRHAPHY REPAIR RUPT UTERUS NONOBSTETRICAL,4249120,CDM,983,RC,58520,HCPCS,Outpatient,,,2107.74,1053.87,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
58542 - Laps supracrv hysterect 250 gm/rmvl tube/ovar,4241835,CDM,960,RC,58542,HCPCS,Outpatient,,,1749.17,874.59,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
58542 - PF Laps Supracrv Hysterect 250 gm/< Rmvl Tube/Ovar,4311909,CDM,960,RC,58542,HCPCS,Outpatient,,,1959.07,979.54,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
"58543 Laparoscopy, surgical, supracervical hysterectomy, for uterus greater than 250 g;",3622389,CDM,510,RC,58543,HCPCS,Outpatient,,,2244.77,1122.39,,1683.58,75,,,percent of total billed charges,75% of total billed charges,1683.58,75,,,percent of total billed charges,75% of total billed charges,8543.54,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,14096.88,165,,,Fee Schedule,165% of CMS OPPS Rate,8854.68,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,24540.24,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,33654.98,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,42156.28,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,8543.54,100,,,Fee Schedule,100% of CMS OPPS Rate,8854.68,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,314.27,14,,,percent of total billed charges,14% of total billed charges,314.27,42156.28,
"58545 Laparoscopy, surgical, myomectomy, excision; 1 to 4 intramural myomas with total weight of 250",3622563,CDM,510,RC,58545,HCPCS,Outpatient,,,2401.35,1200.68,,1801.01,75,,,percent of total billed charges,75% of total billed charges,1801.01,75,,,percent of total billed charges,75% of total billed charges,4900.27,100,,,Fee Schedule,100% of CMS OPPS Rate,1862.49,102,,,Fee Schedule,102% of WV Medicaid Rate,8085.46,165,,,Fee Schedule,165% of CMS OPPS Rate,5078.72,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,14075.4,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,19303.29,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,24179.33,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1825.97,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,4900.27,100,,,Fee Schedule,100% of CMS OPPS Rate,5078.72,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,336.19,14,,,percent of total billed charges,14% of total billed charges,336.19,24179.33,
"58546 Laparoscopy, surgical, myomectomy, excision; 5 or more intramural myomas and/or intramural myo",3622758,CDM,510,RC,58546,HCPCS,Outpatient,,,2978.1,1489.05,,2233.58,75,,,percent of total billed charges,75% of total billed charges,2233.58,75,,,percent of total billed charges,75% of total billed charges,8543.54,100,,,Fee Schedule,100% of CMS OPPS Rate,3066.62,102,,,Fee Schedule,102% of WV Medicaid Rate,14096.88,165,,,Fee Schedule,165% of CMS OPPS Rate,8854.68,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,24540.24,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,33654.98,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,42156.28,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,3006.49,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,8543.54,100,,,Fee Schedule,100% of CMS OPPS Rate,8854.68,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,416.93,14,,,percent of total billed charges,14% of total billed charges,416.93,42156.28,
58548-PF LAP RADICAL HYSTERECTOMY,3430231,CDM,510,RC,58548,HCPCS,Outpatient,,,4980.37,2490.19,,3735.28,75,,,percent of total billed charges,75% of total billed charges,3735.28,75,,,percent of total billed charges,75% of total billed charges,4980.37,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,4980.37,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4980.37,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4980.37,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4980.37,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4980.37,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,4980.37,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4980.37,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,697.25,14,,,percent of total billed charges,14% of total billed charges,697.25,4980.37,
58550 - PF Laps Vaginal Hysterectomy Uterus 250 gm/<,4311910,CDM,960,RC,58550,HCPCS,Outpatient,,,2081.37,1040.69,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
58550- Lap/surg/vag hysterectomy< 250g,3431417,CDM,510,RC,58550,HCPCS,Outpatient,,,2344.97,1172.49,,1758.73,75,,,percent of total billed charges,75% of total billed charges,1758.73,75,,,percent of total billed charges,75% of total billed charges,4900.27,100,,,Fee Schedule,100% of CMS OPPS Rate,1862.49,102,,,Fee Schedule,102% of WV Medicaid Rate,8085.46,165,,,Fee Schedule,165% of CMS OPPS Rate,5078.72,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,14075.4,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,19303.29,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,24179.33,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1825.97,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,4900.27,100,,,Fee Schedule,100% of CMS OPPS Rate,5078.72,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,328.3,14,,,percent of total billed charges,14% of total billed charges,328.3,24179.33,
58552- Laparo-Vag Hyst Incl T/O,3431418,CDM,510,RC,58552,HCPCS,Outpatient,,,2607.47,1303.74,,1955.6,75,,,percent of total billed charges,75% of total billed charges,1955.6,75,,,percent of total billed charges,75% of total billed charges,8543.54,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,14096.88,165,,,Fee Schedule,165% of CMS OPPS Rate,8854.68,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,24540.24,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,33654.98,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,42156.28,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,8543.54,100,,,Fee Schedule,100% of CMS OPPS Rate,8854.68,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,365.05,14,,,percent of total billed charges,14% of total billed charges,365.05,42156.28,
58553- LAVH/uterus > 250g,3431692,CDM,761,RC,58553,HCPCS,Outpatient,,,2994.51,1497.26,,2245.88,75,,,percent of total billed charges,75% of total billed charges,2245.88,75,,,percent of total billed charges,75% of total billed charges,8543.54,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,14096.88,165,,,Fee Schedule,165% of CMS OPPS Rate,8854.68,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,24540.24,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,33654.98,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,42156.28,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,8543.54,100,,,Fee Schedule,100% of CMS OPPS Rate,8854.68,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,419.23,14,,,percent of total billed charges,14% of total billed charges,419.23,42156.28,
58554- LAVH/uterus > 250g/salping/ooph,3431693,CDM,761,RC,58554,HCPCS,Outpatient,,,3480.02,1740.01,,2610.02,75,,,percent of total billed charges,75% of total billed charges,2610.02,75,,,percent of total billed charges,75% of total billed charges,8543.54,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,14096.88,165,,,Fee Schedule,165% of CMS OPPS Rate,8854.68,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,24540.24,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,33654.98,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,42156.28,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,8543.54,100,,,Fee Schedule,100% of CMS OPPS Rate,8854.68,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,487.2,14,,,percent of total billed charges,14% of total billed charges,487.2,42156.28,
58555- Hysterscopy/diagnostic,3431419,CDM,510,RC,58555,HCPCS,Outpatient,,,924.25,462.13,,693.19,75,,,percent of total billed charges,75% of total billed charges,693.19,75,,,percent of total billed charges,75% of total billed charges,2658.26,100,,,Fee Schedule,100% of CMS OPPS Rate,1048.68,102,,,Fee Schedule,102% of WV Medicaid Rate,4386.13,165,,,Fee Schedule,165% of CMS OPPS Rate,2755.05,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,7635.49,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,10471.46,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13116.58,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1028.12,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2658.26,100,,,Fee Schedule,100% of CMS OPPS Rate,2755.05,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,129.4,14,,,percent of total billed charges,14% of total billed charges,129.4,13116.58,
"58555 IN OFFICE Hysteroscopy, diagnostic",4213197,CDM,983,RC,58555,HCPCS,Outpatient,,,6166.53,3083.27,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
58558- Hysteroscopy/endometrium bx,3431420,CDM,510,RC,58558,HCPCS,Outpatient,,,3357.88,1678.94,,2518.41,75,,,percent of total billed charges,75% of total billed charges,2518.41,75,,,percent of total billed charges,75% of total billed charges,2658.26,100,,,Fee Schedule,100% of CMS OPPS Rate,1048.68,102,,,Fee Schedule,102% of WV Medicaid Rate,4386.13,165,,,Fee Schedule,165% of CMS OPPS Rate,2755.05,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,7635.49,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,10471.46,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13116.58,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1028.12,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2658.26,100,,,Fee Schedule,100% of CMS OPPS Rate,2755.05,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,470.1,14,,,percent of total billed charges,14% of total billed charges,470.1,13116.58,
58558 IN OFFICE Hysteroscopy with sampling (biopsy) of endom,4213198,CDM,983,RC,58558,HCPCS,Outpatient,,,8013.58,4006.79,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
58559 - HYSTEROSCOPY LYSIS INTRAUTERINE ADHESIONS,4037694,CDM,983,RC,58559,HCPCS,Outpatient,,,758.14,379.07,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
"58560 Hysteroscopy, surgical; with division or resection of intrauterine septum (any method)",3621643,CDM,510,RC,58560,HCPCS,Outpatient,,,833.68,416.84,,625.26,75,,,percent of total billed charges,75% of total billed charges,625.26,75,,,percent of total billed charges,75% of total billed charges,4357.75,100,,,Fee Schedule,100% of CMS OPPS Rate,1505.68,102,,,Fee Schedule,102% of WV Medicaid Rate,7190.32,165,,,Fee Schedule,165% of CMS OPPS Rate,4516.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,12517.1,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,17166.21,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,21502.42,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1476.16,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,4357.75,100,,,Fee Schedule,100% of CMS OPPS Rate,4516.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,116.72,14,,,percent of total billed charges,14% of total billed charges,116.72,21502.42,
58561- Hysteroscopy/leiomyomata removal,3431421,CDM,510,RC,58561,HCPCS,Outpatient,,,952.79,476.4,,714.59,75,,,percent of total billed charges,75% of total billed charges,714.59,75,,,percent of total billed charges,75% of total billed charges,4357.75,100,,,Fee Schedule,100% of CMS OPPS Rate,1505.68,102,,,Fee Schedule,102% of WV Medicaid Rate,7190.32,165,,,Fee Schedule,165% of CMS OPPS Rate,4516.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,12517.1,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,17166.21,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,21502.42,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1476.16,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,4357.75,100,,,Fee Schedule,100% of CMS OPPS Rate,4516.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,133.39,14,,,percent of total billed charges,14% of total billed charges,133.39,21502.42,
58562- Hysteroscopy/impacted FB removal,3431422,CDM,510,RC,58562,HCPCS,Outpatient,,,1114.1,557.05,,835.58,75,,,percent of total billed charges,75% of total billed charges,835.58,75,,,percent of total billed charges,75% of total billed charges,2658.26,100,,,Fee Schedule,100% of CMS OPPS Rate,1048.68,102,,,Fee Schedule,102% of WV Medicaid Rate,4386.13,165,,,Fee Schedule,165% of CMS OPPS Rate,2755.05,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,7635.49,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,10471.46,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13116.58,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1028.12,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2658.26,100,,,Fee Schedule,100% of CMS OPPS Rate,2755.05,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,155.97,14,,,percent of total billed charges,14% of total billed charges,155.97,13116.58,
58562 IN OFFICE Hysteroscopy with removal of impacted foreig,4213199,CDM,983,RC,58562,HCPCS,Outpatient,,,6316.9,3158.45,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
58563- Hysteroscopy/endometrial ablation,3431423,CDM,510,RC,58563,HCPCS,Outpatient,,,5319.54,2659.77,,3989.66,75,,,percent of total billed charges,75% of total billed charges,3989.66,75,,,percent of total billed charges,75% of total billed charges,4357.75,100,,,Fee Schedule,100% of CMS OPPS Rate,1505.68,102,,,Fee Schedule,102% of WV Medicaid Rate,7190.32,165,,,Fee Schedule,165% of CMS OPPS Rate,4516.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,12517.1,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,17166.21,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,21502.42,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1476.16,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,4357.75,100,,,Fee Schedule,100% of CMS OPPS Rate,4516.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,744.74,14,,,percent of total billed charges,14% of total billed charges,744.74,21502.42,
58565- Hysteroscopy/diagnostic,3431424,CDM,510,RC,58565,HCPCS,Outpatient,,,4225.37,2112.69,,3169.03,75,,,percent of total billed charges,75% of total billed charges,3169.03,75,,,percent of total billed charges,75% of total billed charges,4357.75,100,,,Fee Schedule,100% of CMS OPPS Rate,1960.2,102,,,Fee Schedule,102% of WV Medicaid Rate,7190.32,165,,,Fee Schedule,165% of CMS OPPS Rate,4516.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,12517.1,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,17166.21,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,21502.42,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1921.76,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,4357.75,100,,,Fee Schedule,100% of CMS OPPS Rate,4516.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,591.55,14,,,percent of total billed charges,14% of total billed charges,591.55,21502.42,
58570PF Lap Surgical w/Total Hysterectomy Uterus 250g or Less,4263177,CDM,975,RC,58570,HCPCS,Outpatient,,,1900,950,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
58571PF Laparoscopic Total Hysterectomy Uterus 250g/< w/Removal Tubes Ovaries,4263178,CDM,975,RC,58571,HCPCS,Outpatient,,,2131.83,1065.92,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
58572  Laparoscopy Total Hysterecotmy Uterus >250 GM,3899059,CDM,983,RC,58572,HCPCS,Outpatient,,,2752.62,1376.31,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
"58572 Laparoscopy, surgical, with total hysterectomy, for uterus greater than 250 g;",3622748,CDM,510,RC,58572,HCPCS,Outpatient,,,2752.62,1376.31,,2064.47,75,,,percent of total billed charges,75% of total billed charges,2064.47,75,,,percent of total billed charges,75% of total billed charges,8543.54,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,14096.88,165,,,Fee Schedule,165% of CMS OPPS Rate,8854.68,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,24540.24,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,33654.98,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,42156.28,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,8543.54,100,,,Fee Schedule,100% of CMS OPPS Rate,8854.68,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,385.37,14,,,percent of total billed charges,14% of total billed charges,385.37,42156.28,
58573PF Lap Surgical w/Total Hysterectomy Uterus Greater Than 250g w/Removal Tubes/Ovaries,4263179,CDM,975,RC,58573,HCPCS,Outpatient,,,2865.04,1432.52,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
58575 - PF LAPS TOT HYST RESJ MAL,3527836,CDM,960,RC,58575,HCPCS,Outpatient,,,5122.79,2561.4,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
"58578 - Unlisted laparoscopy procedure, uterus",3899064,CDM,983,RC,58578,HCPCS,Outpatient,,,963.92,481.96,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
58600- Tubal ligation,3431694,CDM,761,RC,58600,HCPCS,Outpatient,,,979.81,489.91,,734.86,75,,,percent of total billed charges,75% of total billed charges,734.86,75,,,percent of total billed charges,75% of total billed charges,2658.26,100,,,Fee Schedule,100% of CMS OPPS Rate,1048.68,102,,,Fee Schedule,102% of WV Medicaid Rate,4386.13,165,,,Fee Schedule,165% of CMS OPPS Rate,2755.05,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,7635.49,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,10471.46,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13116.58,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1028.12,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2658.26,100,,,Fee Schedule,100% of CMS OPPS Rate,2755.05,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,137.17,14,,,percent of total billed charges,14% of total billed charges,137.17,13116.58,
58605- Ligation/transect/fallop tubes/PP,3431425,CDM,510,RC,58605,HCPCS,Outpatient,,,892.79,446.4,,669.59,75,,,percent of total billed charges,75% of total billed charges,669.59,75,,,percent of total billed charges,75% of total billed charges,892.79,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,892.79,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,892.79,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,892.79,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,892.79,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,892.79,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,892.79,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,892.79,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,124.99,14,,,percent of total billed charges,14% of total billed charges,124.99,892.79,
58611- Ligate/fallopian tubes/add-on,3431427,CDM,510,RC,58611,HCPCS,Outpatient,,,203.33,101.67,,152.5,75,,,percent of total billed charges,75% of total billed charges,152.5,75,,,percent of total billed charges,75% of total billed charges,203.33,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,203.33,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,203.33,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,203.33,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,203.33,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,203.33,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,203.33,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,203.33,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,28.47,14,,,percent of total billed charges,14% of total billed charges,28.47,203.33,
58660- Laparoscopy/adhesion lysis,3431428,CDM,510,RC,58660,HCPCS,Outpatient,,,1821.32,910.66,,1365.99,75,,,percent of total billed charges,75% of total billed charges,1365.99,75,,,percent of total billed charges,75% of total billed charges,4900.27,100,,,Fee Schedule,100% of CMS OPPS Rate,1862.49,102,,,Fee Schedule,102% of WV Medicaid Rate,8085.46,165,,,Fee Schedule,165% of CMS OPPS Rate,5078.72,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,14075.4,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,19303.29,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,24179.33,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1825.97,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,4900.27,100,,,Fee Schedule,100% of CMS OPPS Rate,5078.72,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,254.98,14,,,percent of total billed charges,14% of total billed charges,254.98,24179.33,
58661PF Lap Surgical w/Removal Adnexal Structures,4265159,CDM,960,RC,58661,HCPCS,Outpatient,,,1543.4,771.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
58662PF Lap Surgical w/Fulguration/Excision Lesions Ovary/Pe,4265160,CDM,960,RC,58662,HCPCS,Outpatient,,,1680.52,840.26,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
58670- Laparoscopy/oviduct fulguration,3431431,CDM,510,RC,58670,HCPCS,Outpatient,,,982.94,491.47,,737.21,75,,,percent of total billed charges,75% of total billed charges,737.21,75,,,percent of total billed charges,75% of total billed charges,4900.27,100,,,Fee Schedule,100% of CMS OPPS Rate,1862.49,102,,,Fee Schedule,102% of WV Medicaid Rate,8085.46,165,,,Fee Schedule,165% of CMS OPPS Rate,5078.72,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,14075.4,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,19303.29,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,24179.33,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1825.97,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,4900.27,100,,,Fee Schedule,100% of CMS OPPS Rate,5078.72,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,137.61,14,,,percent of total billed charges,14% of total billed charges,137.61,24179.33,
58671- Laparoscopy/surg/occlude/oviducts,3431695,CDM,761,RC,58671,HCPCS,Outpatient,,,981.38,490.69,,736.04,75,,,percent of total billed charges,75% of total billed charges,736.04,75,,,percent of total billed charges,75% of total billed charges,4900.27,100,,,Fee Schedule,100% of CMS OPPS Rate,1862.49,102,,,Fee Schedule,102% of WV Medicaid Rate,8085.46,165,,,Fee Schedule,165% of CMS OPPS Rate,5078.72,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,14075.4,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,19303.29,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,24179.33,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1825.97,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,4900.27,100,,,Fee Schedule,100% of CMS OPPS Rate,5078.72,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,137.39,14,,,percent of total billed charges,14% of total billed charges,137.39,24179.33,
"58672 - Laparoscopy, surgical; with fimbrioplasty",4037695,CDM,983,RC,58672,HCPCS,Outpatient,,,1955.14,977.57,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
58673- Laparoscopy/salpingostomy,3431432,CDM,510,RC,58673,HCPCS,Outpatient,,,2118.6,1059.3,,1588.95,75,,,percent of total billed charges,75% of total billed charges,1588.95,75,,,percent of total billed charges,75% of total billed charges,4900.27,100,,,Fee Schedule,100% of CMS OPPS Rate,1862.49,102,,,Fee Schedule,102% of WV Medicaid Rate,8085.46,165,,,Fee Schedule,165% of CMS OPPS Rate,5078.72,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,14075.4,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,19303.29,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,24179.33,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1825.97,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,4900.27,100,,,Fee Schedule,100% of CMS OPPS Rate,5078.72,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,296.6,14,,,percent of total billed charges,14% of total billed charges,296.6,24179.33,
58700- Salpingectomy,3431433,CDM,510,RC,58700,HCPCS,Outpatient,,,2126.93,1063.47,,1595.2,75,,,percent of total billed charges,75% of total billed charges,1595.2,75,,,percent of total billed charges,75% of total billed charges,2126.93,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,2126.93,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2126.93,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2126.93,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2126.93,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2126.93,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,2126.93,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2126.93,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,297.77,14,,,percent of total billed charges,14% of total billed charges,297.77,2126.93,
58720 - PF Salpingo-Oophorectomy Compl/ Prtl Uni/ Bi Spx,4311911,CDM,960,RC,58720,HCPCS,Outpatient,,,1779.16,889.58,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
58720- Salpingo-oophorectomy,3431434,CDM,510,RC,58720,HCPCS,Outpatient,,,2006.46,1003.23,,1504.85,75,,,percent of total billed charges,75% of total billed charges,1504.85,75,,,percent of total billed charges,75% of total billed charges,2006.46,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,2006.46,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2006.46,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2006.46,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2006.46,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2006.46,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,2006.46,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2006.46,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,280.9,14,,,percent of total billed charges,14% of total billed charges,280.9,2006.46,
58800 - PF Drainage Ovarian Cyst Uni/Bi Spx Vaginal Appr,4305361,CDM,960,RC,58800,HCPCS,Outpatient,,,655.91,327.96,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
58805- Ovarian cyst drainage/abd approach,3431435,CDM,510,RC,58805,HCPCS,Outpatient,,,1127.13,563.57,,845.35,75,,,percent of total billed charges,75% of total billed charges,845.35,75,,,percent of total billed charges,75% of total billed charges,2658.26,100,,,Fee Schedule,100% of CMS OPPS Rate,1048.68,102,,,Fee Schedule,102% of WV Medicaid Rate,4386.13,165,,,Fee Schedule,165% of CMS OPPS Rate,2755.05,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,7635.49,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,10471.46,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13116.58,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1028.12,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2658.26,100,,,Fee Schedule,100% of CMS OPPS Rate,2755.05,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,157.8,14,,,percent of total billed charges,14% of total billed charges,157.8,13116.58,
58825-PF TRANSPOSITION OVARY,3430277,CDM,510,RC,58825,HCPCS,Outpatient,,,1887.83,943.92,,1415.87,75,,,percent of total billed charges,75% of total billed charges,1415.87,75,,,percent of total billed charges,75% of total billed charges,1887.83,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,1887.83,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1887.83,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1887.83,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1887.83,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1887.83,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,1887.83,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1887.83,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,264.3,14,,,percent of total billed charges,14% of total billed charges,264.3,1887.83,
58925 - PF Ovarian Cystectomy Uni/ Bi,4311912,CDM,960,RC,58925,HCPCS,Outpatient,,,1809.87,904.94,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
58925- Ovarian cyctectomy/uni/bilateral,3431696,CDM,510,RC,58925,HCPCS,Outpatient,,,2038.7,1019.35,,1529.03,75,,,percent of total billed charges,75% of total billed charges,1529.03,75,,,percent of total billed charges,75% of total billed charges,4357.75,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,7190.32,165,,,Fee Schedule,165% of CMS OPPS Rate,4516.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,12517.1,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,17166.21,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,21502.42,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,4357.75,100,,,Fee Schedule,100% of CMS OPPS Rate,4516.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,285.42,14,,,percent of total billed charges,14% of total billed charges,285.42,21502.42,
58940- Oophorectomy,3431436,CDM,510,RC,58940,HCPCS,Outpatient,,,1466.83,733.42,,1100.12,75,,,percent of total billed charges,75% of total billed charges,1100.12,75,,,percent of total billed charges,75% of total billed charges,1466.83,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,1466.83,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1466.83,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1466.83,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1466.83,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1466.83,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,1466.83,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1466.83,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,205.36,14,,,percent of total billed charges,14% of total billed charges,205.36,1466.83,
58943-PF REMOVAL OF OVARY(S),3430283,CDM,510,RC,58943,HCPCS,Outpatient,,,3097.37,1548.69,,2323.03,75,,,percent of total billed charges,75% of total billed charges,2323.03,75,,,percent of total billed charges,75% of total billed charges,3097.37,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,3097.37,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3097.37,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3097.37,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3097.37,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3097.37,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,3097.37,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3097.37,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,433.63,14,,,percent of total billed charges,14% of total billed charges,433.63,3097.37,
58951-PF RESECT OVARIAN MALIGNANCY,3430285,CDM,510,RC,58951,HCPCS,Outpatient,,,3819.03,1909.52,,2864.27,75,,,percent of total billed charges,75% of total billed charges,2864.27,75,,,percent of total billed charges,75% of total billed charges,3819.03,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,3819.03,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3819.03,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3819.03,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3819.03,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3819.03,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,3819.03,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3819.03,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,534.66,14,,,percent of total billed charges,14% of total billed charges,534.66,3819.03,
"58952 - (PF) Resection (initial) of ovarian, tubal or primary peritoneal malignancy with bilateral",3635229,CDM,510,RC,58952,HCPCS,Outpatient,,,4354.52,2177.26,,3265.89,75,,,percent of total billed charges,75% of total billed charges,3265.89,75,,,percent of total billed charges,75% of total billed charges,4354.52,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,4354.52,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4354.52,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4354.52,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4354.52,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4354.52,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,4354.52,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4354.52,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,609.63,14,,,percent of total billed charges,14% of total billed charges,609.63,4354.52,
"58953-PF TAH, RAD DISSECT",3430288,CDM,510,RC,58953,HCPCS,Outpatient,,,5301.58,2650.79,,3976.19,75,,,percent of total billed charges,75% of total billed charges,3976.19,75,,,percent of total billed charges,75% of total billed charges,5301.58,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,5301.58,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5301.58,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5301.58,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5301.58,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5301.58,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,5301.58,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5301.58,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,742.22,14,,,percent of total billed charges,14% of total billed charges,742.22,5301.58,
58954-PF TAH RAD DEBULK/LYMPH,3430290,CDM,510,RC,58954,HCPCS,Outpatient,,,5740.48,2870.24,,4305.36,75,,,percent of total billed charges,75% of total billed charges,4305.36,75,,,percent of total billed charges,75% of total billed charges,5740.48,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,5740.48,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5740.48,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5740.48,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5740.48,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5740.48,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,5740.48,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5740.48,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,803.67,14,,,percent of total billed charges,14% of total billed charges,803.67,5740.48,
58956 - BSO W/TOT OMENTECTOMY & HYSTERECTOMY MALIGNANC,4037698,CDM,983,RC,58956,HCPCS,Outpatient,,,3596,1798,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
58957-PF RESECT RECURRENT GYN MAL,3430292,CDM,510,RC,58957,HCPCS,Outpatient,,,4213.45,2106.73,,3160.09,75,,,percent of total billed charges,75% of total billed charges,3160.09,75,,,percent of total billed charges,75% of total billed charges,4213.45,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,4213.45,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4213.45,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4213.45,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4213.45,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4213.45,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,4213.45,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4213.45,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,589.88,14,,,percent of total billed charges,14% of total billed charges,589.88,4213.45,
58958-PF RESECT RECUR GYN MAL W/LYM,3430294,CDM,510,RC,58958,HCPCS,Outpatient,,,4425.47,2212.74,,3319.1,75,,,percent of total billed charges,75% of total billed charges,3319.1,75,,,percent of total billed charges,75% of total billed charges,4425.47,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,4425.47,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4425.47,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4425.47,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4425.47,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4425.47,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,4425.47,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4425.47,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,619.57,14,,,percent of total billed charges,14% of total billed charges,619.57,4425.47,
58999PF Unlisted Procedure Female Genital System Nonobstetri,4265161,CDM,960,RC,58999,HCPCS,Outpatient,,,295.61,147.81,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
59000- Amniocentesis/diagnostic,3431697,CDM,761,RC,59000,HCPCS,Outpatient,,,301.78,150.89,,226.34,75,,,percent of total billed charges,75% of total billed charges,226.34,75,,,percent of total billed charges,75% of total billed charges,661.37,100,,,Fee Schedule,100% of CMS OPPS Rate,48.87,102,,,Fee Schedule,102% of WV Medicaid Rate,1091.26,165,,,Fee Schedule,165% of CMS OPPS Rate,685.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1899.71,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2605.3,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,3263.41,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,47.91,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,661.37,100,,,Fee Schedule,100% of CMS OPPS Rate,685.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,42.25,14,,,percent of total billed charges,14% of total billed charges,42.25,3263.41,
59001- Amniocentesis/fluid reduction/US,3431698,CDM,761,RC,59001,HCPCS,Outpatient,,,480.98,240.49,,360.74,75,,,percent of total billed charges,75% of total billed charges,360.74,75,,,percent of total billed charges,75% of total billed charges,274.47,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,452.9,165,,,Fee Schedule,165% of CMS OPPS Rate,284.48,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,788.43,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1081.27,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1354.41,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,274.47,100,,,Fee Schedule,100% of CMS OPPS Rate,284.48,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,67.34,14,,,percent of total billed charges,14% of total billed charges,67.34,1354.41,
59012- Cordocentesis/intrauterine,3431699,CDM,761,RC,59012,HCPCS,Outpatient,,,543.38,271.69,,407.54,75,,,percent of total billed charges,75% of total billed charges,407.54,75,,,percent of total billed charges,75% of total billed charges,274.47,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,452.9,165,,,Fee Schedule,165% of CMS OPPS Rate,284.48,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,788.43,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1081.27,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1354.41,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,274.47,100,,,Fee Schedule,100% of CMS OPPS Rate,284.48,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,76.07,14,,,percent of total billed charges,14% of total billed charges,76.07,1354.41,
59025 - PF Fetal Nonstress Test,3431701,CDM,920,RC,59025,HCPCS,Outpatient,,,124.16,62.08,,93.12,75,,,percent of total billed charges,75% of total billed charges,93.12,75,,,percent of total billed charges,75% of total billed charges,167.47,100,,,Fee Schedule,100% of CMS OPPS Rate,15.57,102,,,Fee Schedule,102% of WV Medicaid Rate,276.31,165,,,Fee Schedule,165% of CMS OPPS Rate,173.56,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,481.04,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,659.7,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,826.34,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,15.26,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,167.47,100,,,Fee Schedule,100% of CMS OPPS Rate,173.56,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,17.38,14,,,percent of total billed charges,14% of total billed charges,15.26,826.34,
Clinic NST,3428544,CDM,920,RC,59025,HCPCS,Outpatient,,,124.16,62.08,,93.12,75,,,percent of total billed charges,75% of total billed charges,93.12,75,,,percent of total billed charges,75% of total billed charges,167.47,100,,,Fee Schedule,100% of CMS OPPS Rate,15.57,102,,,Fee Schedule,102% of WV Medicaid Rate,276.31,165,,,Fee Schedule,165% of CMS OPPS Rate,173.56,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,481.04,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,659.7,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,826.34,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,15.26,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,167.47,100,,,Fee Schedule,100% of CMS OPPS Rate,173.56,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,17.38,14,,,percent of total billed charges,14% of total billed charges,15.26,826.34,
Fetal Non Stress Test,624591,CDM,920,RC,59025,HCPCS,Outpatient,,,124.16,62.08,,93.12,75,,,percent of total billed charges,75% of total billed charges,93.12,75,,,percent of total billed charges,75% of total billed charges,167.47,100,,,Fee Schedule,100% of CMS OPPS Rate,15.57,102,,,Fee Schedule,102% of WV Medicaid Rate,276.31,165,,,Fee Schedule,165% of CMS OPPS Rate,173.56,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,481.04,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,659.7,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,826.34,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,15.26,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,167.47,100,,,Fee Schedule,100% of CMS OPPS Rate,173.56,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,17.38,14,,,percent of total billed charges,14% of total billed charges,15.26,826.34,
59051- Fetal monitoring/labor/interp only,3431703,CDM,510,RC,59051,HCPCS,Outpatient,,,113.37,56.69,,85.03,75,,,percent of total billed charges,75% of total billed charges,85.03,75,,,percent of total billed charges,75% of total billed charges,36.28,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.87,14,,,percent of total billed charges,14% of total billed charges,15.87,85.03,
59070- Transabdominal amnioinfusion/US,3431704,CDM,761,RC,59070,HCPCS,Outpatient,,,1050.3,525.15,,787.73,75,,,percent of total billed charges,75% of total billed charges,787.73,75,,,percent of total billed charges,75% of total billed charges,274.47,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,452.9,165,,,Fee Schedule,165% of CMS OPPS Rate,284.48,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,788.43,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1081.27,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1354.41,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,274.47,100,,,Fee Schedule,100% of CMS OPPS Rate,284.48,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,147.04,14,,,percent of total billed charges,14% of total billed charges,147.04,1354.41,
59120- Surg tx/ectopic preg/salp/ooph,3431706,CDM,510,RC,59120,HCPCS,Outpatient,,,2200.91,1100.46,,1650.68,75,,,percent of total billed charges,75% of total billed charges,1650.68,75,,,percent of total billed charges,75% of total billed charges,2200.91,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,2200.91,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2200.91,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2200.91,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2200.91,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2200.91,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,2200.91,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2200.91,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,308.13,14,,,percent of total billed charges,14% of total billed charges,308.13,2200.91,
59121- Surg tx/ectopic preg w/o salp/ooph,3431707,CDM,510,RC,59121,HCPCS,Outpatient,,,2204.03,1102.02,,1653.02,75,,,percent of total billed charges,75% of total billed charges,1653.02,75,,,percent of total billed charges,75% of total billed charges,2204.03,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,2204.03,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2204.03,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2204.03,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2204.03,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2204.03,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,2204.03,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2204.03,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,308.56,14,,,percent of total billed charges,14% of total billed charges,308.56,2204.03,
59150 - PF Laps Tx Ectopic Preg w/o Salping &/ Oophorectomy,4311913,CDM,960,RC,59150,HCPCS,Outpatient,,,1911.13,955.57,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
59151 - PF Laps T Ectopic Preg w/ Salping &/ Oophorectomy,4311914,CDM,960,RC,59151,HCPCS,Outpatient,,,1870.51,935.26,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
59151- Lap/ectopic pregnancy/salping/ooph,3431708,CDM,761,RC,59151,HCPCS,Outpatient,,,2090.53,1045.27,,1567.9,75,,,percent of total billed charges,75% of total billed charges,1567.9,75,,,percent of total billed charges,75% of total billed charges,4900.27,100,,,Fee Schedule,100% of CMS OPPS Rate,1862.49,102,,,Fee Schedule,102% of WV Medicaid Rate,8085.46,165,,,Fee Schedule,165% of CMS OPPS Rate,5078.72,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,14075.4,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,19303.29,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,24179.33,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1825.97,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,4900.27,100,,,Fee Schedule,100% of CMS OPPS Rate,5078.72,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,292.67,14,,,percent of total billed charges,14% of total billed charges,292.67,24179.33,
59160- D&C/postpartum,3431710,CDM,761,RC,59160,HCPCS,Outpatient,,,715.87,357.94,,536.9,75,,,percent of total billed charges,75% of total billed charges,536.9,75,,,percent of total billed charges,75% of total billed charges,2658.26,100,,,Fee Schedule,100% of CMS OPPS Rate,1048.68,102,,,Fee Schedule,102% of WV Medicaid Rate,4386.13,165,,,Fee Schedule,165% of CMS OPPS Rate,2755.05,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,7635.49,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,10471.46,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13116.58,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1028.12,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2658.26,100,,,Fee Schedule,100% of CMS OPPS Rate,2755.05,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,100.22,14,,,percent of total billed charges,14% of total billed charges,100.22,13116.58,
59200- Insertion/cervical dilator,3431711,CDM,510,RC,59200,HCPCS,Outpatient,,,269.9,134.95,,202.43,75,,,percent of total billed charges,75% of total billed charges,202.43,75,,,percent of total billed charges,75% of total billed charges,274.47,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,452.9,165,,,Fee Schedule,165% of CMS OPPS Rate,284.48,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,788.43,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1081.27,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1354.41,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,274.47,100,,,Fee Schedule,100% of CMS OPPS Rate,284.48,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,37.79,14,,,percent of total billed charges,14% of total billed charges,37.79,1354.41,
"59300 - Episiotomy or vaginal repair, by other than attending",4037736,CDM,983,RC,59300,HCPCS,Outpatient,,,602.33,301.17,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
59320- Cerclage,3431712,CDM,761,RC,59320,HCPCS,Outpatient,,,407.89,203.95,,305.92,75,,,percent of total billed charges,75% of total billed charges,305.92,75,,,percent of total billed charges,75% of total billed charges,2658.26,100,,,Fee Schedule,100% of CMS OPPS Rate,1048.68,102,,,Fee Schedule,102% of WV Medicaid Rate,4386.13,165,,,Fee Schedule,165% of CMS OPPS Rate,2755.05,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,7635.49,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,10471.46,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13116.58,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1028.12,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2658.26,100,,,Fee Schedule,100% of CMS OPPS Rate,2755.05,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,57.1,14,,,percent of total billed charges,14% of total billed charges,57.1,13116.58,
59325 Removal Cerclage Cervix,3604862,CDM,960,RC,59325,HCPCS,Outpatient,,,649.52,324.76,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
59400- Obstetric care/routine,3431713,CDM,510,RC,59400,HCPCS,Outpatient,,,6389.57,3194.79,,4792.18,75,,,percent of total billed charges,75% of total billed charges,4792.18,75,,,percent of total billed charges,75% of total billed charges,2044.66,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,894.54,14,,,percent of total billed charges,14% of total billed charges,894.54,4792.18,
59409- Vaginal delivery only,3431714,CDM,761,RC,59409,HCPCS,Outpatient,,,2178.25,1089.13,,1633.69,75,,,percent of total billed charges,75% of total billed charges,1633.69,75,,,percent of total billed charges,75% of total billed charges,2658.26,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,4386.13,165,,,Fee Schedule,165% of CMS OPPS Rate,2755.05,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,7635.49,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,10471.46,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13116.58,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,2658.26,100,,,Fee Schedule,100% of CMS OPPS Rate,2755.05,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,304.96,14,,,percent of total billed charges,14% of total billed charges,304.96,13116.58,
59409-PF VAGINAL DELIVERY ONLY,4321484,CDM,981,RC,59409,HCPCS,Outpatient,,,1638.26,819.13,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
OBSTETRICAL DELIVERY,3428491,CDM,981,RC,59409,HCPCS,Outpatient,,,2178.25,1089.13,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
59410- Vaginal delivery/postpartum care,3431715,CDM,761,RC,59410,HCPCS,Outpatient,,,2866.09,1433.05,,2149.57,75,,,percent of total billed charges,75% of total billed charges,2149.57,75,,,percent of total billed charges,75% of total billed charges,917.15,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,401.25,14,,,percent of total billed charges,14% of total billed charges,401.25,2149.57,
59412 - Antepartum Manipulation,4189312,CDM,960,RC,59412,HCPCS,Outpatient,,,247.53,123.77,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
59414- Delivery of placenta,3431717,CDM,761,RC,59414,HCPCS,Outpatient,,,244.85,122.43,,183.64,75,,,percent of total billed charges,75% of total billed charges,183.64,75,,,percent of total billed charges,75% of total billed charges,2658.26,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,4386.13,165,,,Fee Schedule,165% of CMS OPPS Rate,2755.05,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,7635.49,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,10471.46,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13116.58,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,2658.26,100,,,Fee Schedule,100% of CMS OPPS Rate,2755.05,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,34.28,14,,,percent of total billed charges,14% of total billed charges,34.28,13116.58,
59425- Antepartum care only/4-6 visits,3431718,CDM,761,RC,59425,HCPCS,Outpatient,,,1477.15,738.58,,1107.86,75,,,percent of total billed charges,75% of total billed charges,1107.86,75,,,percent of total billed charges,75% of total billed charges,472.69,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,206.8,14,,,percent of total billed charges,14% of total billed charges,206.8,1107.86,
59426- Antepartum care only/7 or > visits,3431719,CDM,761,RC,59426,HCPCS,Outpatient,,,2697.73,1348.87,,2023.3,75,,,percent of total billed charges,75% of total billed charges,2023.3,75,,,percent of total billed charges,75% of total billed charges,863.27,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,377.68,14,,,percent of total billed charges,14% of total billed charges,377.68,2023.3,
59430- Postpartum care only,3431720,CDM,510,RC,59430,HCPCS,Outpatient,,,693.26,346.63,,519.95,75,,,percent of total billed charges,75% of total billed charges,519.95,75,,,percent of total billed charges,75% of total billed charges,221.84,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,97.06,14,,,percent of total billed charges,14% of total billed charges,97.06,519.95,
59510- Total OB care/cesarean delivery,3431721,CDM,761,RC,59510,HCPCS,Outpatient,,,7085.78,3542.89,,5314.34,75,,,percent of total billed charges,75% of total billed charges,5314.34,75,,,percent of total billed charges,75% of total billed charges,2267.45,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,992.01,14,,,percent of total billed charges,14% of total billed charges,992.01,5314.34,
59514- Cesarean delivery only,3431722,CDM,360,RC,59514,HCPCS,Outpatient,,,2470.44,1235.22,,1852.83,75,,,percent of total billed charges,75% of total billed charges,1852.83,75,,,percent of total billed charges,75% of total billed charges,2470.44,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,2470.44,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2470.44,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2470.44,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2470.44,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2470.44,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,2470.44,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2470.44,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,345.86,14,,,percent of total billed charges,14% of total billed charges,345.86,2470.44,
59515- Cesarean deliv w/ postpartum care,3431723,CDM,761,RC,59515,HCPCS,Outpatient,,,3539.59,1769.8,,2654.69,75,,,percent of total billed charges,75% of total billed charges,2654.69,75,,,percent of total billed charges,75% of total billed charges,1132.67,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,495.54,14,,,percent of total billed charges,14% of total billed charges,495.54,2654.69,
59610- Total OB care/VBAC,3431725,CDM,761,RC,59610,HCPCS,Outpatient,,,6714.54,3357.27,,5035.91,75,,,percent of total billed charges,75% of total billed charges,5035.91,75,,,percent of total billed charges,75% of total billed charges,2148.65,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,940.04,14,,,percent of total billed charges,14% of total billed charges,940.04,5035.91,
59612- VBAC delivery only(w/orw/o epis & or forcps);,3569392,CDM,510,RC,59612,HCPCS,Outpatient,,,2470.19,1235.1,,1852.64,75,,,percent of total billed charges,75% of total billed charges,1852.64,75,,,percent of total billed charges,75% of total billed charges,2658.26,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,4386.13,165,,,Fee Schedule,165% of CMS OPPS Rate,2755.05,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,7635.49,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,10471.46,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13116.58,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,2658.26,100,,,Fee Schedule,100% of CMS OPPS Rate,2755.05,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,345.83,14,,,percent of total billed charges,14% of total billed charges,345.83,13116.58,
59614- VBAC/include postpartum care,3431726,CDM,761,RC,59614,HCPCS,Outpatient,,,3119.3,1559.65,,2339.48,75,,,percent of total billed charges,75% of total billed charges,2339.48,75,,,percent of total billed charges,75% of total billed charges,998.18,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,436.7,14,,,percent of total billed charges,14% of total billed charges,436.7,2339.48,
59618- Total OB care/C-sec after VBAC,3431727,CDM,761,RC,59618,HCPCS,Outpatient,,,7166.25,3583.13,,5374.69,75,,,percent of total billed charges,75% of total billed charges,5374.69,75,,,percent of total billed charges,75% of total billed charges,2293.2,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1003.28,14,,,percent of total billed charges,14% of total billed charges,1003.28,5374.69,
59620- Cesarean delivery after failed VBAC,3431728,CDM,510,RC,59620,HCPCS,Outpatient,,,2557.65,1278.83,,1918.24,75,,,percent of total billed charges,75% of total billed charges,1918.24,75,,,percent of total billed charges,75% of total billed charges,2557.65,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,2557.65,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2557.65,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2557.65,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2557.65,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2557.65,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,2557.65,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2557.65,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,358.07,14,,,percent of total billed charges,14% of total billed charges,358.07,2557.65,
59622- Delivery only/pp care/failed VBAC,3431729,CDM,761,RC,59622,HCPCS,Outpatient,,,3665.86,1832.93,,2749.4,75,,,percent of total billed charges,75% of total billed charges,2749.4,75,,,percent of total billed charges,75% of total billed charges,1173.08,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,513.22,14,,,percent of total billed charges,14% of total billed charges,513.22,2749.4,
59812- Surgical tx/miscarriage,3431730,CDM,761,RC,59812,HCPCS,Outpatient,,,959.23,479.62,,719.42,75,,,percent of total billed charges,75% of total billed charges,719.42,75,,,percent of total billed charges,75% of total billed charges,2658.26,100,,,Fee Schedule,100% of CMS OPPS Rate,1048.68,102,,,Fee Schedule,102% of WV Medicaid Rate,4386.13,165,,,Fee Schedule,165% of CMS OPPS Rate,2755.05,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,7635.49,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,10471.46,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13116.58,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1028.12,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2658.26,100,,,Fee Schedule,100% of CMS OPPS Rate,2755.05,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,134.29,14,,,percent of total billed charges,14% of total billed charges,134.29,13116.58,
59820- Tx of miscarriage/surgical/1st tri,3431731,CDM,761,RC,59820,HCPCS,Outpatient,,,1147.93,573.97,,860.95,75,,,percent of total billed charges,75% of total billed charges,860.95,75,,,percent of total billed charges,75% of total billed charges,2658.26,100,,,Fee Schedule,100% of CMS OPPS Rate,1048.68,102,,,Fee Schedule,102% of WV Medicaid Rate,4386.13,165,,,Fee Schedule,165% of CMS OPPS Rate,2755.05,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,7635.49,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,10471.46,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13116.58,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1028.12,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2658.26,100,,,Fee Schedule,100% of CMS OPPS Rate,2755.05,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,160.71,14,,,percent of total billed charges,14% of total billed charges,160.71,13116.58,
59821- Surg tx/missed abortion/2nd tri,3431732,CDM,761,RC,59821,HCPCS,Outpatient,,,1139.01,569.51,,854.26,75,,,percent of total billed charges,75% of total billed charges,854.26,75,,,percent of total billed charges,75% of total billed charges,2658.26,100,,,Fee Schedule,100% of CMS OPPS Rate,1048.68,102,,,Fee Schedule,102% of WV Medicaid Rate,4386.13,165,,,Fee Schedule,165% of CMS OPPS Rate,2755.05,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,7635.49,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,10471.46,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13116.58,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1028.12,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2658.26,100,,,Fee Schedule,100% of CMS OPPS Rate,2755.05,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,159.46,14,,,percent of total billed charges,14% of total billed charges,159.46,13116.58,
59840 - PF Induced Abortion By Dilation and Curettage,4315550,CDM,960,RC,59840,HCPCS,Outpatient,,,471.09,235.55,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
59855- Induced abortion/vag supp/delivery,3431733,CDM,360,RC,59855,HCPCS,Outpatient,,,1140.44,570.22,,855.33,75,,,percent of total billed charges,75% of total billed charges,855.33,75,,,percent of total billed charges,75% of total billed charges,1140.44,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,1140.44,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1140.44,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1140.44,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1140.44,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1140.44,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,1140.44,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1140.44,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,159.66,14,,,percent of total billed charges,14% of total billed charges,159.66,1140.44,
59870- Uterine evac/curet/hydatiform mole,3431735,CDM,761,RC,59870,HCPCS,Outpatient,,,1411.7,705.85,,1058.78,75,,,percent of total billed charges,75% of total billed charges,1058.78,75,,,percent of total billed charges,75% of total billed charges,2658.26,100,,,Fee Schedule,100% of CMS OPPS Rate,1048.68,102,,,Fee Schedule,102% of WV Medicaid Rate,4386.13,165,,,Fee Schedule,165% of CMS OPPS Rate,2755.05,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,7635.49,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,10471.46,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13116.58,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1028.12,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2658.26,100,,,Fee Schedule,100% of CMS OPPS Rate,2755.05,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,197.64,14,,,percent of total billed charges,14% of total billed charges,197.64,13116.58,
59899 Unlisted procedure maternity care and delivery Bakri,3623306,CDM,510,RC,59899,HCPCS,Outpatient,,,6648.32,3324.16,,4986.24,75,,,percent of total billed charges,75% of total billed charges,4986.24,75,,,percent of total billed charges,75% of total billed charges,167.47,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,276.31,165,,,Fee Schedule,165% of CMS OPPS Rate,173.56,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,481.04,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,659.7,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,826.34,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,167.47,100,,,Fee Schedule,100% of CMS OPPS Rate,173.56,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,930.76,14,,,percent of total billed charges,14% of total billed charges,167.47,4986.24,
60100- Bx thyroid/percutan core needle,3431283,CDM,320,RC,60100,HCPCS,Outpatient,,,280.6,140.3,,210.45,75,,,percent of total billed charges,75% of total billed charges,210.45,75,,,percent of total billed charges,75% of total billed charges,610.13,100,,,Fee Schedule,100% of CMS OPPS Rate,42.03,102,,,Fee Schedule,102% of WV Medicaid Rate,1006.72,165,,,Fee Schedule,165% of CMS OPPS Rate,632.35,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1752.53,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2403.46,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,3010.58,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,41.21,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,610.13,100,,,Fee Schedule,100% of CMS OPPS Rate,632.35,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,39.28,14,,,percent of total billed charges,14% of total billed charges,39.28,3010.58,
CT add Needle Bx Thyroid,645120,CDM,320,RC,60100,HCPCS,Outpatient,,,281.04,140.52,,210.78,75,,,percent of total billed charges,75% of total billed charges,210.78,75,,,percent of total billed charges,75% of total billed charges,610.13,100,,,Fee Schedule,100% of CMS OPPS Rate,42.03,102,,,Fee Schedule,102% of WV Medicaid Rate,1006.72,165,,,Fee Schedule,165% of CMS OPPS Rate,632.35,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1752.53,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2403.46,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,3010.58,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,41.21,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,610.13,100,,,Fee Schedule,100% of CMS OPPS Rate,632.35,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,39.35,14,,,percent of total billed charges,14% of total billed charges,39.35,3010.58,
Read,4181210,CDM,972,RC,60100,HCPCS,Outpatient,,,112.41,56.21,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
US add Needle Bx Thyroid,645156,CDM,320,RC,60100,HCPCS,Outpatient,,,281.04,140.52,,210.78,75,,,percent of total billed charges,75% of total billed charges,210.78,75,,,percent of total billed charges,75% of total billed charges,610.13,100,,,Fee Schedule,100% of CMS OPPS Rate,42.03,102,,,Fee Schedule,102% of WV Medicaid Rate,1006.72,165,,,Fee Schedule,165% of CMS OPPS Rate,632.35,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1752.53,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2403.46,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,3010.58,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,41.21,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,610.13,100,,,Fee Schedule,100% of CMS OPPS Rate,632.35,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,39.35,14,,,percent of total billed charges,14% of total billed charges,39.35,3010.58,
60200 - PF Exc Cyst/Adenoma Thyroid/Transection Isthmus,4305362,CDM,960,RC,60200,HCPCS,Outpatient,,,1400.62,700.31,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
60210 - PF Prtl Thyroid Lobectomy Uni w/wo Isthmusectomy,4301618,CDM,960,RC,60210,HCPCS,Outpatient,,,1488.71,744.36,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
60220- Total thyroid lobectomy/unilateral,3431284,CDM,361,RC,60220,HCPCS,Outpatient,,,1870.43,935.22,,1402.82,75,,,percent of total billed charges,75% of total billed charges,1402.82,75,,,percent of total billed charges,75% of total billed charges,4900.27,100,,,Fee Schedule,100% of CMS OPPS Rate,1862.49,102,,,Fee Schedule,102% of WV Medicaid Rate,8085.46,165,,,Fee Schedule,165% of CMS OPPS Rate,5078.72,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,14075.4,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,19303.29,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,24179.33,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1825.97,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,4900.27,100,,,Fee Schedule,100% of CMS OPPS Rate,5078.72,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,261.86,14,,,percent of total billed charges,14% of total billed charges,261.86,24179.33,
"60240- Thyroidectomy, total or complete",3569393,CDM,510,RC,60240,HCPCS,Outpatient,,,2443.68,1221.84,,1832.76,75,,,percent of total billed charges,75% of total billed charges,1832.76,75,,,percent of total billed charges,75% of total billed charges,4900.27,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,8085.46,165,,,Fee Schedule,165% of CMS OPPS Rate,5078.72,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,14075.4,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,19303.29,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,24179.33,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,4900.27,100,,,Fee Schedule,100% of CMS OPPS Rate,5078.72,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,342.12,14,,,percent of total billed charges,14% of total billed charges,342.12,24179.33,
"60260 - Thyroidectomy, total or complete",3899067,CDM,983,RC,60260,HCPCS,Outpatient,,,2897.49,1448.75,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
"60271-PF Rmvl Thyroid, Transcervical",4322117,CDM,960,RC,60271,HCPCS,Outpatient,,,2054.58,1027.29,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
60300- Thyroid cyst/aspiration and/or inj,3431285,CDM,361,RC,60300,HCPCS,Outpatient,,,270.06,135.03,,202.55,75,,,percent of total billed charges,75% of total billed charges,202.55,75,,,percent of total billed charges,75% of total billed charges,610.13,100,,,Fee Schedule,100% of CMS OPPS Rate,58.69,102,,,Fee Schedule,102% of WV Medicaid Rate,1006.72,165,,,Fee Schedule,165% of CMS OPPS Rate,632.35,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1752.53,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2403.46,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,3010.58,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,57.54,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,610.13,100,,,Fee Schedule,100% of CMS OPPS Rate,632.35,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,37.81,14,,,percent of total billed charges,14% of total billed charges,37.81,3010.58,
60500- Parathyroidectomy or expl parathy,3431286,CDM,510,RC,60500,HCPCS,Outpatient,,,2585.62,1292.81,,1939.22,75,,,percent of total billed charges,75% of total billed charges,1939.22,75,,,percent of total billed charges,75% of total billed charges,5020.17,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,8283.28,165,,,Fee Schedule,165% of CMS OPPS Rate,5202.97,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,14419.76,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,19775.56,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,24770.9,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,5020.17,100,,,Fee Schedule,100% of CMS OPPS Rate,5202.97,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,361.99,14,,,percent of total billed charges,14% of total billed charges,361.99,24770.9,
60502- Re-exploration of parathyroids,3431287,CDM,510,RC,60502,HCPCS,Outpatient,,,3474.67,1737.34,,2606,75,,,percent of total billed charges,75% of total billed charges,2606,75,,,percent of total billed charges,75% of total billed charges,5020.17,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,8283.28,165,,,Fee Schedule,165% of CMS OPPS Rate,5202.97,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,14419.76,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,19775.56,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,24770.9,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,5020.17,100,,,Fee Schedule,100% of CMS OPPS Rate,5202.97,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,486.45,14,,,percent of total billed charges,14% of total billed charges,486.45,24770.9,
60512- Parathyroid autotransplantation,3431288,CDM,510,RC,60512,HCPCS,Outpatient,,,649.18,324.59,,486.89,75,,,percent of total billed charges,75% of total billed charges,486.89,75,,,percent of total billed charges,75% of total billed charges,207.74,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,90.89,14,,,percent of total billed charges,14% of total billed charges,90.89,486.89,
60521-PF Thymectomy Prtl/Tot w/o Rad Mdstnl Dsn,4322118,CDM,960,RC,60521,HCPCS,Outpatient,,,2202.7,1101.35,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
60540 - Adrenalectomy w/Expl w/wo Bx Abdl/Lmbr/Drsal Spx,4169599,CDM,983,RC,60540,HCPCS,Outpatient,,,2556.27,1278.14,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
60600- Exc carotid body tumor w/o exc art,3431289,CDM,510,RC,60600,HCPCS,Outpatient,,,3671.01,1835.51,,2753.26,75,,,percent of total billed charges,75% of total billed charges,2753.26,75,,,percent of total billed charges,75% of total billed charges,3671.01,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,3671.01,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3671.01,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3671.01,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3671.01,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3671.01,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,3671.01,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3671.01,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,513.94,14,,,percent of total billed charges,14% of total billed charges,513.94,3671.01,
"60650 - Laparoscopy, surgical, with adrenalectomy, partial or complete, or exploration of adrenal gl",3800931,CDM,983,RC,60650,HCPCS,Outpatient,,,3186.46,1593.23,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
61070- Puncture shunt tube/aspirate/inj,3435318,CDM,510,RC,61070,HCPCS,Outpatient,,,148.81,74.41,,111.61,75,,,percent of total billed charges,75% of total billed charges,111.61,75,,,percent of total billed charges,75% of total billed charges,605.77,100,,,Fee Schedule,100% of CMS OPPS Rate,259.2,102,,,Fee Schedule,102% of WV Medicaid Rate,999.54,165,,,Fee Schedule,165% of CMS OPPS Rate,627.84,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1740.03,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2386.32,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,2989.1,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,254.12,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,605.77,100,,,Fee Schedule,100% of CMS OPPS Rate,627.84,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,20.83,14,,,percent of total billed charges,14% of total billed charges,20.83,2989.1,
61107-PF TWIST DRILL HOLE IMPLT VENTRICULAR CATH/DEVICE,4321485,CDM,981,RC,61107,HCPCS,Outpatient,,,646.52,323.26,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
"61210- Pierce Skull, Implant Devise",3435319,CDM,510,RC,61210,HCPCS,Outpatient,,,998.6,499.3,,748.95,75,,,percent of total billed charges,75% of total billed charges,748.95,75,,,percent of total billed charges,75% of total billed charges,998.6,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,998.6,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,998.6,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,998.6,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,998.6,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,998.6,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,998.6,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,998.6,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,139.8,14,,,percent of total billed charges,14% of total billed charges,139.8,998.6,
61312- Open Skull For Drainage,3435320,CDM,510,RC,61312,HCPCS,Outpatient,,,5609.11,2804.56,,4206.83,75,,,percent of total billed charges,75% of total billed charges,4206.83,75,,,percent of total billed charges,75% of total billed charges,5609.11,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,5609.11,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5609.11,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5609.11,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5609.11,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5609.11,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,5609.11,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5609.11,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,785.28,14,,,percent of total billed charges,14% of total billed charges,785.28,5609.11,
61500- Removal Of Skull Lesion,3435321,CDM,510,RC,61500,HCPCS,Outpatient,,,3479.62,1739.81,,2609.72,75,,,percent of total billed charges,75% of total billed charges,2609.72,75,,,percent of total billed charges,75% of total billed charges,3479.62,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,3479.62,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3479.62,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3479.62,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3479.62,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3479.62,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,3479.62,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3479.62,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,487.15,14,,,percent of total billed charges,14% of total billed charges,487.15,3479.62,
61510- Removal Of Brain Lesion,3435322,CDM,510,RC,61510,HCPCS,Outpatient,,,5934.93,2967.47,,4451.2,75,,,percent of total billed charges,75% of total billed charges,4451.2,75,,,percent of total billed charges,75% of total billed charges,5934.93,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,5934.93,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5934.93,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5934.93,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5934.93,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5934.93,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,5934.93,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5934.93,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,830.89,14,,,percent of total billed charges,14% of total billed charges,830.89,5934.93,
61512- Remove Brain Lining Lesion,3435323,CDM,510,RC,61512,HCPCS,Outpatient,,,6915.56,3457.78,,5186.67,75,,,percent of total billed charges,75% of total billed charges,5186.67,75,,,percent of total billed charges,75% of total billed charges,6915.56,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,6915.56,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6915.56,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6915.56,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6915.56,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6915.56,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,6915.56,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6915.56,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,968.18,14,,,percent of total billed charges,14% of total billed charges,968.18,6915.56,
61781- Stereotac comput assist/cran/intra,3435324,CDM,510,RC,61781,HCPCS,Outpatient,,,641.11,320.56,,480.83,75,,,percent of total billed charges,75% of total billed charges,480.83,75,,,percent of total billed charges,75% of total billed charges,205.16,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,89.76,14,,,percent of total billed charges,14% of total billed charges,89.76,480.83,
61782- Stereotac localiz/cranial/extradur,3435325,CDM,510,RC,61782,HCPCS,Outpatient,,,456.76,228.38,,342.57,75,,,percent of total billed charges,75% of total billed charges,342.57,75,,,percent of total billed charges,75% of total billed charges,146.16,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,63.95,14,,,percent of total billed charges,14% of total billed charges,63.95,342.57,
61783- Sterotactic localization/spinal,3435326,CDM,510,RC,61783,HCPCS,Outpatient,,,629.94,314.97,,472.46,75,,,percent of total billed charges,75% of total billed charges,472.46,75,,,percent of total billed charges,75% of total billed charges,201.58,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,88.19,14,,,percent of total billed charges,14% of total billed charges,88.19,472.46,
61799- Stereotac radiosur/ad cran les/com,3435327,CDM,510,RC,61799,HCPCS,Outpatient,,,825.24,412.62,,618.93,75,,,percent of total billed charges,75% of total billed charges,618.93,75,,,percent of total billed charges,75% of total billed charges,264.08,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,115.53,14,,,percent of total billed charges,14% of total billed charges,115.53,618.93,
61880 - Revision or removal of intracranial neurostimulator electrodes,3783275,CDM,510,RC,61880,HCPCS,Outpatient,,,1555.86,777.93,,1166.9,75,,,percent of total billed charges,75% of total billed charges,1166.9,75,,,percent of total billed charges,75% of total billed charges,3053.35,100,,,Fee Schedule,100% of CMS OPPS Rate,1478.79,102,,,Fee Schedule,102% of WV Medicaid Rate,5038.03,165,,,Fee Schedule,165% of CMS OPPS Rate,3164.54,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8770.35,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,12027.84,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,15066.08,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1449.79,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,3053.35,100,,,Fee Schedule,100% of CMS OPPS Rate,3164.54,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,217.82,14,,,percent of total billed charges,14% of total billed charges,217.82,15066.08,
"61885 Insertion or replacement of cranial neurostimulator pulse generator or receiver, direct or ind",3622067,CDM,510,RC,61885,HCPCS,Outpatient,,,1386.02,693.01,,1039.52,75,,,percent of total billed charges,75% of total billed charges,1039.52,75,,,percent of total billed charges,75% of total billed charges,20228,100,,,Fee Schedule,100% of CMS OPPS Rate,14665.19,102,,,Fee Schedule,102% of WV Medicaid Rate,33376.22,165,,,Fee Schedule,165% of CMS OPPS Rate,20964.61,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,58102.21,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,79682.53,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,99810.46,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,14377.64,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,20228,100,,,Fee Schedule,100% of CMS OPPS Rate,20964.61,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,194.04,14,,,percent of total billed charges,14% of total billed charges,194.04,99810.46,
61888 - REVJ/RMVL NEUROSTIMULATOR PULSE GENERATOR,3997209,CDM,960,RC,61888,HCPCS,Outpatient,,,1068.68,534.34,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
62220- Create shunt/ventric/atri/jug/auri,3435328,CDM,510,RC,62220,HCPCS,Outpatient,,,2635.02,1317.51,,1976.27,75,,,percent of total billed charges,75% of total billed charges,1976.27,75,,,percent of total billed charges,75% of total billed charges,2635.02,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,2635.02,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2635.02,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2635.02,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2635.02,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2635.02,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,2635.02,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2635.02,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,368.9,14,,,percent of total billed charges,14% of total billed charges,368.9,2635.02,
62223- Create shunt/ventric/perito/pleura,3435329,CDM,510,RC,62223,HCPCS,Outpatient,,,2785.67,1392.84,,2089.25,75,,,percent of total billed charges,75% of total billed charges,2089.25,75,,,percent of total billed charges,75% of total billed charges,2785.67,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,2785.67,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2785.67,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2785.67,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2785.67,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2785.67,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,2785.67,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2785.67,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,389.99,14,,,percent of total billed charges,14% of total billed charges,389.99,2785.67,
62252- Reprogram CSF shunt,3435330,CDM,510,RC,62252,HCPCS,Outpatient,,,86.38,43.19,,64.79,75,,,percent of total billed charges,75% of total billed charges,64.79,75,,,percent of total billed charges,75% of total billed charges,260.08,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,429.14,165,,,Fee Schedule,165% of CMS OPPS Rate,269.56,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,747.08,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1024.57,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1283.38,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,260.08,100,,,Fee Schedule,100% of CMS OPPS Rate,269.56,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,12.09,14,,,percent of total billed charges,14% of total billed charges,12.09,1283.38,
62270- Spinal puncture/lumbar/diagnostic,3435331,CDM,320,RC,62270,HCPCS,Outpatient,,,319.89,159.95,,239.92,75,,,percent of total billed charges,75% of total billed charges,239.92,75,,,percent of total billed charges,75% of total billed charges,605.77,100,,,Fee Schedule,100% of CMS OPPS Rate,259.2,102,,,Fee Schedule,102% of WV Medicaid Rate,999.54,165,,,Fee Schedule,165% of CMS OPPS Rate,627.84,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1740.03,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2386.32,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,2989.1,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,254.12,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,605.77,100,,,Fee Schedule,100% of CMS OPPS Rate,627.84,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,44.78,14,,,percent of total billed charges,14% of total billed charges,44.78,2989.1,
62270-PF DIAGNOSTIC LUMBAR SPINAL PUNCTURE,4321603,CDM,981,RC,62270,HCPCS,Outpatient,,,126.32,63.16,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
Clinic Lumbar Puncture,3435540,CDM,510,RC,62270,HCPCS,Outpatient,,,319.89,159.95,,239.92,75,,,percent of total billed charges,75% of total billed charges,239.92,75,,,percent of total billed charges,75% of total billed charges,605.77,100,,,Fee Schedule,100% of CMS OPPS Rate,259.2,102,,,Fee Schedule,102% of WV Medicaid Rate,999.54,165,,,Fee Schedule,165% of CMS OPPS Rate,627.84,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1740.03,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2386.32,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,2989.1,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,254.12,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,605.77,100,,,Fee Schedule,100% of CMS OPPS Rate,627.84,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,44.78,14,,,percent of total billed charges,14% of total billed charges,44.78,2989.1,
DR add Spinal Puncture Diagnostic,645859,CDM,320,RC,62270,HCPCS,Outpatient,,,331.09,165.55,,248.32,75,,,percent of total billed charges,75% of total billed charges,248.32,75,,,percent of total billed charges,75% of total billed charges,605.77,100,,,Fee Schedule,100% of CMS OPPS Rate,259.2,102,,,Fee Schedule,102% of WV Medicaid Rate,999.54,165,,,Fee Schedule,165% of CMS OPPS Rate,627.84,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1740.03,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2386.32,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,2989.1,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,254.12,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,605.77,100,,,Fee Schedule,100% of CMS OPPS Rate,627.84,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,46.35,14,,,percent of total billed charges,14% of total billed charges,46.35,2989.1,
62272- Spinal puncture/CSF drainage,3435332,CDM,510,RC,62272,HCPCS,Outpatient,,,184.2,92.1,,138.15,75,,,percent of total billed charges,75% of total billed charges,138.15,75,,,percent of total billed charges,75% of total billed charges,605.77,100,,,Fee Schedule,100% of CMS OPPS Rate,259.2,102,,,Fee Schedule,102% of WV Medicaid Rate,999.54,165,,,Fee Schedule,165% of CMS OPPS Rate,627.84,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1740.03,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2386.32,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,2989.1,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,254.12,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,605.77,100,,,Fee Schedule,100% of CMS OPPS Rate,627.84,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,25.79,14,,,percent of total billed charges,14% of total billed charges,25.79,2989.1,
62272-PF THERAPEUTIC SPINAL PUNCTURE DRAINAGE CSF,4321602,CDM,981,RC,62272,HCPCS,Outpatient,,,184.2,92.1,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
62273-PF INJECTION EPIDURAL BLOOD/CLOT PATCH,4321601,CDM,981,RC,62273,HCPCS,Outpatient,,,221.12,110.56,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
64400-PF INJECTION AA&/STRD TRIGEMINAL NERVE EACH BRANCH,4321600,CDM,981,RC,64400,HCPCS,Outpatient,,,99.78,49.89,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
64405- Inj/anest/greater occipital nerve,3435384,CDM,510,RC,64405,HCPCS,Outpatient,,,195.72,97.86,,146.79,75,,,percent of total billed charges,75% of total billed charges,146.79,75,,,percent of total billed charges,75% of total billed charges,255.61,100,,,Fee Schedule,100% of CMS OPPS Rate,29.75,102,,,Fee Schedule,102% of WV Medicaid Rate,421.75,165,,,Fee Schedule,165% of CMS OPPS Rate,264.92,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,734.23,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1006.94,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1261.29,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,29.17,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,255.61,100,,,Fee Schedule,100% of CMS OPPS Rate,264.92,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,27.4,14,,,percent of total billed charges,14% of total billed charges,27.4,1261.29,
64405-PF INJECTION AA&/STRD GREATER OCCIPITAL NERVE,4321599,CDM,981,RC,64405,HCPCS,Outpatient,,,106.48,53.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
64417-PF INJECTION AA&/STRD AXILLARY NERVE,4321598,CDM,981,RC,64417,HCPCS,Outpatient,,,124.72,62.36,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
64425- Inj/anest/ilioing/hypogastric nerv,3435387,CDM,510,RC,64425,HCPCS,Outpatient,,,279.15,139.58,,209.36,75,,,percent of total billed charges,75% of total billed charges,209.36,75,,,percent of total billed charges,75% of total billed charges,605.77,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,999.54,165,,,Fee Schedule,165% of CMS OPPS Rate,627.84,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1740.03,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2386.32,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,2989.1,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,605.77,100,,,Fee Schedule,100% of CMS OPPS Rate,627.84,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,39.08,14,,,percent of total billed charges,14% of total billed charges,39.08,2989.1,
64447-PF INJECTION AA&/STRD FEMORAL NERVE,4321597,CDM,981,RC,64447,HCPCS,Outpatient,,,124.16,62.08,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
64450- Inj/anesth/other perph nerv/branch,3435391,CDM,360,RC,64450,HCPCS,Outpatient,,,191.07,95.54,,143.3,75,,,percent of total billed charges,75% of total billed charges,143.3,75,,,percent of total billed charges,75% of total billed charges,605.77,100,,,Fee Schedule,100% of CMS OPPS Rate,38.77,102,,,Fee Schedule,102% of WV Medicaid Rate,999.54,165,,,Fee Schedule,165% of CMS OPPS Rate,627.84,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1740.03,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2386.32,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,2989.1,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,38.01,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,605.77,100,,,Fee Schedule,100% of CMS OPPS Rate,627.84,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,26.75,14,,,percent of total billed charges,14% of total billed charges,26.75,2989.1,
64450-PF INJECTION AA&/STRD OTHER PERIPHERAL NERVE/BRANCH,4321596,CDM,981,RC,64450,HCPCS,Outpatient,,,81.6,40.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
64455-PF NJX AA&/STRD PLANTAR COMMON DIGITAL NERVES,4321595,CDM,981,RC,64455,HCPCS,Outpatient,,,66.48,33.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
64520-PF INJECTION ANES LMBR/THRC PARAVERTBRL SYMPATHETIC,4321594,CDM,981,RC,64520,HCPCS,Outpatient,,,161.24,80.62,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
64561 Percutaneous neurostimulator,3428327,CDM,960,RC,64561,HCPCS,Outpatient,,,706.19,353.1,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
64581- Implant neurostim electrode/sacral,3435405,CDM,510,RC,64581,HCPCS,Outpatient,,,1735.96,867.98,,1301.97,75,,,percent of total billed charges,75% of total billed charges,1301.97,75,,,percent of total billed charges,75% of total billed charges,6208.71,100,,,Fee Schedule,100% of CMS OPPS Rate,3901.15,102,,,Fee Schedule,102% of WV Medicaid Rate,10244.37,165,,,Fee Schedule,165% of CMS OPPS Rate,6434.8,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,17833.68,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,24457.48,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,30635.47,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,3824.66,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,6208.71,100,,,Fee Schedule,100% of CMS OPPS Rate,6434.8,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,243.03,14,,,percent of total billed charges,14% of total billed charges,243.03,30635.47,
64585- Revise/rmv/perph neurostim electro,3435406,CDM,510,RC,64585,HCPCS,Outpatient,,,615.13,307.57,,461.35,75,,,percent of total billed charges,75% of total billed charges,461.35,75,,,percent of total billed charges,75% of total billed charges,3053.35,100,,,Fee Schedule,100% of CMS OPPS Rate,1478.79,102,,,Fee Schedule,102% of WV Medicaid Rate,5038.03,165,,,Fee Schedule,165% of CMS OPPS Rate,3164.54,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8770.35,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,12027.84,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,15066.08,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1449.79,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,3053.35,100,,,Fee Schedule,100% of CMS OPPS Rate,3164.54,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,86.12,14,,,percent of total billed charges,14% of total billed charges,86.12,15066.08,
64590- Ins/rpl prph sac/gstr npgr,3435407,CDM,510,RC,64590,HCPCS,Outpatient,,,666.45,333.23,,499.84,75,,,percent of total billed charges,75% of total billed charges,499.84,75,,,percent of total billed charges,75% of total billed charges,20228,100,,,Fee Schedule,100% of CMS OPPS Rate,14539.57,102,,,Fee Schedule,102% of WV Medicaid Rate,33376.22,165,,,Fee Schedule,165% of CMS OPPS Rate,20964.61,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,58102.21,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,79682.53,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,99810.46,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,14254.48,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,20228,100,,,Fee Schedule,100% of CMS OPPS Rate,20964.61,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,93.3,14,,,percent of total billed charges,14% of total billed charges,93.3,99810.46,
64595- Rev/rmv prph sac/gstr npgr,3621302,CDM,510,RC,64595,HCPCS,Outpatient,,,580.66,290.33,,435.5,75,,,percent of total billed charges,75% of total billed charges,435.5,75,,,percent of total billed charges,75% of total billed charges,3053.35,100,,,Fee Schedule,100% of CMS OPPS Rate,2364.23,102,,,Fee Schedule,102% of WV Medicaid Rate,5038.03,165,,,Fee Schedule,165% of CMS OPPS Rate,3164.54,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8770.35,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,12027.84,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,15066.08,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,2317.87,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,3053.35,100,,,Fee Schedule,100% of CMS OPPS Rate,3164.54,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,81.29,14,,,percent of total billed charges,14% of total billed charges,81.29,15066.08,
64831-PF SUTURE DIGITAL NERVE HAND/FOOT 1 NERVE,4321592,CDM,981,RC,64831,HCPCS,Outpatient,,,1349.3,674.65,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
64999-PF UNLISTED PROCEDURE NERVOUS SYSTEM,4321486,CDM,981,RC,64999,HCPCS,Outpatient,,,208,104,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
65093 - Revise Eye w/ Implant,4189313,CDM,960,RC,65093,HCPCS,Outpatient,,,1405.18,702.59,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
65101 - Enucleation of eye; without implant,3899071,CDM,983,RC,65101,HCPCS,Outpatient,,,1623.96,811.98,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
"65103 - PF Enucleation of eye; with implant, muscles not attached to implant",3715277,CDM,960,RC,65103,HCPCS,Outpatient,,,1679.85,839.93,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
"65135 - Insertion of ocular implant secondary; after enucleation, muscles not attached to implant",3800918,CDM,983,RC,65135,HCPCS,Outpatient,,,1651.44,825.72,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
65205- Remove FB/extern eye/Conjunc/sup,3431303,CDM,960,RC,65205,HCPCS,Outpatient,,,57.13,28.57,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
65205-PF REMOVAL FB EYE CONJUNCTIVAL SUPERFICIAL,4321591,CDM,981,RC,65205,HCPCS,Outpatient,,,57.13,28.57,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
65210- Rmv FB/conjunc/sub/sclera/nonperf,3431304,CDM,960,RC,65210,HCPCS,Outpatient,,,70.26,35.13,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
65210-PF RMVL FB XTRNL EYE EMBED SCJNCL/SCLERAL NONPERFOR,4321590,CDM,981,RC,65210,HCPCS,Outpatient,,,70.26,35.13,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
65220- Removal/FB/corneal/slit lamp,3431305,CDM,510,RC,65220,HCPCS,Outpatient,,,83.34,41.67,,62.51,75,,,percent of total billed charges,75% of total billed charges,62.51,75,,,percent of total billed charges,75% of total billed charges,354.97,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,585.71,165,,,Fee Schedule,165% of CMS OPPS Rate,367.9,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1019.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1398.33,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1751.55,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,354.97,100,,,Fee Schedule,100% of CMS OPPS Rate,367.9,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,11.67,14,,,percent of total billed charges,14% of total billed charges,11.67,1751.55,
65220-PF RMVL FB XTRNL EYE CORNEAL W/O SLIT LAMP,4321589,CDM,981,RC,65220,HCPCS,Outpatient,,,83.34,41.67,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
65222- Rmv FB/extern eye/cornea/slit lamp,3431306,CDM,510,RC,65222,HCPCS,Outpatient,,,98.83,49.42,,74.12,75,,,percent of total billed charges,75% of total billed charges,74.12,75,,,percent of total billed charges,75% of total billed charges,109.16,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,180.11,165,,,Fee Schedule,165% of CMS OPPS Rate,113.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,313.55,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,430.01,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,538.63,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,109.16,100,,,Fee Schedule,100% of CMS OPPS Rate,113.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,13.84,14,,,percent of total billed charges,14% of total billed charges,13.84,538.63,
65222-PF RMVL FB XTRNL EYE CORNEAL W/SLIT LAMP,4321588,CDM,981,RC,65222,HCPCS,Outpatient,,,98.83,49.42,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
65435- Rmv corneal epith/w w/o chem caut,3431307,CDM,510,RC,65435,HCPCS,Outpatient,,,204.02,102.01,,153.02,75,,,percent of total billed charges,75% of total billed charges,153.02,75,,,percent of total billed charges,75% of total billed charges,820.41,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1353.69,165,,,Fee Schedule,165% of CMS OPPS Rate,850.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,2356.56,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,3231.83,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,4048.2,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,820.41,100,,,Fee Schedule,100% of CMS OPPS Rate,850.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,28.56,14,,,percent of total billed charges,14% of total billed charges,28.56,4048.2,
65435-PF RMVL CORNEAL EPITHELIUM W/WO CHEMOCAUTERIZATION,4321487,CDM,981,RC,65435,HCPCS,Outpatient,,,128.98,64.49,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
66821- Cataract/secondar/discission/laser,3431308,CDM,510,RC,66821,HCPCS,Outpatient,,,822.4,411.2,,616.8,75,,,percent of total billed charges,75% of total billed charges,616.8,75,,,percent of total billed charges,75% of total billed charges,499.01,100,,,Fee Schedule,100% of CMS OPPS Rate,205.42,102,,,Fee Schedule,102% of WV Medicaid Rate,823.36,165,,,Fee Schedule,165% of CMS OPPS Rate,517.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1433.33,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1965.71,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,2462.25,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,201.39,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,499.01,100,,,Fee Schedule,100% of CMS OPPS Rate,517.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,115.14,14,,,percent of total billed charges,14% of total billed charges,115.14,2462.25,
66984- Extracaps catarac rmv/w lens prost,3431309,CDM,510,RC,66984,HCPCS,Outpatient,,,1356.41,678.21,,1017.31,75,,,percent of total billed charges,75% of total billed charges,1017.31,75,,,percent of total billed charges,75% of total billed charges,2030.23,100,,,Fee Schedule,100% of CMS OPPS Rate,838.09,102,,,Fee Schedule,102% of WV Medicaid Rate,3349.87,165,,,Fee Schedule,165% of CMS OPPS Rate,2104.15,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,5831.56,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,7997.52,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,10017.7,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,821.66,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2030.23,100,,,Fee Schedule,100% of CMS OPPS Rate,2104.15,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,189.9,14,,,percent of total billed charges,14% of total billed charges,189.9,10017.7,
67229- Tx retionpathy/preterm/birth-1yr,3431311,CDM,510,RC,67229,HCPCS,Outpatient,,,2896.83,1448.42,,2172.62,75,,,percent of total billed charges,75% of total billed charges,2172.62,75,,,percent of total billed charges,75% of total billed charges,499.01,100,,,Fee Schedule,100% of CMS OPPS Rate,205.42,102,,,Fee Schedule,102% of WV Medicaid Rate,823.36,165,,,Fee Schedule,165% of CMS OPPS Rate,517.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1433.33,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1965.71,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,2462.25,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,201.39,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,499.01,100,,,Fee Schedule,100% of CMS OPPS Rate,517.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,405.56,14,,,percent of total billed charges,14% of total billed charges,201.39,2462.25,
67299- Unlisted procedure/post seg/eye,3431312,CDM,510,RC,67229,HCPCS,Outpatient,,,2896.83,1448.42,,2172.62,75,,,percent of total billed charges,75% of total billed charges,2172.62,75,,,percent of total billed charges,75% of total billed charges,499.01,100,,,Fee Schedule,100% of CMS OPPS Rate,205.42,102,,,Fee Schedule,102% of WV Medicaid Rate,823.36,165,,,Fee Schedule,165% of CMS OPPS Rate,517.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1433.33,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1965.71,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,2462.25,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,201.39,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,499.01,100,,,Fee Schedule,100% of CMS OPPS Rate,517.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,405.56,14,,,percent of total billed charges,14% of total billed charges,201.39,2462.25,
"67400 Orbitotomy without bone flap (frontal or transconjunctival approach); for exploration, with or",3622572,CDM,960,RC,67400,HCPCS,Outpatient,,,1988.43,994.22,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
67412 - Orbitotomy without bone flap (frontal or transconjunctival approach); with removal of lesion,3572815,CDM,960,RC,67412,HCPCS,Outpatient,,,1893.2,946.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
67413 - PF Orbitotomy without bone flap (frontal or transconjunctival approach); with removal of for,3715383,CDM,960,RC,67413,HCPCS,Outpatient,,,1846.18,923.09,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
67700-PF BLEPHAROTOMY DRAINAGE ABSCESS EYELID,4321488,CDM,981,RC,67700,HCPCS,Outpatient,,,224.66,112.33,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
67800 - PF Excision of chalazion; single,4371199,CDM,960,RC,67800,HCPCS,Outpatient,,,199,99.5,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
"67801 Excision of chalazion; multiple, same lid",3621303,CDM,510,RC,67801,HCPCS,Outpatient,,,256.56,128.28,,192.42,75,,,percent of total billed charges,75% of total billed charges,192.42,75,,,percent of total billed charges,75% of total billed charges,820.41,100,,,Fee Schedule,100% of CMS OPPS Rate,73.71,102,,,Fee Schedule,102% of WV Medicaid Rate,1353.69,165,,,Fee Schedule,165% of CMS OPPS Rate,850.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,2356.56,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,3231.83,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,4048.2,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,72.26,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,820.41,100,,,Fee Schedule,100% of CMS OPPS Rate,850.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,35.92,14,,,percent of total billed charges,14% of total billed charges,35.92,4048.2,
"67801- PF Excision Chalazion Mltpl,Les, same eyelid",4347142,CDM,960,RC,67801,HCPCS,Outpatient,,,256.56,128.28,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
"67808- PF Excision Chalazion Mltpl,Les, same eyelid",4347143,CDM,960,RC,67808,HCPCS,Outpatient,,,712.32,356.16,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
67810- Incisional biopsy/eyelid,3586925,CDM,983,RC,67810,HCPCS,Outpatient,,,457.08,228.54,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
67810- Incisional biopsy/eyelid,3431318,CDM,510,RC,67810,HCPCS,Outpatient,,,135.17,67.59,,101.38,75,,,percent of total billed charges,75% of total billed charges,101.38,75,,,percent of total billed charges,75% of total billed charges,248.85,100,,,Fee Schedule,100% of CMS OPPS Rate,106.77,102,,,Fee Schedule,102% of WV Medicaid Rate,410.63,165,,,Fee Schedule,165% of CMS OPPS Rate,257.92,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,714.84,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,980.35,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1227.99,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,104.68,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,248.85,100,,,Fee Schedule,100% of CMS OPPS Rate,257.92,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,18.92,14,,,percent of total billed charges,14% of total billed charges,18.92,1227.99,
67820- PF Correction Trichiasis Epilation Forceps Only,4347144,CDM,960,RC,67820,HCPCS,Outpatient,,,43.21,21.61,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
"67825 - PF Correction of trichiasis; epilation by other than forceps (eg, by electrosurgery, cryothe",3700901,CDM,960,RC,67825,HCPCS,Outpatient,,,235.11,117.56,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
67825 - PF Correction Trichiasis Epilation Other Than Forceps,4347145,CDM,960,RC,67825,HCPCS,Outpatient,,,235.11,117.56,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
67840-EYE RMV EYELID LESION -NOT CHAL,3430499,CDM,510,RC,67840,HCPCS,Outpatient,,,305.03,152.52,,228.77,75,,,percent of total billed charges,75% of total billed charges,228.77,75,,,percent of total billed charges,75% of total billed charges,820.41,100,,,Fee Schedule,100% of CMS OPPS Rate,167.07,102,,,Fee Schedule,102% of WV Medicaid Rate,1353.69,165,,,Fee Schedule,165% of CMS OPPS Rate,850.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,2356.56,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,3231.83,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,4048.2,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,163.79,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,820.41,100,,,Fee Schedule,100% of CMS OPPS Rate,850.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,42.7,14,,,percent of total billed charges,14% of total billed charges,42.7,4048.2,
67840-OCC Exc eyelid lesion/excpt chalazion,3536978,CDM,983,RC,67840,HCPCS,Outpatient,,,695.43,347.72,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
67850- PF Destruction Lesion Lid Margn <1cm,4347146,CDM,960,RC,67850,HCPCS,Outpatient,,,255.86,127.93,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
67875 - PF Temp Closure Eyelids Suture,4347147,CDM,960,RC,67875,HCPCS,Outpatient,,,186.79,93.4,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
67880- PF Construction Intermargin Adhes/Tarsorrh/Canthorrh,4347148,CDM,960,RC,67880,HCPCS,Outpatient,,,712.32,356.16,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
67900- PF Rpr Brown Ptosis,4347149,CDM,960,RC,67900,HCPCS,Outpatient,,,984.38,492.19,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
67900- Repair brow ptosis,3431324,CDM,960,RC,67900,HCPCS,Outpatient,,,984.38,492.19,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
67901- PF Rpr Blepharoptosis Frontalis Musc Sutr/Oth Matrl,4347150,CDM,960,RC,67901,HCPCS,Outpatient,,,1141.66,570.83,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
67903- Blepharoptosis/levator resct/int,3431325,CDM,510,RC,67903,HCPCS,Outpatient,,,1505.09,752.55,,1128.82,75,,,percent of total billed charges,75% of total billed charges,1128.82,75,,,percent of total billed charges,75% of total billed charges,1987.7,100,,,Fee Schedule,100% of CMS OPPS Rate,688.56,102,,,Fee Schedule,102% of WV Medicaid Rate,3279.73,165,,,Fee Schedule,165% of CMS OPPS Rate,2060.09,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,5709.44,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,7830.05,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,9807.93,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,675.06,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1987.7,100,,,Fee Schedule,100% of CMS OPPS Rate,2060.09,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,210.71,14,,,percent of total billed charges,14% of total billed charges,210.71,9807.93,
67903 -OCC Blepharoptosis/levator resct/int,3548670,CDM,510,RC,67903,HCPCS,Outpatient,,,1505.09,752.55,,1128.82,75,,,percent of total billed charges,75% of total billed charges,1128.82,75,,,percent of total billed charges,75% of total billed charges,1987.7,100,,,Fee Schedule,100% of CMS OPPS Rate,688.56,102,,,Fee Schedule,102% of WV Medicaid Rate,3279.73,165,,,Fee Schedule,165% of CMS OPPS Rate,2060.09,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,5709.44,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,7830.05,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,9807.93,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,675.06,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1987.7,100,,,Fee Schedule,100% of CMS OPPS Rate,2060.09,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,210.71,14,,,percent of total billed charges,14% of total billed charges,210.71,9807.93,
67904 - PF Repair of blepharoptosis; (tarso) levator resecti,3641193,CDM,510,RC,67904,HCPCS,Outpatient,,,1157.12,578.56,,867.84,75,,,percent of total billed charges,75% of total billed charges,867.84,75,,,percent of total billed charges,75% of total billed charges,1987.7,100,,,Fee Schedule,100% of CMS OPPS Rate,688.56,102,,,Fee Schedule,102% of WV Medicaid Rate,3279.73,165,,,Fee Schedule,165% of CMS OPPS Rate,2060.09,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,5709.44,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,7830.05,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,9807.93,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,675.06,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1987.7,100,,,Fee Schedule,100% of CMS OPPS Rate,2060.09,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,162,14,,,percent of total billed charges,14% of total billed charges,162,9807.93,
67904- Blepharoptosis/levator resct/ext,3431326,CDM,960,RC,67904,HCPCS,Outpatient,,,1157.12,578.56,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
67904- PF Rpr Blepharoptosis Levator Resc/Advmnt Xtrnl,4347151,CDM,960,RC,67904,HCPCS,Outpatient,,,1157.12,578.56,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
67909- PF Reduction Overcorrection Ptosis,4347152,CDM,960,RC,67909,HCPCS,Outpatient,,,846.9,423.45,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
67911- Correction of lid retraction,3566797,CDM,960,RC,67911,HCPCS,Outpatient,,,1086.63,543.32,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
67912- Lagophthalmos/implt up eyelid load,3431328,CDM,960,RC,67912,HCPCS,Outpatient,,,948.74,474.37,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
67914 - Repair of ectropion; suture,3572816,CDM,960,RC,67914,HCPCS,Outpatient,,,635.26,317.63,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
67917- Repair ectropion/extensive,3431329,CDM,960,RC,67917,HCPCS,Outpatient,,,884.23,442.12,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
67923- Rpr entropion/excise tarsal wedge,3431330,CDM,960,RC,67923,HCPCS,Outpatient,,,832.21,416.11,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
"67924 - PF Repair of entropion; extensive (eg, tarsal strip or capsulopalpebral fascia repairs opera",3641194,CDM,960,RC,67924,HCPCS,Outpatient,,,883.91,441.96,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
67924- Repair entropion/extensive,3431331,CDM,960,RC,67924,HCPCS,Outpatient,,,883.91,441.96,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
67950- Canthoplasty/reconstruct canthus,3431334,CDM,960,RC,67950,HCPCS,Outpatient,,,896.57,448.29,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
67961- Exc/rpr eyelid/to 1/4 lid margin,3431335,CDM,510,RC,67961,HCPCS,Outpatient,,,879.65,439.83,,659.74,75,,,percent of total billed charges,75% of total billed charges,659.74,75,,,percent of total billed charges,75% of total billed charges,1987.7,100,,,Fee Schedule,100% of CMS OPPS Rate,688.56,102,,,Fee Schedule,102% of WV Medicaid Rate,3279.73,165,,,Fee Schedule,165% of CMS OPPS Rate,2060.09,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,5709.44,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,7830.05,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,9807.93,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,675.06,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1987.7,100,,,Fee Schedule,100% of CMS OPPS Rate,2060.09,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,123.15,14,,,percent of total billed charges,14% of total billed charges,123.15,9807.93,
67961- PF Excision & Rpr Eyelid < 1/4 Lid Margin,4347153,CDM,960,RC,67961,HCPCS,Outpatient,,,879.65,439.83,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
67966- PF Excision & Rpr Eyelid 1/4 Lid Margin,4347154,CDM,960,RC,67966,HCPCS,Outpatient,,,1271.3,635.65,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
"67971 Reconstruction of eyelid, full thickness by transfer of tarsoconjunctival flap from opposing e",3622247,CDM,960,RC,67971,HCPCS,Outpatient,,,1397.84,698.92,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
67973 - Reconstruction of Eyelid,3899074,CDM,983,RC,67973,HCPCS,Outpatient,,,1802.23,901.12,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
67975- EYE RECONSTRUCTION OF EYELID,3514655,CDM,960,RC,67975,HCPCS,Outpatient,,,1323.2,661.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
"67999 - PF Unlisted Procedure, Eyelids",4309237,CDM,960,RC,67999,HCPCS,Outpatient,,,696,348,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
"68020 - Incision of conjunctiva, drainage of cyst",3899075,CDM,983,RC,68020,HCPCS,Outpatient,,,213.14,106.57,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
68320 - Conjunctivoplasty; with conjunctival graft or extensive rearrangement,3572817,CDM,960,RC,68320,HCPCS,Outpatient,,,1042.53,521.27,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
68330 - Revise Eyelid Lining,4189314,CDM,960,RC,68330,HCPCS,Outpatient,,,889.28,444.64,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
68420- Incise/drain tear sac,3431338,CDM,510,RC,68420,HCPCS,Outpatient,,,821.84,410.92,,616.38,75,,,percent of total billed charges,75% of total billed charges,616.38,75,,,percent of total billed charges,75% of total billed charges,1987.7,100,,,Fee Schedule,100% of CMS OPPS Rate,201.74,102,,,Fee Schedule,102% of WV Medicaid Rate,3279.73,165,,,Fee Schedule,165% of CMS OPPS Rate,2060.09,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,5709.44,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,7830.05,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,9807.93,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,197.78,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1987.7,100,,,Fee Schedule,100% of CMS OPPS Rate,2060.09,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,115.06,14,,,percent of total billed charges,14% of total billed charges,115.06,9807.93,
68440- PF Snip Incision Lacrimal Punctum,4347155,CDM,960,RC,68440,HCPCS,Outpatient,,,191.61,95.81,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
68510 Biopsy of lacrimal gland,3621571,CDM,960,RC,68510,HCPCS,Outpatient,,,563.26,281.63,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
68700 Plastic repair of canaliculi,3622075,CDM,960,RC,68700,HCPCS,Outpatient,,,1166.76,583.38,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
68705- PF Correction Everted Punctum Cautery,4347156,CDM,960,RC,68705,HCPCS,Outpatient,,,320.78,160.39,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
68720- Dacryocystorhinostomy,3431339,CDM,510,RC,68720,HCPCS,Outpatient,,,2028.62,1014.31,,1521.47,75,,,percent of total billed charges,75% of total billed charges,1521.47,75,,,percent of total billed charges,75% of total billed charges,3286.34,100,,,Fee Schedule,100% of CMS OPPS Rate,1088.02,102,,,Fee Schedule,102% of WV Medicaid Rate,5422.47,165,,,Fee Schedule,165% of CMS OPPS Rate,3406.01,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,9439.58,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,12945.64,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,16215.73,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1066.69,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,3286.34,100,,,Fee Schedule,100% of CMS OPPS Rate,3406.01,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,284.01,14,,,percent of total billed charges,14% of total billed charges,284.01,16215.73,
68720 -OCC Dacryocystorhinostomy,3548682,CDM,510,RC,68720,HCPCS,Outpatient,,,2028.62,1014.31,,1521.47,75,,,percent of total billed charges,75% of total billed charges,1521.47,75,,,percent of total billed charges,75% of total billed charges,3286.34,100,,,Fee Schedule,100% of CMS OPPS Rate,1088.02,102,,,Fee Schedule,102% of WV Medicaid Rate,5422.47,165,,,Fee Schedule,165% of CMS OPPS Rate,3406.01,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,9439.58,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,12945.64,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,16215.73,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1066.69,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,3286.34,100,,,Fee Schedule,100% of CMS OPPS Rate,3406.01,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,284.01,14,,,percent of total billed charges,14% of total billed charges,284.01,16215.73,
"68760 - PF Closure of the lacrimal punctum; by thermocauterization, ligation, or laser surgery",4347157,CDM,960,RC,68760,HCPCS,Outpatient,,,281.92,140.96,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
68761- PF Clsr Lacrimal Punctum Plug Ea,4347158,CDM,960,RC,68761,HCPCS,Outpatient,,,224.95,112.48,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
68801- PF Dilation Lacrimal Punctum w/wo Irrigation,4347159,CDM,960,RC,68801,HCPCS,Outpatient,,,151.9,75.95,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
"68811 - (PF) Probing of nasolacrimal duct, with or without irrigation; requiring general anesth",3635230,CDM,960,RC,68811,HCPCS,Outpatient,,,262.12,131.06,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
"68811 - Probing of nasolacrimal duct, with or without irrigation; requiring general anesthesia",3699550,CDM,510,RC,68811,HCPCS,Outpatient,,,262.12,131.06,,196.59,75,,,percent of total billed charges,75% of total billed charges,196.59,75,,,percent of total billed charges,75% of total billed charges,1987.7,100,,,Fee Schedule,100% of CMS OPPS Rate,688.56,102,,,Fee Schedule,102% of WV Medicaid Rate,3279.73,165,,,Fee Schedule,165% of CMS OPPS Rate,2060.09,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,5709.44,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,7830.05,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,9807.93,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,675.06,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1987.7,100,,,Fee Schedule,100% of CMS OPPS Rate,2060.09,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,36.7,14,,,percent of total billed charges,14% of total billed charges,36.7,9807.93,
"68811-PF Probe Nasolacrimal Duct w/wo Irrig, Req Gen Anes",4347160,CDM,960,RC,68811,HCPCS,Outpatient,,,262.12,131.06,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
68815- PF Probe Nasolacrimal Duct w/wo Irrig Ins Tube/Stnt,4347161,CDM,960,RC,68815,HCPCS,Outpatient,,,429.19,214.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
68840- PF Probe Lacrimal Canaliculi w/wo Irrig,4347162,CDM,960,RC,68840,HCPCS,Outpatient,,,225.17,112.59,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
69000- Drainage external ear/simple,3430621,CDM,510,RC,69000,HCPCS,Outpatient,,,468.97,234.49,,351.73,75,,,percent of total billed charges,75% of total billed charges,351.73,75,,,percent of total billed charges,75% of total billed charges,610.13,100,,,Fee Schedule,100% of CMS OPPS Rate,105.65,102,,,Fee Schedule,102% of WV Medicaid Rate,1006.72,165,,,Fee Schedule,165% of CMS OPPS Rate,632.35,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1752.53,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2403.46,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,3010.58,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,103.58,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,610.13,100,,,Fee Schedule,100% of CMS OPPS Rate,632.35,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,65.66,14,,,percent of total billed charges,14% of total billed charges,65.66,3010.58,
69000-PF DRAINAGE EXTERNAL EAR ABSCESS/HEMATOMA SIMPLE,4321586,CDM,981,RC,69000,HCPCS,Outpatient,,,238.86,119.43,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
69005-PF DRAINAGE EXTERNAL EAR ABSCESS/HEMATOMA CMPLX,4321489,CDM,981,RC,69005,HCPCS,Outpatient,,,309.1,154.55,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
69020 Drain outer ear canal lesion,3584872,CDM,960,RC,69020,HCPCS,Outpatient,,,585.93,292.97,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
69020-PF DRAINAGE EXTERNAL AUDITORY CANAL ABSCESS,4321585,CDM,981,RC,69020,HCPCS,Outpatient,,,274.12,137.06,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
69100- Biopsy external ear,3430622,CDM,510,RC,69100,HCPCS,Outpatient,,,93.28,46.64,,69.96,75,,,percent of total billed charges,75% of total billed charges,69.96,75,,,percent of total billed charges,75% of total billed charges,195.39,100,,,Fee Schedule,100% of CMS OPPS Rate,54.05,102,,,Fee Schedule,102% of WV Medicaid Rate,322.39,165,,,Fee Schedule,165% of CMS OPPS Rate,202.5,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,561.23,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,769.7,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,964.12,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,52.99,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,195.39,100,,,Fee Schedule,100% of CMS OPPS Rate,202.5,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,13.06,14,,,percent of total billed charges,14% of total billed charges,13.06,964.12,
69105- Biopsy external auditory canal,3435906,CDM,976,RC,69105,HCPCS,Outpatient,,,126.95,63.48,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
69200 Remove foreign body from external auditory canal; without general anesthesia,3584873,CDM,960,RC,69200,HCPCS,Outpatient,,,201.44,100.72,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
69200-PF RMVL FB XTRNL AUDITORY CANAL W/O ANES,4321584,CDM,981,RC,69200,HCPCS,Outpatient,,,92.52,46.26,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
69205 Remove foreign body from external auditory canal; with general anesthesia,3584874,CDM,960,RC,69205,HCPCS,Outpatient,,,242.21,121.11,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
69205-PF RMVL FB XTRNL AUDITORY CANAL ANES,4321490,CDM,981,RC,69205,HCPCS,Outpatient,,,184.3,92.15,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
69209- Ear Irrigation,3435631,CDM,450,RC,69209,HCPCS,Outpatient,,,35.85,17.93,,26.89,75,,,percent of total billed charges,75% of total billed charges,26.89,75,,,percent of total billed charges,75% of total billed charges,54.04,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,89.16,165,,,Fee Schedule,165% of CMS OPPS Rate,56,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,155.22,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,212.87,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,266.65,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,54.04,100,,,Fee Schedule,100% of CMS OPPS Rate,56,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,5.02,14,,,percent of total billed charges,14% of total billed charges,5.02,266.65,
69209-PF Remove Impacted Ear Wax Uni,4321583,CDM,981,RC,69209,HCPCS,Outpatient,,,27.08,13.54,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
69210- Remove impacted ear wax-,3430623,CDM,761,RC,69210,HCPCS,Outpatient,,,121.35,60.68,,91.01,75,,,percent of total billed charges,75% of total billed charges,91.01,75,,,percent of total billed charges,75% of total billed charges,54.04,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,89.16,165,,,Fee Schedule,165% of CMS OPPS Rate,56,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,155.22,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,212.87,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,266.65,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,54.04,100,,,Fee Schedule,100% of CMS OPPS Rate,56,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,16.99,14,,,percent of total billed charges,14% of total billed charges,16.99,266.65,
69210-PF REMOVAL IMPACTED CERUMEN INSTRUMENTATION UNILAT,4321582,CDM,981,RC,69210,HCPCS,Outpatient,,,64.52,32.26,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
"69222 Debridement, mastoidectomy cavity, complex (eg, with anesthesia or more than routine cleaning)",3584876,CDM,960,RC,69222,HCPCS,Outpatient,,,538.78,269.39,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
69420 Maringotomy including aspiration and/or eustacian tube inflation,3584877,CDM,960,RC,69420,HCPCS,Outpatient,,,475.94,237.97,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
69421 Maringotomy including aspiration and/or eustacian tube inflation requiring general anesthesia,3584878,CDM,960,RC,69421,HCPCS,Outpatient,,,386.4,193.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
"69433 Tympanostomy (requiring insertion of ventilating tube), local or topical anesthesia",3584879,CDM,960,RC,69433,HCPCS,Outpatient,,,504.31,252.16,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
"69436 Tympanostomy (requiring insertion of ventilating tube), general anesthesia",3584880,CDM,960,RC,69436,HCPCS,Outpatient,,,407.73,203.87,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
69610 Repair of eardrum,3584881,CDM,960,RC,69610,HCPCS,Outpatient,,,980.97,490.49,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
69631 Repair eardrum structures,3584882,CDM,960,RC,69631,HCPCS,Outpatient,,,2284.81,1142.41,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
"69705 - (50) Nasopharyngoscopy, surgical, with dilation of eustachian tube (ie, balloon dilation); u",3715282,CDM,510,RC,69705,HCPCS,Outpatient,,,6764.82,3382.41,,5073.62,75,,,percent of total billed charges,75% of total billed charges,5073.62,75,,,percent of total billed charges,75% of total billed charges,5020.17,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,8283.28,165,,,Fee Schedule,165% of CMS OPPS Rate,5202.97,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,14419.76,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,19775.56,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,24770.9,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,5020.17,100,,,Fee Schedule,100% of CMS OPPS Rate,5202.97,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,947.07,14,,,percent of total billed charges,14% of total billed charges,947.07,24770.9,
"69705 - PF Nasopharyngoscopy, surgical, with dilation of eustachian tube (ie, balloon dilation); uni",3715278,CDM,510,RC,69705,HCPCS,Outpatient,,,455.84,227.92,,341.88,75,,,percent of total billed charges,75% of total billed charges,341.88,75,,,percent of total billed charges,75% of total billed charges,5020.17,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,8283.28,165,,,Fee Schedule,165% of CMS OPPS Rate,5202.97,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,14419.76,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,19775.56,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,24770.9,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,5020.17,100,,,Fee Schedule,100% of CMS OPPS Rate,5202.97,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,63.82,14,,,percent of total billed charges,14% of total billed charges,63.82,24770.9,
69705 - Surg Naspharyngoscopy Dilat Eustachian Tube Uni,3899078,CDM,983,RC,69705,HCPCS,Outpatient,,,6764.82,3382.41,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
72170-PELVIS AP,3431942,CDM,320,RC,72170,HCPCS,Outpatient,,,20.78,10.39,,15.59,75,,,percent of total billed charges,75% of total billed charges,15.59,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,18.19,100,,,Fee Schedule,100% of WV Medicaid Rate,165.8,165,,,Fee Schedule,165% of CMS OPPS Rate,104.14,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.83,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,18.19,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.14,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,2.91,14,,,percent of total billed charges,14% of total billed charges,2.91,495.81,
72170-PF PELVIS AP,3580896,CDM,960,RC,72170,HCPCS,Outpatient,,,68.39,34.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
"73206(26)- Computed tomographic angiography, upper extremity, with contrast material(s), including n",3621200,CDM,510,RC,73206,HCPCS,Outpatient,,,225.46,112.73,,169.1,75,,,percent of total billed charges,75% of total billed charges,169.1,75,,,percent of total billed charges,75% of total billed charges,169.55,100,,,Fee Schedule,100% of CMS OPPS Rate,171.61,100,,,Fee Schedule,100% of WV Medicaid Rate,279.75,165,,,Fee Schedule,165% of CMS OPPS Rate,175.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,486.99,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,667.88,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,836.59,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,171.61,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,169.55,100,,,Fee Schedule,100% of CMS OPPS Rate,175.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,31.56,14,,,percent of total billed charges,14% of total billed charges,31.56,836.59,
"74330 - (26) XR Cmbnd NDSC Cath Bilatry & Pancreatic Ductal Sys, RS&I",3899079,CDM,960,RC,74330,HCPCS,Outpatient,,,150.15,75.08,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
"74330 - (TC) XR Cmbnd NDSC Cath Bilatry & Pancreatic Ductal Sys, RS&I",3899080,CDM,960,RC,74330,HCPCS,Outpatient,,,150.15,75.08,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
"74330 - XR Cmbnd NDSC Cath Bilatry & Pancreatic Ductal Sys, RS&I",3899081,CDM,960,RC,74330,HCPCS,Outpatient,,,150.15,75.08,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
74340 - XR Guide for GI Tube,3896935,CDM,960,RC,74340,HCPCS,Outpatient,,,138.23,69.12,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
74360 - XR Guide GI Dilation,3896941,CDM,960,RC,74360,HCPCS,Outpatient,,,142.96,71.48,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
74360-PF XR Guide GI Dilation,4322119,CDM,960,RC,74360,HCPCS,Outpatient,,,51.58,25.79,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
DR Retrograde Cysto in OR,603432,CDM,320,RC,74430,HCPCS,Outpatient,,,100.89,50.45,,75.67,75,,,percent of total billed charges,75% of total billed charges,75.67,75,,,percent of total billed charges,75% of total billed charges,346.38,100,,,Fee Schedule,100% of CMS OPPS Rate,26.79,100,,,Fee Schedule,100% of WV Medicaid Rate,571.53,165,,,Fee Schedule,165% of CMS OPPS Rate,358.99,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,994.94,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1364.48,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1709.15,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,26.79,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,346.38,100,,,Fee Schedule,100% of CMS OPPS Rate,358.99,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,14.12,14,,,percent of total billed charges,14% of total billed charges,14.12,1709.15,
Read,602093,CDM,972,RC,74430,HCPCS,Outpatient,,,40.35,20.18,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
Read,602310,CDM,972,RC,74430,HCPCS,Outpatient,,,40.35,20.18,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
Read,601958,CDM,972,RC,74455,HCPCS,Outpatient,,,99.26,49.63,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
"74740 - Hysterosalpingography, radiological supervision and interpretation",3640901,CDM,510,RC,74740,HCPCS,Outpatient,,,238.05,119.03,,178.54,75,,,percent of total billed charges,75% of total billed charges,178.54,75,,,percent of total billed charges,75% of total billed charges,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,63.66,100,,,Fee Schedule,100% of WV Medicaid Rate,362.25,165,,,Fee Schedule,165% of CMS OPPS Rate,227.54,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,630.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,864.84,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1083.3,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,63.66,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,227.54,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,33.33,14,,,percent of total billed charges,14% of total billed charges,33.33,1083.3,
Read,602099,CDM,972,RC,74740,HCPCS,Outpatient,,,91.32,45.66,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
75557 - (PF) Cardiac magnetic resonance imaging for morphology and function without contrast mat,3635232,CDM,510,RC,75557,HCPCS,Outpatient,,,291.73,145.87,,218.8,75,,,percent of total billed charges,75% of total billed charges,218.8,75,,,percent of total billed charges,75% of total billed charges,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,195.17,100,,,Fee Schedule,100% of WV Medicaid Rate,362.24,165,,,Fee Schedule,165% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,630.61,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,864.84,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1083.29,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,195.17,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,40.84,14,,,percent of total billed charges,14% of total billed charges,40.84,1083.29,
75557- (26) - Cardiac magnetic resonance imaging for morphology and function without contrast materi,3715134,CDM,510,RC,75557,HCPCS,Outpatient,,,731.08,365.54,,548.31,75,,,percent of total billed charges,75% of total billed charges,548.31,75,,,percent of total billed charges,75% of total billed charges,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,195.17,100,,,Fee Schedule,100% of WV Medicaid Rate,362.24,165,,,Fee Schedule,165% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,630.61,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,864.84,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1083.29,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,195.17,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,102.35,14,,,percent of total billed charges,14% of total billed charges,102.35,1083.29,
Read,3347959,CDM,972,RC,75557,HCPCS,Outpatient,,,731.08,365.54,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
75559 - (PF) Cardiac magnetic resonance imaging for morphology and function without contrast mat,3635233,CDM,510,RC,75559,HCPCS,Outpatient,,,363.05,181.53,,272.29,75,,,percent of total billed charges,75% of total billed charges,272.29,75,,,percent of total billed charges,75% of total billed charges,473.01,100,,,Fee Schedule,100% of CMS OPPS Rate,262.27,100,,,Fee Schedule,100% of WV Medicaid Rate,780.48,165,,,Fee Schedule,165% of CMS OPPS Rate,490.24,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1358.69,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1863.34,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,2334.03,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,262.27,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,473.01,100,,,Fee Schedule,100% of CMS OPPS Rate,490.24,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,50.83,14,,,percent of total billed charges,14% of total billed charges,50.83,2334.03,
75561(26)- Cardiac magnetic resonance imaging for morphology and function without contrast material(,3621301,CDM,510,RC,75561,HCPCS,Outpatient,,,322.95,161.48,,242.21,75,,,percent of total billed charges,75% of total billed charges,242.21,75,,,percent of total billed charges,75% of total billed charges,346.38,100,,,Fee Schedule,100% of CMS OPPS Rate,254.4,100,,,Fee Schedule,100% of WV Medicaid Rate,571.51,165,,,Fee Schedule,165% of CMS OPPS Rate,358.99,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,994.94,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1364.48,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1709.15,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,254.4,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,346.38,100,,,Fee Schedule,100% of CMS OPPS Rate,358.99,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,45.21,14,,,percent of total billed charges,14% of total billed charges,45.21,1709.15,
Read,3347961,CDM,972,RC,75561,HCPCS,Outpatient,,,952.9,476.45,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
75565 (26) Cardiac MRI for velocity flow mapping,3620978,CDM,510,RC,75565,HCPCS,Outpatient,,,31.23,15.62,,23.42,75,,,percent of total billed charges,75% of total billed charges,23.42,75,,,percent of total billed charges,75% of total billed charges,9.99,32,,,percent of total billed charges,32% of total billed charges,31.23,100,,,Fee Schedule,100% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.23,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.37,14,,,percent of total billed charges,14% of total billed charges,4.37,31.23,
75571PF CT Heart No Contrast Quant Eval Coronary Calcium,4281207,CDM,960,RC,75571,HCPCS,Outpatient,,,198.2,99.1,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
"75572 - (PF) Computed tomography, heart, with contrast mater",3635236,CDM,510,RC,75572,HCPCS,Outpatient,,,218.84,109.42,,164.13,75,,,percent of total billed charges,75% of total billed charges,164.13,75,,,percent of total billed charges,75% of total billed charges,169.55,100,,,Fee Schedule,100% of CMS OPPS Rate,155.59,100,,,Fee Schedule,100% of WV Medicaid Rate,279.75,165,,,Fee Schedule,165% of CMS OPPS Rate,175.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,486.99,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,667.88,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,836.59,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,155.59,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,169.55,100,,,Fee Schedule,100% of CMS OPPS Rate,175.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,30.64,14,,,percent of total billed charges,14% of total billed charges,30.64,836.59,
"75574(26)- Computed tomographic angiography, heart, coronary arteries and bypass grafts (when presen",3621300,CDM,510,RC,75574,HCPCS,Outpatient,,,298.21,149.11,,223.66,75,,,percent of total billed charges,75% of total billed charges,223.66,75,,,percent of total billed charges,75% of total billed charges,169.55,100,,,Fee Schedule,100% of CMS OPPS Rate,191.04,100,,,Fee Schedule,100% of WV Medicaid Rate,279.75,165,,,Fee Schedule,165% of CMS OPPS Rate,175.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,486.99,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,667.88,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,836.59,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,191.04,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,169.55,100,,,Fee Schedule,100% of CMS OPPS Rate,175.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,41.75,14,,,percent of total billed charges,14% of total billed charges,41.75,836.59,
FFR professional fee,3616894,CDM,960,RC,75580,HCPCS,Outpatient,,,265.93,132.97,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
"75605- Aortography/thor, serialogrph,radio sup& intp",3569425,CDM,510,RC,75605,HCPCS,Outpatient,,,304.81,152.41,,228.61,75,,,percent of total billed charges,75% of total billed charges,228.61,75,,,percent of total billed charges,75% of total billed charges,4832.22,100,,,Fee Schedule,100% of CMS OPPS Rate,81.61,100,,,Fee Schedule,100% of WV Medicaid Rate,7973.18,165,,,Fee Schedule,165% of CMS OPPS Rate,5008.19,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,13879.91,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,19035.19,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,23843.51,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,81.61,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,4832.22,100,,,Fee Schedule,100% of CMS OPPS Rate,5008.19,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,42.67,14,,,percent of total billed charges,14% of total billed charges,42.67,23843.51,
"75605-Aortography, thoracic, by serialography",4271185,CDM,481,RC,75605,HCPCS,Outpatient,,,238.29,119.15,,178.72,75,,,percent of total billed charges,75% of total billed charges,178.72,75,,,percent of total billed charges,75% of total billed charges,4832.22,100,,,Fee Schedule,100% of CMS OPPS Rate,81.61,100,,,Fee Schedule,100% of WV Medicaid Rate,7973.18,165,,,Fee Schedule,165% of CMS OPPS Rate,5008.19,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,13879.91,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,19035.19,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,23843.51,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,81.61,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,4832.22,100,,,Fee Schedule,100% of CMS OPPS Rate,5008.19,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,33.36,14,,,percent of total billed charges,14% of total billed charges,33.36,23843.51,
"75605-PF Aortography, thoracic, by serialography",4271186,CDM,960,RC,75605,HCPCS,Outpatient,,,238.29,119.15,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
"75625(26)- Aortography, abdominal, by serialography, radiological supervision and interpretation",3621145,CDM,510,RC,75625,HCPCS,Outpatient,,,169.79,84.9,,127.34,75,,,percent of total billed charges,75% of total billed charges,127.34,75,,,percent of total billed charges,75% of total billed charges,2800.72,100,,,Fee Schedule,100% of CMS OPPS Rate,87.26,100,,,Fee Schedule,100% of WV Medicaid Rate,4621.2,165,,,Fee Schedule,165% of CMS OPPS Rate,2902.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8044.7,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11032.67,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13819.54,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,87.26,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2800.72,100,,,Fee Schedule,100% of CMS OPPS Rate,2902.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,23.77,14,,,percent of total billed charges,14% of total billed charges,23.77,13819.54,
"75625-IR AORTOGRAPHY, ABDOMINAL",3431943,CDM,320,RC,75625,HCPCS,Outpatient,,,169.79,84.9,,127.34,75,,,percent of total billed charges,75% of total billed charges,127.34,75,,,percent of total billed charges,75% of total billed charges,2800.72,100,,,Fee Schedule,100% of CMS OPPS Rate,87.26,100,,,Fee Schedule,100% of WV Medicaid Rate,4621.2,165,,,Fee Schedule,165% of CMS OPPS Rate,2902.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8044.7,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11032.67,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13819.54,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,87.26,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2800.72,100,,,Fee Schedule,100% of CMS OPPS Rate,2902.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,23.77,14,,,percent of total billed charges,14% of total billed charges,23.77,13819.54,
75625-Peripheral Angio Aortagram,3431944,CDM,320,RC,75625,HCPCS,Outpatient,,,169.79,84.9,,127.34,75,,,percent of total billed charges,75% of total billed charges,127.34,75,,,percent of total billed charges,75% of total billed charges,2800.72,100,,,Fee Schedule,100% of CMS OPPS Rate,87.26,100,,,Fee Schedule,100% of WV Medicaid Rate,4621.2,165,,,Fee Schedule,165% of CMS OPPS Rate,2902.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8044.7,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11032.67,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13819.54,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,87.26,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2800.72,100,,,Fee Schedule,100% of CMS OPPS Rate,2902.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,23.77,14,,,percent of total billed charges,14% of total billed charges,23.77,13819.54,
Aortography (Cardiology),,,320,RC,75625,HCPCS,Outpatient,,,169.79,84.9,,127.34,75,,,percent of total billed charges,75% of total billed charges,127.34,75,,,percent of total billed charges,75% of total billed charges,2800.72,100,,,Fee Schedule,100% of CMS OPPS Rate,87.26,100,,,Fee Schedule,100% of WV Medicaid Rate,4621.2,165,,,Fee Schedule,165% of CMS OPPS Rate,2902.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8044.7,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11032.67,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13819.54,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,87.26,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2800.72,100,,,Fee Schedule,100% of CMS OPPS Rate,2902.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,23.77,14,,,percent of total billed charges,14% of total billed charges,23.77,13819.54,
IR Abdominal Aortagram,603549,CDM,320,RC,75625,HCPCS,Outpatient,,,169.79,84.9,,127.34,75,,,percent of total billed charges,75% of total billed charges,127.34,75,,,percent of total billed charges,75% of total billed charges,2800.72,100,,,Fee Schedule,100% of CMS OPPS Rate,87.26,100,,,Fee Schedule,100% of WV Medicaid Rate,4621.2,165,,,Fee Schedule,165% of CMS OPPS Rate,2902.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8044.7,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11032.67,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13819.54,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,87.26,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2800.72,100,,,Fee Schedule,100% of CMS OPPS Rate,2902.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,23.77,14,,,percent of total billed charges,14% of total billed charges,23.77,13819.54,
"75630 - PF - Aortography, abdominal plus bilateral iliofemoral lower extremity, catheter, by serialo",3640904,CDM,510,RC,75630,HCPCS,Outpatient,,,191.18,95.59,,143.39,75,,,percent of total billed charges,75% of total billed charges,143.39,75,,,percent of total billed charges,75% of total billed charges,2800.72,100,,,Fee Schedule,100% of CMS OPPS Rate,108.4,100,,,Fee Schedule,100% of WV Medicaid Rate,4621.2,165,,,Fee Schedule,165% of CMS OPPS Rate,2902.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8044.7,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11032.67,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13819.54,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,108.4,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2800.72,100,,,Fee Schedule,100% of CMS OPPS Rate,2902.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,26.77,14,,,percent of total billed charges,14% of total billed charges,26.77,13819.54,
75630-ABD ANGIOGRAM W BILATERAL RUNOFF,3431945,CDM,320,RC,75630,HCPCS,Outpatient,,,191.18,95.59,,143.39,75,,,percent of total billed charges,75% of total billed charges,143.39,75,,,percent of total billed charges,75% of total billed charges,2800.72,100,,,Fee Schedule,100% of CMS OPPS Rate,108.4,100,,,Fee Schedule,100% of WV Medicaid Rate,4621.2,165,,,Fee Schedule,165% of CMS OPPS Rate,2902.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8044.7,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11032.67,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13819.54,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,108.4,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2800.72,100,,,Fee Schedule,100% of CMS OPPS Rate,2902.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,26.77,14,,,percent of total billed charges,14% of total billed charges,26.77,13819.54,
75630-Peripheral Angio Aortagram w Runoff,3431946,CDM,320,RC,75630,HCPCS,Outpatient,,,191.18,95.59,,143.39,75,,,percent of total billed charges,75% of total billed charges,143.39,75,,,percent of total billed charges,75% of total billed charges,2800.72,100,,,Fee Schedule,100% of CMS OPPS Rate,108.4,100,,,Fee Schedule,100% of WV Medicaid Rate,4621.2,165,,,Fee Schedule,165% of CMS OPPS Rate,2902.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8044.7,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11032.67,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13819.54,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,108.4,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2800.72,100,,,Fee Schedule,100% of CMS OPPS Rate,2902.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,26.77,14,,,percent of total billed charges,14% of total billed charges,26.77,13819.54,
Peripheral Angio Aortagram w Runoff,3427191,CDM,320,RC,75630,HCPCS,Outpatient,,,191.18,95.59,,143.39,75,,,percent of total billed charges,75% of total billed charges,143.39,75,,,percent of total billed charges,75% of total billed charges,2800.72,100,,,Fee Schedule,100% of CMS OPPS Rate,108.4,100,,,Fee Schedule,100% of WV Medicaid Rate,4621.2,165,,,Fee Schedule,165% of CMS OPPS Rate,2902.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8044.7,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11032.67,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13819.54,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,108.4,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2800.72,100,,,Fee Schedule,100% of CMS OPPS Rate,2902.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,26.77,14,,,percent of total billed charges,14% of total billed charges,26.77,13819.54,
"75710 - Angiography, extremity, unilateral, radiological supervision and interpretation",3640905,CDM,510,RC,75710,HCPCS,Outpatient,,,169.68,84.84,,127.26,75,,,percent of total billed charges,75% of total billed charges,127.26,75,,,percent of total billed charges,75% of total billed charges,2800.72,100,,,Fee Schedule,100% of CMS OPPS Rate,103.48,100,,,Fee Schedule,100% of WV Medicaid Rate,4621.2,165,,,Fee Schedule,165% of CMS OPPS Rate,2902.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8044.7,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11032.67,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13819.54,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,103.48,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2800.72,100,,,Fee Schedule,100% of CMS OPPS Rate,2902.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,23.76,14,,,percent of total billed charges,14% of total billed charges,23.76,13819.54,
75710-IR FEMORAL OR POPLITEAL ANGIO LT,3431947,CDM,320,RC,75710,HCPCS,Outpatient,,,169.68,84.84,,127.26,75,,,percent of total billed charges,75% of total billed charges,127.26,75,,,percent of total billed charges,75% of total billed charges,2800.72,100,,,Fee Schedule,100% of CMS OPPS Rate,103.48,100,,,Fee Schedule,100% of WV Medicaid Rate,4621.2,165,,,Fee Schedule,165% of CMS OPPS Rate,2902.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8044.7,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11032.67,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13819.54,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,103.48,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2800.72,100,,,Fee Schedule,100% of CMS OPPS Rate,2902.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,23.76,14,,,percent of total billed charges,14% of total billed charges,23.76,13819.54,
75710-IR PERIPHERAL ANGIOGRAPHY RT,3431948,CDM,320,RC,75710,HCPCS,Outpatient,,,169.68,84.84,,127.26,75,,,percent of total billed charges,75% of total billed charges,127.26,75,,,percent of total billed charges,75% of total billed charges,2800.72,100,,,Fee Schedule,100% of CMS OPPS Rate,103.48,100,,,Fee Schedule,100% of WV Medicaid Rate,4621.2,165,,,Fee Schedule,165% of CMS OPPS Rate,2902.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8044.7,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11032.67,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13819.54,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,103.48,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2800.72,100,,,Fee Schedule,100% of CMS OPPS Rate,2902.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,23.76,14,,,percent of total billed charges,14% of total billed charges,23.76,13819.54,
75710-Peripheral Angio Lower Extremity LT,3431949,CDM,320,RC,75710,HCPCS,Outpatient,,,169.68,84.84,,127.26,75,,,percent of total billed charges,75% of total billed charges,127.26,75,,,percent of total billed charges,75% of total billed charges,2800.72,100,,,Fee Schedule,100% of CMS OPPS Rate,103.48,100,,,Fee Schedule,100% of WV Medicaid Rate,4621.2,165,,,Fee Schedule,165% of CMS OPPS Rate,2902.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8044.7,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11032.67,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13819.54,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,103.48,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2800.72,100,,,Fee Schedule,100% of CMS OPPS Rate,2902.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,23.76,14,,,percent of total billed charges,14% of total billed charges,23.76,13819.54,
75710-Peripheral Angio Lower Extremity RT,3431950,CDM,320,RC,75710,HCPCS,Outpatient,,,169.68,84.84,,127.26,75,,,percent of total billed charges,75% of total billed charges,127.26,75,,,percent of total billed charges,75% of total billed charges,2800.72,100,,,Fee Schedule,100% of CMS OPPS Rate,103.48,100,,,Fee Schedule,100% of WV Medicaid Rate,4621.2,165,,,Fee Schedule,165% of CMS OPPS Rate,2902.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8044.7,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11032.67,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13819.54,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,103.48,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2800.72,100,,,Fee Schedule,100% of CMS OPPS Rate,2902.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,23.76,14,,,percent of total billed charges,14% of total billed charges,23.76,13819.54,
75710-Peripheral Angio Tibal Peroneal,3431951,CDM,320,RC,75710,HCPCS,Outpatient,,,169.68,84.84,,127.26,75,,,percent of total billed charges,75% of total billed charges,127.26,75,,,percent of total billed charges,75% of total billed charges,2800.72,100,,,Fee Schedule,100% of CMS OPPS Rate,103.48,100,,,Fee Schedule,100% of WV Medicaid Rate,4621.2,165,,,Fee Schedule,165% of CMS OPPS Rate,2902.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8044.7,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11032.67,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13819.54,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,103.48,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2800.72,100,,,Fee Schedule,100% of CMS OPPS Rate,2902.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,23.76,14,,,percent of total billed charges,14% of total billed charges,23.76,13819.54,
75710-Peripherial Angio Left,3431952,CDM,320,RC,75710,HCPCS,Outpatient,,,169.68,84.84,,127.26,75,,,percent of total billed charges,75% of total billed charges,127.26,75,,,percent of total billed charges,75% of total billed charges,2800.72,100,,,Fee Schedule,100% of CMS OPPS Rate,103.48,100,,,Fee Schedule,100% of WV Medicaid Rate,4621.2,165,,,Fee Schedule,165% of CMS OPPS Rate,2902.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8044.7,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11032.67,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13819.54,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,103.48,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2800.72,100,,,Fee Schedule,100% of CMS OPPS Rate,2902.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,23.76,14,,,percent of total billed charges,14% of total billed charges,23.76,13819.54,
Peripheral Angio Lower Extremity LT,3427218,CDM,320,RC,75710,HCPCS,Outpatient,,,169.68,84.84,,127.26,75,,,percent of total billed charges,75% of total billed charges,127.26,75,,,percent of total billed charges,75% of total billed charges,2800.72,100,,,Fee Schedule,100% of CMS OPPS Rate,103.48,100,,,Fee Schedule,100% of WV Medicaid Rate,4621.2,165,,,Fee Schedule,165% of CMS OPPS Rate,2902.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8044.7,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11032.67,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13819.54,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,103.48,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2800.72,100,,,Fee Schedule,100% of CMS OPPS Rate,2902.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,23.76,14,,,percent of total billed charges,14% of total billed charges,23.76,13819.54,
Peripheral Angio Lower Extremity RT,3427219,CDM,320,RC,75710,HCPCS,Outpatient,,,169.68,84.84,,127.26,75,,,percent of total billed charges,75% of total billed charges,127.26,75,,,percent of total billed charges,75% of total billed charges,2800.72,100,,,Fee Schedule,100% of CMS OPPS Rate,103.48,100,,,Fee Schedule,100% of WV Medicaid Rate,4621.2,165,,,Fee Schedule,165% of CMS OPPS Rate,2902.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8044.7,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11032.67,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13819.54,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,103.48,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2800.72,100,,,Fee Schedule,100% of CMS OPPS Rate,2902.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,23.76,14,,,percent of total billed charges,14% of total billed charges,23.76,13819.54,
Peripheral Angio Tibal Peroneal,3427225,CDM,320,RC,75710,HCPCS,Outpatient,,,169.68,84.84,,127.26,75,,,percent of total billed charges,75% of total billed charges,127.26,75,,,percent of total billed charges,75% of total billed charges,2800.72,100,,,Fee Schedule,100% of CMS OPPS Rate,103.48,100,,,Fee Schedule,100% of WV Medicaid Rate,4621.2,165,,,Fee Schedule,165% of CMS OPPS Rate,2902.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8044.7,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11032.67,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13819.54,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,103.48,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2800.72,100,,,Fee Schedule,100% of CMS OPPS Rate,2902.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,23.76,14,,,percent of total billed charges,14% of total billed charges,23.76,13819.54,
Read,630452,CDM,972,RC,75710,HCPCS,Outpatient,,,169.68,84.84,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
Read,630454,CDM,972,RC,75710,HCPCS,Outpatient,,,169.68,84.84,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
"75716 - PF - Angiography, extremity, bilateral, radiological supervision and interpretation",3640906,CDM,510,RC,75716,HCPCS,Outpatient,,,247.87,123.94,,185.9,75,,,percent of total billed charges,75% of total billed charges,185.9,75,,,percent of total billed charges,75% of total billed charges,2800.72,100,,,Fee Schedule,100% of CMS OPPS Rate,111.84,100,,,Fee Schedule,100% of WV Medicaid Rate,4621.2,165,,,Fee Schedule,165% of CMS OPPS Rate,2902.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8044.7,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11032.67,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13819.54,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,111.84,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2800.72,100,,,Fee Schedule,100% of CMS OPPS Rate,2902.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,34.7,14,,,percent of total billed charges,14% of total billed charges,34.7,13819.54,
75716-BILATERIAL RUN OFF,3431953,CDM,320,RC,75716,HCPCS,Outpatient,,,229.51,114.76,,172.13,75,,,percent of total billed charges,75% of total billed charges,172.13,75,,,percent of total billed charges,75% of total billed charges,2800.72,100,,,Fee Schedule,100% of CMS OPPS Rate,111.84,100,,,Fee Schedule,100% of WV Medicaid Rate,4621.2,165,,,Fee Schedule,165% of CMS OPPS Rate,2902.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8044.7,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11032.67,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13819.54,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,111.84,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2800.72,100,,,Fee Schedule,100% of CMS OPPS Rate,2902.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,32.13,14,,,percent of total billed charges,14% of total billed charges,32.13,13819.54,
75716-Peripheral Angio Bilateral,3431954,CDM,320,RC,75716,HCPCS,Outpatient,,,229.51,114.76,,172.13,75,,,percent of total billed charges,75% of total billed charges,172.13,75,,,percent of total billed charges,75% of total billed charges,2800.72,100,,,Fee Schedule,100% of CMS OPPS Rate,111.84,100,,,Fee Schedule,100% of WV Medicaid Rate,4621.2,165,,,Fee Schedule,165% of CMS OPPS Rate,2902.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8044.7,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11032.67,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13819.54,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,111.84,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2800.72,100,,,Fee Schedule,100% of CMS OPPS Rate,2902.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,32.13,14,,,percent of total billed charges,14% of total billed charges,32.13,13819.54,
75716-Peripheral Angio Lower Extremity BILAT,3431955,CDM,320,RC,75716,HCPCS,Outpatient,,,229.51,114.76,,172.13,75,,,percent of total billed charges,75% of total billed charges,172.13,75,,,percent of total billed charges,75% of total billed charges,2800.72,100,,,Fee Schedule,100% of CMS OPPS Rate,111.84,100,,,Fee Schedule,100% of WV Medicaid Rate,4621.2,165,,,Fee Schedule,165% of CMS OPPS Rate,2902.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8044.7,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11032.67,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13819.54,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,111.84,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2800.72,100,,,Fee Schedule,100% of CMS OPPS Rate,2902.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,32.13,14,,,percent of total billed charges,14% of total billed charges,32.13,13819.54,
IR Ext Run Off Bilat,603550,CDM,320,RC,75716,HCPCS,Outpatient,,,408.13,204.07,,306.1,75,,,percent of total billed charges,75% of total billed charges,306.1,75,,,percent of total billed charges,75% of total billed charges,2800.72,100,,,Fee Schedule,100% of CMS OPPS Rate,111.84,100,,,Fee Schedule,100% of WV Medicaid Rate,4621.2,165,,,Fee Schedule,165% of CMS OPPS Rate,2902.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8044.7,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11032.67,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13819.54,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,111.84,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2800.72,100,,,Fee Schedule,100% of CMS OPPS Rate,2902.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,57.14,14,,,percent of total billed charges,14% of total billed charges,57.14,13819.54,
Peripheral Angio Lower Extremity BILAT,,,320,RC,75716,HCPCS,Outpatient,,,408.13,204.07,,306.1,75,,,percent of total billed charges,75% of total billed charges,306.1,75,,,percent of total billed charges,75% of total billed charges,2800.72,100,,,Fee Schedule,100% of CMS OPPS Rate,111.84,100,,,Fee Schedule,100% of WV Medicaid Rate,4621.2,165,,,Fee Schedule,165% of CMS OPPS Rate,2902.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8044.7,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11032.67,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13819.54,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,111.84,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2800.72,100,,,Fee Schedule,100% of CMS OPPS Rate,2902.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,57.14,14,,,percent of total billed charges,14% of total billed charges,57.14,13819.54,
Peripheral Angiography Bilat (Cardiology),,,320,RC,75716,HCPCS,Outpatient,,,408.13,204.07,,306.1,75,,,percent of total billed charges,75% of total billed charges,306.1,75,,,percent of total billed charges,75% of total billed charges,2800.72,100,,,Fee Schedule,100% of CMS OPPS Rate,111.84,100,,,Fee Schedule,100% of WV Medicaid Rate,4621.2,165,,,Fee Schedule,165% of CMS OPPS Rate,2902.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8044.7,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11032.67,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13819.54,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,111.84,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2800.72,100,,,Fee Schedule,100% of CMS OPPS Rate,2902.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,57.14,14,,,percent of total billed charges,14% of total billed charges,57.14,13819.54,
Read,630450,CDM,972,RC,75716,HCPCS,Outpatient,,,163.25,81.63,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
75726 - (26) ANGIOGRAPHY VISCERAL SLCTV/SUPRASLCTV RS&I,3999217,CDM,960,RC,75726,HCPCS,Outpatient,,,431.5,215.75,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
75726 - (TC) ANGIOGRAPHY VISCERAL SLCTV/SUPRASLCTV RS&I,3997609,CDM,960,RC,75726,HCPCS,Outpatient,,,431.5,215.75,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
75726 - ANGIOGRAPHY VISCERAL SLCTV/SUPRASLCTV RS&I,3997210,CDM,960,RC,75726,HCPCS,Outpatient,,,431.5,215.75,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
75726-Peripheral Angio Celiac,3431956,CDM,320,RC,75726,HCPCS,Outpatient,,,233.28,116.64,,174.96,75,,,percent of total billed charges,75% of total billed charges,174.96,75,,,percent of total billed charges,75% of total billed charges,4832.22,100,,,Fee Schedule,100% of CMS OPPS Rate,115.28,100,,,Fee Schedule,100% of WV Medicaid Rate,7973.18,165,,,Fee Schedule,165% of CMS OPPS Rate,5008.19,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,13879.91,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,19035.19,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,23843.51,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,115.28,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,4832.22,100,,,Fee Schedule,100% of CMS OPPS Rate,5008.19,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,32.66,14,,,percent of total billed charges,14% of total billed charges,32.66,23843.51,
75726-Peripheral Angio Mesenteric,3431957,CDM,320,RC,75726,HCPCS,Outpatient,,,233.28,116.64,,174.96,75,,,percent of total billed charges,75% of total billed charges,174.96,75,,,percent of total billed charges,75% of total billed charges,4832.22,100,,,Fee Schedule,100% of CMS OPPS Rate,115.28,100,,,Fee Schedule,100% of WV Medicaid Rate,7973.18,165,,,Fee Schedule,165% of CMS OPPS Rate,5008.19,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,13879.91,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,19035.19,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,23843.51,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,115.28,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,4832.22,100,,,Fee Schedule,100% of CMS OPPS Rate,5008.19,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,32.66,14,,,percent of total billed charges,14% of total billed charges,32.66,23843.51,
75726-Peripheral Angio Splenic,3431958,CDM,320,RC,75726,HCPCS,Outpatient,,,233.28,116.64,,174.96,75,,,percent of total billed charges,75% of total billed charges,174.96,75,,,percent of total billed charges,75% of total billed charges,4832.22,100,,,Fee Schedule,100% of CMS OPPS Rate,115.28,100,,,Fee Schedule,100% of WV Medicaid Rate,7973.18,165,,,Fee Schedule,165% of CMS OPPS Rate,5008.19,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,13879.91,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,19035.19,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,23843.51,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,115.28,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,4832.22,100,,,Fee Schedule,100% of CMS OPPS Rate,5008.19,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,32.66,14,,,percent of total billed charges,14% of total billed charges,32.66,23843.51,
Peripheral Angio Celiac,,,320,RC,75726,HCPCS,Outpatient,,,428.88,214.44,,321.66,75,,,percent of total billed charges,75% of total billed charges,321.66,75,,,percent of total billed charges,75% of total billed charges,4832.22,100,,,Fee Schedule,100% of CMS OPPS Rate,115.28,100,,,Fee Schedule,100% of WV Medicaid Rate,7973.18,165,,,Fee Schedule,165% of CMS OPPS Rate,5008.19,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,13879.91,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,19035.19,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,23843.51,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,115.28,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,4832.22,100,,,Fee Schedule,100% of CMS OPPS Rate,5008.19,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,60.04,14,,,percent of total billed charges,14% of total billed charges,60.04,23843.51,
Peripheral Angio Mesenteric,,,320,RC,75726,HCPCS,Outpatient,,,428.88,214.44,,321.66,75,,,percent of total billed charges,75% of total billed charges,321.66,75,,,percent of total billed charges,75% of total billed charges,4832.22,100,,,Fee Schedule,100% of CMS OPPS Rate,115.28,100,,,Fee Schedule,100% of WV Medicaid Rate,7973.18,165,,,Fee Schedule,165% of CMS OPPS Rate,5008.19,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,13879.91,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,19035.19,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,23843.51,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,115.28,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,4832.22,100,,,Fee Schedule,100% of CMS OPPS Rate,5008.19,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,60.04,14,,,percent of total billed charges,14% of total billed charges,60.04,23843.51,
Peripheral Angio Splenic,,,320,RC,75726,HCPCS,Outpatient,,,428.88,214.44,,321.66,75,,,percent of total billed charges,75% of total billed charges,321.66,75,,,percent of total billed charges,75% of total billed charges,4832.22,100,,,Fee Schedule,100% of CMS OPPS Rate,115.28,100,,,Fee Schedule,100% of WV Medicaid Rate,7973.18,165,,,Fee Schedule,165% of CMS OPPS Rate,5008.19,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,13879.91,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,19035.19,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,23843.51,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,115.28,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,4832.22,100,,,Fee Schedule,100% of CMS OPPS Rate,5008.19,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,60.04,14,,,percent of total billed charges,14% of total billed charges,60.04,23843.51,
75736-Peripheral Angio Iliac,3431959,CDM,320,RC,75736,HCPCS,Outpatient,,,130.07,65.04,,97.55,75,,,percent of total billed charges,75% of total billed charges,97.55,75,,,percent of total billed charges,75% of total billed charges,4832.22,100,,,Fee Schedule,100% of CMS OPPS Rate,93.4,100,,,Fee Schedule,100% of WV Medicaid Rate,7973.18,165,,,Fee Schedule,165% of CMS OPPS Rate,5008.19,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,13879.91,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,19035.19,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,23843.51,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,93.4,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,4832.22,100,,,Fee Schedule,100% of CMS OPPS Rate,5008.19,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,18.21,14,,,percent of total billed charges,14% of total billed charges,18.21,23843.51,
75736-Peripheral Angio Pelvic Selective Supra,3431960,CDM,320,RC,75736,HCPCS,Outpatient,,,101.1,50.55,,75.83,75,,,percent of total billed charges,75% of total billed charges,75.83,75,,,percent of total billed charges,75% of total billed charges,4832.22,100,,,Fee Schedule,100% of CMS OPPS Rate,93.4,100,,,Fee Schedule,100% of WV Medicaid Rate,7973.18,165,,,Fee Schedule,165% of CMS OPPS Rate,5008.19,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,13879.91,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,19035.19,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,23843.51,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,93.4,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,4832.22,100,,,Fee Schedule,100% of CMS OPPS Rate,5008.19,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,14.15,14,,,percent of total billed charges,14% of total billed charges,14.15,23843.51,
Peripheral Angio Iliac,,,320,RC,75736,HCPCS,Outpatient,,,349.99,175,,262.49,75,,,percent of total billed charges,75% of total billed charges,262.49,75,,,percent of total billed charges,75% of total billed charges,4832.22,100,,,Fee Schedule,100% of CMS OPPS Rate,93.4,100,,,Fee Schedule,100% of WV Medicaid Rate,7973.18,165,,,Fee Schedule,165% of CMS OPPS Rate,5008.19,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,13879.91,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,19035.19,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,23843.51,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,93.4,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,4832.22,100,,,Fee Schedule,100% of CMS OPPS Rate,5008.19,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,49,14,,,percent of total billed charges,14% of total billed charges,49,23843.51,
Peripheral Angio Pelvic Selective Supra,,,320,RC,75736,HCPCS,Outpatient,,,349.99,175,,262.49,75,,,percent of total billed charges,75% of total billed charges,262.49,75,,,percent of total billed charges,75% of total billed charges,4832.22,100,,,Fee Schedule,100% of CMS OPPS Rate,93.4,100,,,Fee Schedule,100% of WV Medicaid Rate,7973.18,165,,,Fee Schedule,165% of CMS OPPS Rate,5008.19,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,13879.91,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,19035.19,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,23843.51,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,93.4,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,4832.22,100,,,Fee Schedule,100% of CMS OPPS Rate,5008.19,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,49,14,,,percent of total billed charges,14% of total billed charges,49,23843.51,
75741 - Angiography Pulm Unil Slctv RS&I,4189315,CDM,960,RC,75741,HCPCS,Outpatient,,,292.34,146.17,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
75741-Pulmonary Angiography,3431961,CDM,320,RC,75741,HCPCS,Outpatient,,,150.51,75.26,,112.88,75,,,percent of total billed charges,75% of total billed charges,112.88,75,,,percent of total billed charges,75% of total billed charges,2800.72,100,,,Fee Schedule,100% of CMS OPPS Rate,87.5,100,,,Fee Schedule,100% of WV Medicaid Rate,4621.2,165,,,Fee Schedule,165% of CMS OPPS Rate,2902.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8044.7,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11032.67,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13819.54,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,87.5,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2800.72,100,,,Fee Schedule,100% of CMS OPPS Rate,2902.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,21.07,14,,,percent of total billed charges,14% of total billed charges,21.07,13819.54,
75741-Pulmonary Angiography RT,3431962,CDM,320,RC,75741,HCPCS,Outpatient,,,150.51,75.26,,112.88,75,,,percent of total billed charges,75% of total billed charges,112.88,75,,,percent of total billed charges,75% of total billed charges,2800.72,100,,,Fee Schedule,100% of CMS OPPS Rate,87.5,100,,,Fee Schedule,100% of WV Medicaid Rate,4621.2,165,,,Fee Schedule,165% of CMS OPPS Rate,2902.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8044.7,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11032.67,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13819.54,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,87.5,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2800.72,100,,,Fee Schedule,100% of CMS OPPS Rate,2902.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,21.07,14,,,percent of total billed charges,14% of total billed charges,21.07,13819.54,
Pulmonary Angiography LT,,,320,RC,75741,HCPCS,Outpatient,,,323.6,161.8,,242.7,75,,,percent of total billed charges,75% of total billed charges,242.7,75,,,percent of total billed charges,75% of total billed charges,2800.72,100,,,Fee Schedule,100% of CMS OPPS Rate,87.5,100,,,Fee Schedule,100% of WV Medicaid Rate,4621.2,165,,,Fee Schedule,165% of CMS OPPS Rate,2902.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8044.7,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11032.67,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13819.54,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,87.5,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2800.72,100,,,Fee Schedule,100% of CMS OPPS Rate,2902.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,45.3,14,,,percent of total billed charges,14% of total billed charges,45.3,13819.54,
Pulmonary Angiography RT,,,320,RC,75741,HCPCS,Outpatient,,,323.6,161.8,,242.7,75,,,percent of total billed charges,75% of total billed charges,242.7,75,,,percent of total billed charges,75% of total billed charges,2800.72,100,,,Fee Schedule,100% of CMS OPPS Rate,87.5,100,,,Fee Schedule,100% of WV Medicaid Rate,4621.2,165,,,Fee Schedule,165% of CMS OPPS Rate,2902.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8044.7,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11032.67,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13819.54,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,87.5,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2800.72,100,,,Fee Schedule,100% of CMS OPPS Rate,2902.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,45.3,14,,,percent of total billed charges,14% of total billed charges,45.3,13819.54,
75743-Pulmonary Angiography BILAT,3431963,CDM,320,RC,75743,HCPCS,Outpatient,,,191.45,95.73,,143.59,75,,,percent of total billed charges,75% of total billed charges,143.59,75,,,percent of total billed charges,75% of total billed charges,2800.72,100,,,Fee Schedule,100% of CMS OPPS Rate,100.29,100,,,Fee Schedule,100% of WV Medicaid Rate,4621.2,165,,,Fee Schedule,165% of CMS OPPS Rate,2902.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8044.7,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11032.67,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13819.54,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,100.29,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2800.72,100,,,Fee Schedule,100% of CMS OPPS Rate,2902.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,26.8,14,,,percent of total billed charges,14% of total billed charges,26.8,13819.54,
Pulmonary Angiography BILAT,3427256,CDM,960,RC,75743,HCPCS,Outpatient,,,368.88,184.44,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
75746 - Angrph Pulm Nonslctv Cath/Ven NJX RS&I,4189316,CDM,960,RC,75746,HCPCS,Outpatient,,,297.39,148.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
75746-Pulmonary Angiography Non Selective,3431964,CDM,481,RC,75746,HCPCS,Outpatient,,,131.28,65.64,,98.46,75,,,percent of total billed charges,75% of total billed charges,98.46,75,,,percent of total billed charges,75% of total billed charges,2800.71,100,,,Fee Schedule,100% of CMS OPPS Rate,88.98,100,,,Fee Schedule,100% of WV Medicaid Rate,4621.18,165,,,Fee Schedule,165% of CMS OPPS Rate,2902.7,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8044.7,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11032.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13819.53,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,88.98,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2800.71,100,,,Fee Schedule,100% of CMS OPPS Rate,2902.7,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,18.38,14,,,percent of total billed charges,14% of total billed charges,18.38,13819.53,
Pulmonary Angiography Non Selective,,,320,RC,75746,HCPCS,Outpatient,,,329.98,164.99,,247.49,75,,,percent of total billed charges,75% of total billed charges,247.49,75,,,percent of total billed charges,75% of total billed charges,2800.71,100,,,Fee Schedule,100% of CMS OPPS Rate,88.98,100,,,Fee Schedule,100% of WV Medicaid Rate,4621.18,165,,,Fee Schedule,165% of CMS OPPS Rate,2902.7,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8044.7,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11032.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13819.53,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,88.98,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2800.71,100,,,Fee Schedule,100% of CMS OPPS Rate,2902.7,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,46.2,14,,,percent of total billed charges,14% of total billed charges,46.2,13819.53,
75756 - (26) Artery XR Chest,3899082,CDM,960,RC,75756,HCPCS,Outpatient,,,390.88,195.44,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
75756 - (TC) Artery XR Chest,3899085,CDM,960,RC,75756,HCPCS,Outpatient,,,390.88,195.44,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
"75756 - Angiography, internal mammary, radiological supervision and interpretation",3760901,CDM,983,RC,75756,HCPCS,Outpatient,,,390.88,195.44,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
75774 - Angrph Slctv Ea Vsl Studied After Basic XM RS&I,4201242,CDM,983,RC,75774,HCPCS,Outpatient,,,99,49.5,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
75774-Periph Angio Selec add Visceral,3431965,CDM,320,RC,75774,HCPCS,Outpatient,,,246.09,123.05,,184.57,75,,,percent of total billed charges,75% of total billed charges,184.57,75,,,percent of total billed charges,75% of total billed charges,78.75,32,,,percent of total billed charges,32% of total billed charges,65.63,100,,,Fee Schedule,100% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,65.63,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.45,14,,,percent of total billed charges,14% of total billed charges,34.45,184.57,
Periph Angio Selec add Visceral,,,320,RC,75774,HCPCS,Outpatient,,,240.73,120.37,,180.55,75,,,percent of total billed charges,75% of total billed charges,180.55,75,,,percent of total billed charges,75% of total billed charges,77.03,32,,,percent of total billed charges,32% of total billed charges,65.63,100,,,Fee Schedule,100% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,65.63,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.7,14,,,percent of total billed charges,14% of total billed charges,33.7,180.55,
75820 - Venography Extremity Unilateral RS&I,4201239,CDM,983,RC,75820,HCPCS,Outpatient,,,105.72,52.86,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
75820-Venography Extremity,3431966,CDM,320,RC,75820,HCPCS,Outpatient,,,82.55,41.28,,61.91,75,,,percent of total billed charges,75% of total billed charges,61.91,75,,,percent of total billed charges,75% of total billed charges,1398.82,100,,,Fee Schedule,100% of CMS OPPS Rate,73.98,100,,,Fee Schedule,100% of WV Medicaid Rate,2308.06,165,,,Fee Schedule,165% of CMS OPPS Rate,1449.76,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4017.93,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5510.28,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6902.18,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,73.98,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1398.82,100,,,Fee Schedule,100% of CMS OPPS Rate,1449.76,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,11.56,14,,,percent of total billed charges,14% of total billed charges,11.56,6902.18,
75820-Venography Extremity RT,3431967,CDM,320,RC,75820,HCPCS,Outpatient,,,82.55,41.28,,61.91,75,,,percent of total billed charges,75% of total billed charges,61.91,75,,,percent of total billed charges,75% of total billed charges,1398.82,100,,,Fee Schedule,100% of CMS OPPS Rate,73.98,100,,,Fee Schedule,100% of WV Medicaid Rate,2308.06,165,,,Fee Schedule,165% of CMS OPPS Rate,1449.76,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4017.93,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5510.28,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6902.18,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,73.98,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1398.82,100,,,Fee Schedule,100% of CMS OPPS Rate,1449.76,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,11.56,14,,,percent of total billed charges,14% of total billed charges,11.56,6902.18,
Read,601960,CDM,972,RC,75820,HCPCS,Outpatient,,,107.61,53.81,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
Read,601962,CDM,972,RC,75820,HCPCS,Outpatient,,,107.61,53.81,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
Read,601965,CDM,972,RC,75820,HCPCS,Outpatient,,,107.61,53.81,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
Read,601969,CDM,972,RC,75820,HCPCS,Outpatient,,,107.61,53.81,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
Read,601971,CDM,972,RC,75820,HCPCS,Outpatient,,,107.61,53.81,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
Venogram Arm Lt (Cardiology),,,320,RC,75820,HCPCS,Outpatient,,,269.03,134.52,,201.77,75,,,percent of total billed charges,75% of total billed charges,201.77,75,,,percent of total billed charges,75% of total billed charges,1398.82,100,,,Fee Schedule,100% of CMS OPPS Rate,73.98,100,,,Fee Schedule,100% of WV Medicaid Rate,2308.06,165,,,Fee Schedule,165% of CMS OPPS Rate,1449.76,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4017.93,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5510.28,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6902.18,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,73.98,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1398.82,100,,,Fee Schedule,100% of CMS OPPS Rate,1449.76,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,37.66,14,,,percent of total billed charges,14% of total billed charges,37.66,6902.18,
Venogram Rt. (Cardiology),,,320,RC,75820,HCPCS,Outpatient,,,269.03,134.52,,201.77,75,,,percent of total billed charges,75% of total billed charges,201.77,75,,,percent of total billed charges,75% of total billed charges,1398.82,100,,,Fee Schedule,100% of CMS OPPS Rate,73.98,100,,,Fee Schedule,100% of WV Medicaid Rate,2308.06,165,,,Fee Schedule,165% of CMS OPPS Rate,1449.76,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4017.93,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5510.28,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6902.18,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,73.98,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1398.82,100,,,Fee Schedule,100% of CMS OPPS Rate,1449.76,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,37.66,14,,,percent of total billed charges,14% of total billed charges,37.66,6902.18,
Venography Extremity LT,,,320,RC,75820,HCPCS,Outpatient,,,269.03,134.52,,201.77,75,,,percent of total billed charges,75% of total billed charges,201.77,75,,,percent of total billed charges,75% of total billed charges,1398.82,100,,,Fee Schedule,100% of CMS OPPS Rate,73.98,100,,,Fee Schedule,100% of WV Medicaid Rate,2308.06,165,,,Fee Schedule,165% of CMS OPPS Rate,1449.76,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4017.93,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5510.28,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6902.18,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,73.98,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1398.82,100,,,Fee Schedule,100% of CMS OPPS Rate,1449.76,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,37.66,14,,,percent of total billed charges,14% of total billed charges,37.66,6902.18,
Venography Extremity RT,3427267,CDM,960,RC,75820,HCPCS,Outpatient,,,269.03,134.52,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
"75822 - PF Venography, extremity, bilateral, radiological supervision and interpretation",3761000,CDM,983,RC,75822,HCPCS,Outpatient,,,338.16,169.08,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
"75822 - Venography, extremity, bilateral, radiological supervision and interpretation",3761052,CDM,320,RC,75822,HCPCS,Outpatient,,,338.16,169.08,,253.62,75,,,percent of total billed charges,75% of total billed charges,253.62,75,,,percent of total billed charges,75% of total billed charges,1398.82,100,,,Fee Schedule,100% of CMS OPPS Rate,90.21,100,,,Fee Schedule,100% of WV Medicaid Rate,2308.05,165,,,Fee Schedule,165% of CMS OPPS Rate,1449.76,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4017.93,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5510.28,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6902.18,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,90.21,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1398.82,100,,,Fee Schedule,100% of CMS OPPS Rate,1449.76,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,47.34,14,,,percent of total billed charges,14% of total billed charges,47.34,6902.18,
75822-Venography Extremity BILAT,3431968,CDM,320,RC,75822,HCPCS,Outpatient,,,123.95,61.98,,92.96,75,,,percent of total billed charges,75% of total billed charges,92.96,75,,,percent of total billed charges,75% of total billed charges,1398.82,100,,,Fee Schedule,100% of CMS OPPS Rate,90.21,100,,,Fee Schedule,100% of WV Medicaid Rate,2308.05,165,,,Fee Schedule,165% of CMS OPPS Rate,1449.76,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4017.93,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5510.28,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6902.18,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,90.21,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1398.82,100,,,Fee Schedule,100% of CMS OPPS Rate,1449.76,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,17.35,14,,,percent of total billed charges,14% of total billed charges,17.35,6902.18,
Read,601967,CDM,972,RC,75822,HCPCS,Outpatient,,,132.29,66.15,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
Venogram Arms Bilat (Cardiology),,,320,RC,75822,HCPCS,Outpatient,,,330.72,165.36,,248.04,75,,,percent of total billed charges,75% of total billed charges,248.04,75,,,percent of total billed charges,75% of total billed charges,1398.82,100,,,Fee Schedule,100% of CMS OPPS Rate,90.21,100,,,Fee Schedule,100% of WV Medicaid Rate,2308.05,165,,,Fee Schedule,165% of CMS OPPS Rate,1449.76,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4017.93,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5510.28,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6902.18,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,90.21,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1398.82,100,,,Fee Schedule,100% of CMS OPPS Rate,1449.76,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,46.3,14,,,percent of total billed charges,14% of total billed charges,46.3,6902.18,
Venography Extremity BILAT,,,320,RC,75822,HCPCS,Outpatient,,,330.72,165.36,,248.04,75,,,percent of total billed charges,75% of total billed charges,248.04,75,,,percent of total billed charges,75% of total billed charges,1398.82,100,,,Fee Schedule,100% of CMS OPPS Rate,90.21,100,,,Fee Schedule,100% of WV Medicaid Rate,2308.05,165,,,Fee Schedule,165% of CMS OPPS Rate,1449.76,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4017.93,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5510.28,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6902.18,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,90.21,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1398.82,100,,,Fee Schedule,100% of CMS OPPS Rate,1449.76,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,46.3,14,,,percent of total billed charges,14% of total billed charges,46.3,6902.18,
75825 - Venography caval inferior w/ serial,4241822,CDM,510,RC,75825,HCPCS,Outpatient,,,227.14,113.57,,170.36,75,,,percent of total billed charges,75% of total billed charges,170.36,75,,,percent of total billed charges,75% of total billed charges,2800.72,100,,,Fee Schedule,100% of CMS OPPS Rate,76.94,100,,,Fee Schedule,100% of WV Medicaid Rate,4621.2,165,,,Fee Schedule,165% of CMS OPPS Rate,2902.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8044.7,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11032.67,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13819.54,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,76.94,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2800.72,100,,,Fee Schedule,100% of CMS OPPS Rate,2902.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,31.8,14,,,percent of total billed charges,14% of total billed charges,31.8,13819.54,
75825-Venography Caval Inferior w serial,3431969,CDM,320,RC,75825,HCPCS,Outpatient,,,133.27,66.64,,99.95,75,,,percent of total billed charges,75% of total billed charges,99.95,75,,,percent of total billed charges,75% of total billed charges,2800.72,100,,,Fee Schedule,100% of CMS OPPS Rate,76.94,100,,,Fee Schedule,100% of WV Medicaid Rate,4621.2,165,,,Fee Schedule,165% of CMS OPPS Rate,2902.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8044.7,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11032.67,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13819.54,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,76.94,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2800.72,100,,,Fee Schedule,100% of CMS OPPS Rate,2902.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,18.66,14,,,percent of total billed charges,14% of total billed charges,18.66,13819.54,
Inferior VenaCava Gram (Cardiology),3316227,CDM,960,RC,75825,HCPCS,Outpatient,,,283.92,141.96,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
Read,631581,CDM,972,RC,75825,HCPCS,Outpatient,,,113.57,56.79,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
Venography Caval Inferior w serial,3427269,CDM,960,RC,75825,HCPCS,Outpatient,,,283.92,141.96,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
75827-Venography Caval Sup w Serialography,3431970,CDM,320,RC,75827,HCPCS,Outpatient,,,134.34,67.17,,100.76,75,,,percent of total billed charges,75% of total billed charges,100.76,75,,,percent of total billed charges,75% of total billed charges,1398.82,100,,,Fee Schedule,100% of CMS OPPS Rate,80.62,100,,,Fee Schedule,100% of WV Medicaid Rate,2308.06,165,,,Fee Schedule,165% of CMS OPPS Rate,1449.76,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4017.93,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5510.28,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6902.18,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,80.62,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1398.82,100,,,Fee Schedule,100% of CMS OPPS Rate,1449.76,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,18.81,14,,,percent of total billed charges,14% of total billed charges,18.81,6902.18,
Venography Caval Sup w Serialography,,,320,RC,75827,HCPCS,Outpatient,,,296.27,148.14,,222.2,75,,,percent of total billed charges,75% of total billed charges,222.2,75,,,percent of total billed charges,75% of total billed charges,1398.82,100,,,Fee Schedule,100% of CMS OPPS Rate,80.62,100,,,Fee Schedule,100% of WV Medicaid Rate,2308.06,165,,,Fee Schedule,165% of CMS OPPS Rate,1449.76,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4017.93,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5510.28,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6902.18,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,80.62,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1398.82,100,,,Fee Schedule,100% of CMS OPPS Rate,1449.76,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,41.48,14,,,percent of total billed charges,14% of total billed charges,41.48,6902.18,
"75893-PF Venous sampling through catheter, w/wo angiography",4271259,CDM,960,RC,75893,HCPCS,Outpatient,,,199.32,99.66,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
"75893-Venous sampling through catheter, w/wo angiography",4271258,CDM,481,RC,75893,HCPCS,Outpatient,,,199.32,99.66,,149.49,75,,,percent of total billed charges,75% of total billed charges,149.49,75,,,percent of total billed charges,75% of total billed charges,4832.22,100,,,Fee Schedule,100% of CMS OPPS Rate,67.34,100,,,Fee Schedule,100% of WV Medicaid Rate,7973.18,165,,,Fee Schedule,165% of CMS OPPS Rate,5008.19,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,13879.91,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,19035.19,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,23843.51,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,67.34,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,4832.22,100,,,Fee Schedule,100% of CMS OPPS Rate,5008.19,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,27.9,14,,,percent of total billed charges,14% of total billed charges,27.9,23843.51,
75957-ENDOVASCULAR TAA REPAIR INTERP,3430924,CDM,510,RC,75957,HCPCS,Outpatient,,,1555.02,777.51,,1166.27,75,,,percent of total billed charges,75% of total billed charges,1166.27,75,,,percent of total billed charges,75% of total billed charges,1555.02,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,1555.02,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1555.02,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1555.02,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1555.02,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1555.02,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,1555.02,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1555.02,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,217.7,14,,,percent of total billed charges,14% of total billed charges,217.7,1555.02,
75984-NEPHROSTOMY TUBE CHANGE SUP/INTREP,3431972,CDM,320,RC,75984,HCPCS,Outpatient,,,83.2,41.6,,62.4,75,,,percent of total billed charges,75% of total billed charges,62.4,75,,,percent of total billed charges,75% of total billed charges,26.62,32,,,percent of total billed charges,32% of total billed charges,64.65,100,,,Fee Schedule,100% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.65,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.65,14,,,percent of total billed charges,14% of total billed charges,11.65,64.65,
75984-PF NEPHROSTOMY TUBE CHANGE SUP/INTREP,3580897,CDM,960,RC,75984,HCPCS,Outpatient,,,242.19,121.1,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
DR Cath Exchange,3334388,CDM,320,RC,75984,HCPCS,Outpatient,,,234.68,117.34,,176.01,75,,,percent of total billed charges,75% of total billed charges,176.01,75,,,percent of total billed charges,75% of total billed charges,75.1,32,,,percent of total billed charges,32% of total billed charges,64.65,100,,,Fee Schedule,100% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.65,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.86,14,,,percent of total billed charges,14% of total billed charges,32.86,176.01,
Read,596772,CDM,972,RC,75984,HCPCS,Outpatient,,,93.87,46.94,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
Read,1449207,CDM,972,RC,75984,HCPCS,Outpatient,,,93.87,46.94,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
Fluid Drainage w Tube Placement,3323636,CDM,350,RC,75989,HCPCS,Outpatient,,,279.29,139.65,,209.47,75,,,percent of total billed charges,75% of total billed charges,209.47,75,,,percent of total billed charges,75% of total billed charges,89.37,32,,,percent of total billed charges,32% of total billed charges,77.18,100,,,Fee Schedule,100% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,77.18,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.1,14,,,percent of total billed charges,14% of total billed charges,39.1,209.47,
76000-CARDIAC FLURO,3431973,CDM,320,RC,76000,HCPCS,Outpatient,,,42.4,21.2,,31.8,75,,,percent of total billed charges,75% of total billed charges,31.8,75,,,percent of total billed charges,75% of total billed charges,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,28.51,100,,,Fee Schedule,100% of WV Medicaid Rate,362.24,165,,,Fee Schedule,165% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,630.61,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,864.84,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1083.29,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,28.51,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,5.94,14,,,percent of total billed charges,14% of total billed charges,5.94,1083.29,
Cardiac Fluoro,3348623,CDM,960,RC,76000,HCPCS,Outpatient,,,42.4,21.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
Read,602005,CDM,972,RC,76000,HCPCS,Outpatient,,,42.4,21.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
Read,602029,CDM,972,RC,76000,HCPCS,Outpatient,,,42.4,21.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
Read,602035,CDM,972,RC,76010,HCPCS,Outpatient,,,29,14.5,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
Read,602057,CDM,972,RC,76080,HCPCS,Outpatient,,,59.05,29.53,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
3D TEE Imaging,3569848,CDM,350,RC,76376,HCPCS,Outpatient,,,25.03,12.52,,18.77,75,,,percent of total billed charges,75% of total billed charges,18.77,75,,,percent of total billed charges,75% of total billed charges,8.01,32,,,percent of total billed charges,32% of total billed charges,14.99,100,,,Fee Schedule,100% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.99,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.5,14,,,percent of total billed charges,14% of total billed charges,3.5,18.77,
"76376(26)- 3D rendering with interpretation and reporting of computed tomography, magnetic resonance",3620958,CDM,510,RC,76376,HCPCS,Outpatient,,,25.03,12.52,,18.77,75,,,percent of total billed charges,75% of total billed charges,18.77,75,,,percent of total billed charges,75% of total billed charges,8.01,32,,,percent of total billed charges,32% of total billed charges,14.99,100,,,Fee Schedule,100% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.99,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.5,14,,,percent of total billed charges,14% of total billed charges,3.5,18.77,
76512-PF OPHTHALMIC US DX B-SCAN W/WO NON-QUAN A-SCAN,4321493,CDM,981,RC,76512,HCPCS,Outpatient,,,89.22,44.61,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
76536-PF US SOFT TISSUE HEAD & NECK REAL TIME IMGE DOCM,4321494,CDM,981,RC,76536,HCPCS,Outpatient,,,201.94,100.97,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
76604-PF US CHEST REAL TIME W/IMAGE DOCUMENTATION,4321495,CDM,981,RC,76604,HCPCS,Outpatient,,,106.06,53.03,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
76641 - (26) US Breast Complete,3896985,CDM,960,RC,76641,HCPCS,Outpatient,,,92.11,46.06,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
76642-PF US BREAST UNI REAL TIME WITH IMAGE LIMITED,4321496,CDM,981,RC,76642,HCPCS,Outpatient,,,157.04,78.52,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
Read,596621,CDM,972,RC,76700,HCPCS,Outpatient,,,101.84,50.92,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
Read,3370923,CDM,972,RC,76700,HCPCS,Outpatient,,,101.84,50.92,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
US HKBT Abdomen  Complete:Read,3317830,CDM,983,RC,76700,HCPCS,Outpatient,,,101.84,50.92,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
"76705 (26) Ultrasound, abdominal, real time with image documentation; limited (eg, single organ, qua",3621066,CDM,510,RC,76705,HCPCS,Outpatient,,,75.28,37.64,,56.46,75,,,percent of total billed charges,75% of total billed charges,56.46,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,58.25,100,,,Fee Schedule,100% of WV Medicaid Rate,165.79,165,,,Fee Schedule,165% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.82,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,58.25,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,10.54,14,,,percent of total billed charges,14% of total billed charges,10.54,495.81,
76705-PF US ABDOMINAL REAL TIME W/IMAGE LIMITED,4321499,CDM,981,RC,76705,HCPCS,Outpatient,,,161.44,80.72,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
Read,3351898,CDM,402,RC,76705,HCPCS,Outpatient,,,161.44,80.72,,121.08,75,,,percent of total billed charges,75% of total billed charges,121.08,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,58.25,100,,,Fee Schedule,100% of WV Medicaid Rate,165.79,165,,,Fee Schedule,165% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.82,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,58.25,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,22.6,14,,,percent of total billed charges,14% of total billed charges,22.6,495.81,
Read,3358604,CDM,402,RC,76705,HCPCS,Outpatient,,,161.44,80.72,,121.08,75,,,percent of total billed charges,75% of total billed charges,121.08,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,58.25,100,,,Fee Schedule,100% of WV Medicaid Rate,165.79,165,,,Fee Schedule,165% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.82,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,58.25,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,22.6,14,,,percent of total billed charges,14% of total billed charges,22.6,495.81,
Read,596618,CDM,972,RC,76705,HCPCS,Outpatient,,,130.63,65.32,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
Read,3351918,CDM,972,RC,76705,HCPCS,Outpatient,,,161.44,80.72,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
Read,3351922,CDM,972,RC,76705,HCPCS,Outpatient,,,161.44,80.72,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
US Abdomen Limited,3345544,CDM,402,RC,76705,HCPCS,Outpatient,,,130.63,65.32,,97.97,75,,,percent of total billed charges,75% of total billed charges,97.97,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,58.25,100,,,Fee Schedule,100% of WV Medicaid Rate,165.79,165,,,Fee Schedule,165% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.82,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,58.25,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,18.29,14,,,percent of total billed charges,14% of total billed charges,18.29,495.81,
76775-CL Renal Artery Ultrasound BILAT,3431974,CDM,972,RC,76775,HCPCS,Outpatient,,,130.63,65.32,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
76775-CL Renal Artery Ultrasound LT,3431975,CDM,972,RC,76775,HCPCS,Outpatient,,,130.63,65.32,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
76775-CL Renal Artery Ultrasound RT,3431976,CDM,972,RC,76775,HCPCS,Outpatient,,,130.63,65.32,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
76775PF Us exam abdo back wall lim,4267406,CDM,972,RC,76775,HCPCS,Outpatient,,,130.63,65.32,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
76775-PF US RETROPERITONEAL REAL TIME W/IMAGE LIMITED,4321500,CDM,981,RC,76775,HCPCS,Outpatient,,,110.04,55.02,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
US Retroperitoneal Organs Limited,1225055,CDM,402,RC,76775,HCPCS,Outpatient,,,130.63,65.32,,97.97,75,,,percent of total billed charges,75% of total billed charges,97.97,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,38.84,100,,,Fee Schedule,100% of WV Medicaid Rate,165.8,165,,,Fee Schedule,165% of CMS OPPS Rate,104.14,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.83,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,38.84,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.14,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,18.29,14,,,percent of total billed charges,14% of total billed charges,18.29,495.81,
76815-PF US PREGNANT UTERUS LIMITED 1/> FETUSES,4321501,CDM,981,RC,76815,HCPCS,Outpatient,,,150.34,75.17,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
76817-PF US PREG UTERUS REAL TIME W/IMAGE DCMTN TRANSVAG,4321502,CDM,981,RC,76817,HCPCS,Outpatient,,,171.12,85.56,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
76830-PF US TRANSVAGINAL,4321505,CDM,981,RC,76830,HCPCS,Outpatient,,,218.34,109.17,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
76870PF Us exam scrotum,4267407,CDM,972,RC,76870,HCPCS,Outpatient,,,219.21,109.61,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
76882-PF US LMTD JT/FCL EVAL NONVASC XTR STRUX R-T W/IMG,4321506,CDM,981,RC,76882,HCPCS,Outpatient,,,81.36,40.68,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
76937-PF Ultrasound Guided Access,3580899,CDM,960,RC,76937,HCPCS,Outpatient,,,96.94,48.47,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
76937-PF US Guided Access,3580898,CDM,960,RC,76937,HCPCS,Outpatient,,,96.94,48.47,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
76937-PF US VASC ACCESS SITS VSL PATENCY NDL ENTRY,4321507,CDM,981,RC,76937,HCPCS,Outpatient,,,72.72,36.36,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
76937-Ultrasound Guided Access,3560636,CDM,402,RC,76937,HCPCS,Outpatient,,,34.45,17.23,,25.84,75,,,percent of total billed charges,75% of total billed charges,25.84,75,,,percent of total billed charges,75% of total billed charges,11.02,32,,,percent of total billed charges,32% of total billed charges,25.81,100,,,Fee Schedule,100% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.81,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.82,14,,,percent of total billed charges,14% of total billed charges,4.82,25.84,
76937-US Guided Access,3552626,CDM,402,RC,76937,HCPCS,Outpatient,,,34.45,17.23,,25.84,75,,,percent of total billed charges,75% of total billed charges,25.84,75,,,percent of total billed charges,75% of total billed charges,11.02,32,,,percent of total billed charges,32% of total billed charges,25.81,100,,,Fee Schedule,100% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.81,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.82,14,,,percent of total billed charges,14% of total billed charges,4.82,25.84,
"76942 (TC) - Ultrasonic guidance for needle placement (eg, biopsy, aspiration, injection, localizati",3676898,CDM,402,RC,76942,HCPCS,Outpatient,,,144.64,72.32,,108.48,75,,,percent of total billed charges,75% of total billed charges,108.48,75,,,percent of total billed charges,75% of total billed charges,46.28,32,,,percent of total billed charges,32% of total billed charges,39.08,100,,,Fee Schedule,100% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.08,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.25,14,,,percent of total billed charges,14% of total billed charges,20.25,108.48,
"76942- Ultrasonic guidance for needle placement (eg, biopsy, aspiration, injection, localizati",3676897,CDM,402,RC,76942,HCPCS,Outpatient,,,81.09,40.55,,60.82,75,,,percent of total billed charges,75% of total billed charges,60.82,75,,,percent of total billed charges,75% of total billed charges,25.95,32,,,percent of total billed charges,32% of total billed charges,39.08,100,,,Fee Schedule,100% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.08,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.35,14,,,percent of total billed charges,14% of total billed charges,11.35,60.82,
Read,3370937,CDM,972,RC,76942,HCPCS,Outpatient,,,57.85,28.93,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
Read,3370947,CDM,972,RC,76942,HCPCS,Outpatient,,,57.85,28.93,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
Read,3575235,CDM,972,RC,76942,HCPCS,Outpatient,,,129.6,64.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
Read,3575237,CDM,972,RC,76942,HCPCS,Outpatient,,,129.6,64.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
Read,3575241,CDM,972,RC,76942,HCPCS,Outpatient,,,129.6,64.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
Read,3575273,CDM,972,RC,76942,HCPCS,Outpatient,,,129.6,64.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
Read,3575291,CDM,972,RC,76942,HCPCS,Outpatient,,,129.6,64.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
Read,3575293,CDM,972,RC,76942,HCPCS,Outpatient,,,129.6,64.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
Read,3575313,CDM,972,RC,76942,HCPCS,Outpatient,,,129.6,64.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
Read,3575339,CDM,972,RC,76942,HCPCS,Outpatient,,,129.6,64.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
Read,3749005,CDM,972,RC,76942,HCPCS,Outpatient,,,57.85,28.93,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
Read,3997155,CDM,972,RC,76942,HCPCS,Outpatient,,,129.6,64.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
Read,3997157,CDM,972,RC,76942,HCPCS,Outpatient,,,129.6,64.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
Read,3749007,CDM,402,RC,76942,HCPCS,Outpatient,,,129.6,64.8,,97.2,75,,,percent of total billed charges,75% of total billed charges,97.2,75,,,percent of total billed charges,75% of total billed charges,41.47,32,,,percent of total billed charges,32% of total billed charges,39.08,100,,,Fee Schedule,100% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.08,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.14,14,,,percent of total billed charges,14% of total billed charges,18.14,97.2,
Ultrasound Guided Access,3427174,CDM,972,RC,76942,HCPCS,Outpatient,,,129.6,64.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
US Guidance Aspiration Bx or Injection:Read,596563,CDM,972,RC,76942,HCPCS,Outpatient,,,129.6,64.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
"US Guide for BX, Cyst asp, inject,loc",630214,CDM,402,RC,76942,HCPCS,Outpatient,,,129.6,64.8,,97.2,75,,,percent of total billed charges,75% of total billed charges,97.2,75,,,percent of total billed charges,75% of total billed charges,41.47,32,,,percent of total billed charges,32% of total billed charges,39.08,100,,,Fee Schedule,100% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.08,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.14,14,,,percent of total billed charges,14% of total billed charges,18.14,97.2,
76946- Echo guide for amniocentesis,3430620,CDM,510,RC,76946,HCPCS,Outpatient,,,80.6,40.3,,60.45,75,,,percent of total billed charges,75% of total billed charges,60.45,75,,,percent of total billed charges,75% of total billed charges,25.79,32,,,percent of total billed charges,32% of total billed charges,21.38,100,,,Fee Schedule,100% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.38,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.28,14,,,percent of total billed charges,14% of total billed charges,11.28,60.45,
Read,1980101,CDM,972,RC,76946,HCPCS,Outpatient,,,32.48,16.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
76965 (26) Ultrasonic guidance for interstitial radioelement application,3621073,CDM,510,RC,76965,HCPCS,Outpatient,,,172.75,86.38,,129.56,75,,,percent of total billed charges,75% of total billed charges,129.56,75,,,percent of total billed charges,75% of total billed charges,55.28,32,,,percent of total billed charges,32% of total billed charges,62.68,100,,,Fee Schedule,100% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62.68,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.19,14,,,percent of total billed charges,14% of total billed charges,24.19,129.56,
"76998 -PF Ultrasonic Guidance, Intraoperative",4349188,CDM,983,RC,76998,HCPCS,Outpatient,,,91.06,45.53,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
"77001 (26) Fluoroscopic guidance for central venous access device placement, replacement (catheter o",3620979,CDM,510,RC,77001,HCPCS,Outpatient,,,48.86,24.43,,36.65,75,,,percent of total billed charges,75% of total billed charges,36.65,75,,,percent of total billed charges,75% of total billed charges,15.64,32,,,percent of total billed charges,32% of total billed charges,48.86,100,,,Fee Schedule,100% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.86,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.84,14,,,percent of total billed charges,14% of total billed charges,6.84,48.86,
"77001 Fluoroscopic guidance for central venous access device placement, replacement (catheter only o",3620980,CDM,510,RC,77001,HCPCS,Outpatient,,,249.74,124.87,,187.31,75,,,percent of total billed charges,75% of total billed charges,187.31,75,,,percent of total billed charges,75% of total billed charges,79.92,32,,,percent of total billed charges,32% of total billed charges,66.61,100,,,Fee Schedule,100% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.61,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.96,14,,,percent of total billed charges,14% of total billed charges,34.96,187.31,
"77001-Add On Code: Fluoro guidance with a central venous catheter insert, replacement, removal",4331251,CDM,481,RC,77001,HCPCS,Outpatient,,,48.86,24.43,,36.65,75,,,percent of total billed charges,75% of total billed charges,36.65,75,,,percent of total billed charges,75% of total billed charges,15.64,32,,,percent of total billed charges,32% of total billed charges,48.86,100,,,Fee Schedule,100% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.86,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.84,14,,,percent of total billed charges,14% of total billed charges,6.84,48.86,
"77001-PF Add On Code: Fluoro guidance with a central venous catheter insert, replacement, removal",4331252,CDM,960,RC,77001,HCPCS,Outpatient,,,48.86,24.43,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
77001-PF Fluoro Central Venous Access Dev Plcmnt,4322120,CDM,960,RC,77001,HCPCS,Outpatient,,,34.58,17.29,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
"Add On Code: Fluoro guidance with a central venous catheter insert, replacement, removal",,,320,RC,77001,HCPCS,Outpatient,,,48.86,24.43,,36.65,75,,,percent of total billed charges,75% of total billed charges,36.65,75,,,percent of total billed charges,75% of total billed charges,15.64,32,,,percent of total billed charges,32% of total billed charges,48.86,100,,,Fee Schedule,100% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.86,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.84,14,,,percent of total billed charges,14% of total billed charges,6.84,48.86,
DR Central Venous Placement,655838,CDM,320,RC,77001,HCPCS,Outpatient,,,239.83,119.92,,179.87,75,,,percent of total billed charges,75% of total billed charges,179.87,75,,,percent of total billed charges,75% of total billed charges,76.75,32,,,percent of total billed charges,32% of total billed charges,66.61,100,,,Fee Schedule,100% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.61,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.58,14,,,percent of total billed charges,14% of total billed charges,33.58,179.87,
Read,2960105,CDM,972,RC,77001,HCPCS,Outpatient,,,95.93,47.97,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
Read,3370935,CDM,972,RC,77001,HCPCS,Outpatient,,,95.93,47.97,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
Read,3575271,CDM,972,RC,77001,HCPCS,Outpatient,,,95.93,47.97,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
DR Fluoro Guidance Non-Spine,3318488,CDM,320,RC,77002,HCPCS,Outpatient,,,278.92,139.46,,209.19,75,,,percent of total billed charges,75% of total billed charges,209.19,75,,,percent of total billed charges,75% of total billed charges,89.25,32,,,percent of total billed charges,32% of total billed charges,75.95,100,,,Fee Schedule,100% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,75.95,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.05,14,,,percent of total billed charges,14% of total billed charges,39.05,209.19,
Read,3351618,CDM,972,RC,77002,HCPCS,Outpatient,,,111.57,55.79,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
Read,3351620,CDM,972,RC,77002,HCPCS,Outpatient,,,111.57,55.79,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
Read,3351886,CDM,972,RC,77002,HCPCS,Outpatient,,,111.57,55.79,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
Read,3351888,CDM,972,RC,77002,HCPCS,Outpatient,,,111.57,55.79,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
77013-PF CT Guide/Mon  for Tiss Abl,4322121,CDM,960,RC,77013,HCPCS,Outpatient,,,346.92,173.46,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
77014-COMPUTED TOMOGRAPHY GUID PLACEMENT,3424707,CDM,983,RC,77014,HCPCS,Outpatient,,,105.66,52.83,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
Read,1551103,CDM,972,RC,77021,HCPCS,Outpatient,,,406.12,203.06,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
GYN VFA with DEXA:Read,3576812,CDM,972,RC,77085,HCPCS,Outpatient,,,123.79,61.9,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
Read,3575425,CDM,972,RC,77086,HCPCS,Outpatient,,,79.44,39.72,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
77263-RADIATION THERAPY PLANNING,3400483,CDM,983,RC,77263,HCPCS,Outpatient,,,357.69,178.85,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
77280-SET RADIATION THERAPY FIELD SIMPLE Profee,3565220,CDM,983,RC,77280,HCPCS,Outpatient,,,86.67,43.34,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
77285-SET RADIATION THERAPY FIELD INTERMEDIATE Profee,3571478,CDM,983,RC,77285,HCPCS,Outpatient,,,1054.74,527.37,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
77290-SET RADIATION THERAPY FIELD COMPLEX Profee,3565221,CDM,983,RC,77290,HCPCS,Outpatient,,,194.7,97.35,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
77293-RESPIRATOR MOTION MGMT SIMUL Profee,3565222,CDM,983,RC,77293,HCPCS,Outpatient,,,249.31,124.66,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
77295-3D TREATMENT COMP DOSIMETRY Profee,3565223,CDM,983,RC,77295,HCPCS,Outpatient,,,531.87,265.94,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
77300-RADIATION THERAPY DOSE PLAN Profee,3565225,CDM,983,RC,77300,HCPCS,Outpatient,,,78.36,39.18,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
77301-RADIOTHERAPY DOSE PLAN IMRT Profee,3565226,CDM,983,RC,77301,HCPCS,Outpatient,,,991.31,495.66,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
77307-(26) TELETHX ISODOSE PLAN CPLX Profee,3565228,CDM,983,RC,77307,HCPCS,Outpatient,,,359.72,179.86,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
77316 - (26) Brachytx Isodose Plan Simple,3898893,CDM,960,RC,77316,HCPCS,Outpatient,,,188.84,94.42,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
77316 - Brachytx Isodose Plan Simple,3898907,CDM,960,RC,77316,HCPCS,Outpatient,,,188.84,94.42,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
77316-(26)-BRACHYTX ISODOSE PLAN SIMPLE,3537568,CDM,333,RC,77316,HCPCS,Outpatient,,,168.58,84.29,,126.44,75,,,percent of total billed charges,75% of total billed charges,126.44,75,,,percent of total billed charges,75% of total billed charges,337.24,100,,,Fee Schedule,100% of CMS OPPS Rate,155.59,100,,,Fee Schedule,100% of WV Medicaid Rate,556.45,165,,,Fee Schedule,165% of CMS OPPS Rate,349.52,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,968.72,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1328.52,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1664.11,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,155.59,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,337.24,100,,,Fee Schedule,100% of CMS OPPS Rate,349.52,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,23.6,14,,,percent of total billed charges,14% of total billed charges,23.6,1664.11,
77317 - (26) Brachytx Isodose Intermed,3898913,CDM,960,RC,77317,HCPCS,Outpatient,,,249.1,124.55,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
77317 - Brachytx Isodose Intermed,3898927,CDM,960,RC,77317,HCPCS,Outpatient,,,249.1,124.55,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
77318 - (26) Bractx Isodose Complex,3898933,CDM,960,RC,77318,HCPCS,Outpatient,,,391.94,195.97,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
77318 - Bractx Isodose Complex,3898947,CDM,960,RC,77318,HCPCS,Outpatient,,,391.94,195.97,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
77321-SPECIAL TELETX PORT PLAN Profee,3565229,CDM,983,RC,77321,HCPCS,Outpatient,,,118.72,59.36,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
77331-SPECIAL RADIATION DOSIMETRY,3400452,CDM,333,RC,77331,HCPCS,Outpatient,,,161.81,80.91,,121.36,75,,,percent of total billed charges,75% of total billed charges,121.36,75,,,percent of total billed charges,75% of total billed charges,125.39,100,,,Fee Schedule,100% of CMS OPPS Rate,43.26,100,,,Fee Schedule,100% of WV Medicaid Rate,206.89,165,,,Fee Schedule,165% of CMS OPPS Rate,129.96,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,360.18,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,493.97,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,618.74,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,43.26,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,125.39,100,,,Fee Schedule,100% of CMS OPPS Rate,129.96,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,22.65,14,,,percent of total billed charges,14% of total billed charges,22.65,618.74,
77331-SPECIAL RADIATION DOSIMETRY Profee,3565230,CDM,983,RC,77331,HCPCS,Outpatient,,,109.22,54.61,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
77332-RADIATION TREATMENT AID(S) SIMPLE,3400453,CDM,333,RC,77332,HCPCS,Outpatient,,,94.8,47.4,,71.1,75,,,percent of total billed charges,75% of total billed charges,71.1,75,,,percent of total billed charges,75% of total billed charges,125.39,100,,,Fee Schedule,100% of CMS OPPS Rate,25.81,100,,,Fee Schedule,100% of WV Medicaid Rate,206.89,165,,,Fee Schedule,165% of CMS OPPS Rate,129.96,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,360.18,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,493.97,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,618.74,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,25.81,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,125.39,100,,,Fee Schedule,100% of CMS OPPS Rate,129.96,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,13.27,14,,,percent of total billed charges,14% of total billed charges,13.27,618.74,
77332-RADIATION TREATMENT AID(S) SIMPLE Profee,3565231,CDM,983,RC,77332,HCPCS,Outpatient,,,67.67,33.84,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
77333-RADIATION TREAT AID(S) INTERMEDIATE Profee,3565232,CDM,983,RC,77333,HCPCS,Outpatient,,,104.47,52.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
77334-RADIATION TREATMENT AID(S) COMPLEX Profee,3565233,CDM,983,RC,77334,HCPCS,Outpatient,,,154.34,77.17,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
77338-DESIGN MIC DEVICE FOR IMRT Profee,3565234,CDM,983,RC,77338,HCPCS,Outpatient,,,531.87,265.94,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
Hospital Outpatient Clinic Visit,3400485,CDM,510,RC,77427,HCPCS,Outpatient,,,445.2,222.6,,333.9,75,,,percent of total billed charges,75% of total billed charges,333.9,75,,,percent of total billed charges,75% of total billed charges,142.46,32,,,percent of total billed charges,32% of total billed charges,131.26,100,,,Fee Schedule,100% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,131.26,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62.33,14,,,percent of total billed charges,14% of total billed charges,62.33,333.9,
77431-TREATMENT MANAGEMENT 1-2 FRACTIONS,3400486,CDM,983,RC,77431,HCPCS,Outpatient,,,244.56,122.28,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
77432-Sterotactic Radiation Treatment,4169511,CDM,333,RC,77432,HCPCS,Outpatient,,,1097.63,548.82,,823.22,75,,,percent of total billed charges,75% of total billed charges,823.22,75,,,percent of total billed charges,75% of total billed charges,351.24,32,,,percent of total billed charges,32% of total billed charges,294.7,100,,,Fee Schedule,100% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,294.7,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,153.67,14,,,percent of total billed charges,14% of total billed charges,153.67,823.22,
77435-SBRT MANAGEMENT Profee,3565384,CDM,983,RC,77435,HCPCS,Outpatient,,,1521.99,761,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
77470-SPECIAL RAD TREATMENT Profee,3565553,CDM,983,RC,77470,HCPCS,Outpatient,,,303.92,151.96,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
77470-SPECIAL RAD TREATMENT READ Profee,3565554,CDM,983,RC,77470,HCPCS,Outpatient,,,250.5,125.25,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
77770 - (26) Remote afterloading high dose rate radionuclide,3938961,CDM,333,RC,77770,HCPCS,Outpatient,,,264.86,132.43,,198.65,75,,,percent of total billed charges,75% of total billed charges,198.65,75,,,percent of total billed charges,75% of total billed charges,678.53,100,,,Fee Schedule,100% of CMS OPPS Rate,222.45,100,,,Fee Schedule,100% of WV Medicaid Rate,1119.56,165,,,Fee Schedule,165% of CMS OPPS Rate,703.23,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1948.99,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2672.9,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,3348.08,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,222.45,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,678.53,100,,,Fee Schedule,100% of CMS OPPS Rate,703.23,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,37.08,14,,,percent of total billed charges,14% of total billed charges,37.08,3348.08,
77770-HDR Rdncl Ntrstl/Icav Brchtx - Pro Fee,4169514,CDM,983,RC,77770,HCPCS,Outpatient,,,236.49,118.25,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
77771 - (26) Remote afterloading high dose rate radionuclide,3938958,CDM,342,RC,77771,HCPCS,Outpatient,,,511.39,255.7,,383.54,75,,,percent of total billed charges,75% of total billed charges,383.54,75,,,percent of total billed charges,75% of total billed charges,678.53,100,,,Fee Schedule,100% of CMS OPPS Rate,383.94,100,,,Fee Schedule,100% of WV Medicaid Rate,1119.56,165,,,Fee Schedule,165% of CMS OPPS Rate,703.23,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1948.99,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2672.9,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,3348.08,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,383.94,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,678.53,100,,,Fee Schedule,100% of CMS OPPS Rate,703.23,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,71.59,14,,,percent of total billed charges,14% of total billed charges,71.59,3348.08,
77771-HDR Rdncl Ntrstl/Icav Brchtx 2-12 Chnl - Pro Fee,4169515,CDM,983,RC,77771,HCPCS,Outpatient,,,456.6,228.3,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
77772-HDR RDNCL NTRSTL/ICAV BRCHTX < 12,3537578,CDM,342,RC,77772,HCPCS,Outpatient,,,2147.98,1073.99,,1610.99,75,,,percent of total billed charges,75% of total billed charges,1610.99,75,,,percent of total billed charges,75% of total billed charges,678.53,100,,,Fee Schedule,100% of CMS OPPS Rate,570.26,100,,,Fee Schedule,100% of WV Medicaid Rate,1119.56,165,,,Fee Schedule,165% of CMS OPPS Rate,703.23,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1948.99,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2672.9,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,3348.08,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,570.26,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,678.53,100,,,Fee Schedule,100% of CMS OPPS Rate,703.23,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,300.72,14,,,percent of total billed charges,14% of total billed charges,300.72,3348.08,
NM Brachytherapy Seed Implant,671978,CDM,342,RC,77778,HCPCS,Outpatient,,,2234.19,1117.1,,1675.64,75,,,percent of total billed charges,75% of total billed charges,1675.64,75,,,percent of total billed charges,75% of total billed charges,678.53,100,,,Fee Schedule,100% of CMS OPPS Rate,591.89,100,,,Fee Schedule,100% of WV Medicaid Rate,1119.56,165,,,Fee Schedule,165% of CMS OPPS Rate,703.23,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1948.99,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2672.9,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,3348.08,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,591.89,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,678.53,100,,,Fee Schedule,100% of CMS OPPS Rate,703.23,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,312.79,14,,,percent of total billed charges,14% of total billed charges,312.79,3348.08,
77790-RADIATION HANDLING,3537579,CDM,342,RC,77790,HCPCS,Outpatient,,,40.89,20.45,,30.67,75,,,percent of total billed charges,75% of total billed charges,30.67,75,,,percent of total billed charges,75% of total billed charges,13.08,32,,,percent of total billed charges,32% of total billed charges,9.83,100,,,Fee Schedule,100% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.83,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.72,14,,,percent of total billed charges,14% of total billed charges,5.72,30.67,
NM Cardiac Shunt Study:Read,597279,CDM,972,RC,78428,HCPCS,Outpatient,,,435.14,217.57,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
78451 - (26) Myocardial Spect SNGL Study at Rest or Stress,3899086,CDM,960,RC,78451,HCPCS,Outpatient,,,781.58,390.79,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
78451 - Myocardial Spect SNGL Study at Rest or Stress,3899088,CDM,960,RC,78451,HCPCS,Outpatient,,,781.58,390.79,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
NM Myocardial Rest or Stress Spect,603532,CDM,340,RC,78451,HCPCS,Outpatient,,,750.09,375.05,,562.57,75,,,percent of total billed charges,75% of total billed charges,562.57,75,,,percent of total billed charges,75% of total billed charges,1247.84,100,,,Fee Schedule,100% of CMS OPPS Rate,208.68,100,,,Fee Schedule,100% of WV Medicaid Rate,2058.94,165,,,Fee Schedule,165% of CMS OPPS Rate,1293.28,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,3584.29,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,4915.56,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6157.24,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,208.68,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1247.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1293.28,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,105.01,14,,,percent of total billed charges,14% of total billed charges,105.01,6157.24,
78452 Ht muscle image spect mult,3428339,CDM,983,RC,78452,HCPCS,Outpatient,,,150.92,75.46,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
78452-NM Myocardial EF Rest Stress Spect Add-on,4263188,CDM,340,RC,78452,HCPCS,Outpatient,,,150.92,75.46,,113.19,75,,,percent of total billed charges,75% of total billed charges,113.19,75,,,percent of total billed charges,75% of total billed charges,1247.84,100,,,Fee Schedule,100% of CMS OPPS Rate,150.92,100,,,Fee Schedule,100% of WV Medicaid Rate,2058.94,165,,,Fee Schedule,165% of CMS OPPS Rate,1293.28,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,3584.29,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,4915.56,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6157.24,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,150.92,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1247.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1293.28,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,21.13,14,,,percent of total billed charges,14% of total billed charges,21.13,6157.24,
NM Myocardial EF Rest Stress Spect,603531,CDM,340,RC,78452,HCPCS,Outpatient,,,150.92,75.46,,113.19,75,,,percent of total billed charges,75% of total billed charges,113.19,75,,,percent of total billed charges,75% of total billed charges,1247.84,100,,,Fee Schedule,100% of CMS OPPS Rate,150.92,100,,,Fee Schedule,100% of WV Medicaid Rate,2058.94,165,,,Fee Schedule,165% of CMS OPPS Rate,1293.28,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,3584.29,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,4915.56,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6157.24,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,150.92,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1247.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1293.28,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,21.13,14,,,percent of total billed charges,14% of total billed charges,21.13,6157.24,
78466 - (26) MYOCARDIAL IMAGING INFARCT AVID PLANAR QUAL/QUA,3997214,CDM,960,RC,78466,HCPCS,Outpatient,,,448.18,224.09,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
Read,3348398,CDM,972,RC,78466,HCPCS,Outpatient,,,165.58,82.79,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
NM Cardiac Eject Fract 1st pass rest,603526,CDM,340,RC,78468,HCPCS,Outpatient,,,435.45,217.73,,326.59,75,,,percent of total billed charges,75% of total billed charges,326.59,75,,,percent of total billed charges,75% of total billed charges,474.31,100,,,Fee Schedule,100% of CMS OPPS Rate,121.43,100,,,Fee Schedule,100% of WV Medicaid Rate,782.61,165,,,Fee Schedule,165% of CMS OPPS Rate,491.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1362.39,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1868.42,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,2340.39,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,121.43,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,474.31,100,,,Fee Schedule,100% of CMS OPPS Rate,491.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,60.96,14,,,percent of total billed charges,14% of total billed charges,60.96,2340.39,
NM Tomo SPECT w/wo quantification,4061197,CDM,340,RC,78468,HCPCS,Outpatient,,,435.45,217.73,,326.59,75,,,percent of total billed charges,75% of total billed charges,326.59,75,,,percent of total billed charges,75% of total billed charges,474.31,100,,,Fee Schedule,100% of CMS OPPS Rate,121.43,100,,,Fee Schedule,100% of WV Medicaid Rate,782.61,165,,,Fee Schedule,165% of CMS OPPS Rate,491.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1362.39,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1868.42,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,2340.39,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,121.43,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,474.31,100,,,Fee Schedule,100% of CMS OPPS Rate,491.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,60.96,14,,,percent of total billed charges,14% of total billed charges,60.96,2340.39,
NM Cardiac Wall Motion Study,645957,CDM,340,RC,78472,HCPCS,Outpatient,,,507.19,253.6,,380.39,75,,,percent of total billed charges,75% of total billed charges,380.39,75,,,percent of total billed charges,75% of total billed charges,365.42,100,,,Fee Schedule,100% of CMS OPPS Rate,140.84,100,,,Fee Schedule,100% of WV Medicaid Rate,602.94,165,,,Fee Schedule,165% of CMS OPPS Rate,378.72,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1049.61,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1439.48,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1803.09,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,140.84,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,365.42,100,,,Fee Schedule,100% of CMS OPPS Rate,378.72,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,71.01,14,,,percent of total billed charges,14% of total billed charges,71.01,1803.09,
NM Lung Scan Perfusion,603570,CDM,340,RC,78580,HCPCS,Outpatient,,,523.48,261.74,,392.61,75,,,percent of total billed charges,75% of total billed charges,392.61,75,,,percent of total billed charges,75% of total billed charges,365.42,100,,,Fee Schedule,100% of CMS OPPS Rate,144.78,100,,,Fee Schedule,100% of WV Medicaid Rate,602.94,165,,,Fee Schedule,165% of CMS OPPS Rate,378.72,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1049.61,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1439.48,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1803.09,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,144.78,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,365.42,100,,,Fee Schedule,100% of CMS OPPS Rate,378.72,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,73.29,14,,,percent of total billed charges,14% of total billed charges,73.29,1803.09,
NM Lung Scan Perf and Vent,603567,CDM,340,RC,78582,HCPCS,Outpatient,,,731.51,365.76,,548.63,75,,,percent of total billed charges,75% of total billed charges,548.63,75,,,percent of total billed charges,75% of total billed charges,474.31,100,,,Fee Schedule,100% of CMS OPPS Rate,203.03,100,,,Fee Schedule,100% of WV Medicaid Rate,782.61,165,,,Fee Schedule,165% of CMS OPPS Rate,491.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1362.39,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1868.42,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,2340.39,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,203.03,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,474.31,100,,,Fee Schedule,100% of CMS OPPS Rate,491.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,102.41,14,,,percent of total billed charges,14% of total billed charges,102.41,2340.39,
NM Lung Differential Scan,603569,CDM,340,RC,78597,HCPCS,Outpatient,,,447.14,223.57,,335.36,75,,,percent of total billed charges,75% of total billed charges,335.36,75,,,percent of total billed charges,75% of total billed charges,365.42,100,,,Fee Schedule,100% of CMS OPPS Rate,123.39,100,,,Fee Schedule,100% of WV Medicaid Rate,602.94,165,,,Fee Schedule,165% of CMS OPPS Rate,378.72,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1049.61,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1439.48,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1803.09,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,123.39,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,365.42,100,,,Fee Schedule,100% of CMS OPPS Rate,378.72,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,62.6,14,,,percent of total billed charges,14% of total billed charges,62.6,1803.09,
NM Lung Differential Scan Vent & Pref,603572,CDM,340,RC,78598,HCPCS,Outpatient,,,665.42,332.71,,499.07,75,,,percent of total billed charges,75% of total billed charges,499.07,75,,,percent of total billed charges,75% of total billed charges,474.31,100,,,Fee Schedule,100% of CMS OPPS Rate,185.09,100,,,Fee Schedule,100% of WV Medicaid Rate,782.61,165,,,Fee Schedule,165% of CMS OPPS Rate,491.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1362.39,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1868.42,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,2340.39,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,185.09,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,474.31,100,,,Fee Schedule,100% of CMS OPPS Rate,491.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,93.16,14,,,percent of total billed charges,14% of total billed charges,93.16,2340.39,
NM Renal Scan with Diuretic,603516,CDM,340,RC,78708,HCPCS,Outpatient,,,419.71,209.86,,314.78,75,,,percent of total billed charges,75% of total billed charges,314.78,75,,,percent of total billed charges,75% of total billed charges,474.31,100,,,Fee Schedule,100% of CMS OPPS Rate,114.3,100,,,Fee Schedule,100% of WV Medicaid Rate,782.61,165,,,Fee Schedule,165% of CMS OPPS Rate,491.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1362.39,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1868.42,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,2340.39,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,114.3,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,474.31,100,,,Fee Schedule,100% of CMS OPPS Rate,491.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,58.76,14,,,percent of total billed charges,14% of total billed charges,58.76,2340.39,
Read,597089,CDM,972,RC,78740,HCPCS,Outpatient,,,192.18,96.09,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
NM PYP no spect,3697192,CDM,341,RC,78800,HCPCS,Outpatient,,,555.44,277.72,,416.58,75,,,percent of total billed charges,75% of total billed charges,416.58,75,,,percent of total billed charges,75% of total billed charges,365.42,100,,,Fee Schedule,100% of CMS OPPS Rate,154.61,100,,,Fee Schedule,100% of WV Medicaid Rate,602.94,165,,,Fee Schedule,165% of CMS OPPS Rate,378.72,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1049.61,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1439.48,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1803.09,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,154.61,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,365.42,100,,,Fee Schedule,100% of CMS OPPS Rate,378.72,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,77.76,14,,,percent of total billed charges,14% of total billed charges,77.76,1803.09,
NM Breast Whole Body,603536,CDM,340,RC,78802,HCPCS,Outpatient,,,680.23,340.12,,510.17,75,,,percent of total billed charges,75% of total billed charges,510.17,75,,,percent of total billed charges,75% of total billed charges,1247.84,100,,,Fee Schedule,100% of CMS OPPS Rate,189.02,100,,,Fee Schedule,100% of WV Medicaid Rate,2058.94,165,,,Fee Schedule,165% of CMS OPPS Rate,1293.28,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,3584.29,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,4915.56,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6157.24,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,189.02,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1247.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1293.28,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,95.23,14,,,percent of total billed charges,14% of total billed charges,95.23,6157.24,
NM Tumor Loc Whole Body:NM Tumor Loc Whole Body,603544,CDM,340,RC,78802,HCPCS,Outpatient,,,680.23,340.12,,510.17,75,,,percent of total billed charges,75% of total billed charges,510.17,75,,,percent of total billed charges,75% of total billed charges,1247.84,100,,,Fee Schedule,100% of CMS OPPS Rate,189.02,100,,,Fee Schedule,100% of WV Medicaid Rate,2058.94,165,,,Fee Schedule,165% of CMS OPPS Rate,1293.28,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,3584.29,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,4915.56,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6157.24,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,189.02,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1247.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1293.28,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,95.23,14,,,percent of total billed charges,14% of total billed charges,95.23,6157.24,
NM WBC Imaging Whole Body,603546,CDM,340,RC,78802,HCPCS,Outpatient,,,680.23,340.12,,510.17,75,,,percent of total billed charges,75% of total billed charges,510.17,75,,,percent of total billed charges,75% of total billed charges,1247.84,100,,,Fee Schedule,100% of CMS OPPS Rate,189.02,100,,,Fee Schedule,100% of WV Medicaid Rate,2058.94,165,,,Fee Schedule,165% of CMS OPPS Rate,1293.28,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,3584.29,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,4915.56,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6157.24,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,189.02,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1247.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1293.28,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,95.23,14,,,percent of total billed charges,14% of total billed charges,95.23,6157.24,
Read,597073,CDM,972,RC,78802,HCPCS,Outpatient,,,272.09,136.05,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
NM Brain Spect,603562,CDM,340,RC,78803,HCPCS,Outpatient,,,837.56,418.78,,628.17,75,,,percent of total billed charges,75% of total billed charges,628.17,75,,,percent of total billed charges,75% of total billed charges,1247.84,100,,,Fee Schedule,100% of CMS OPPS Rate,233.76,100,,,Fee Schedule,100% of WV Medicaid Rate,2058.94,165,,,Fee Schedule,165% of CMS OPPS Rate,1293.28,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,3584.29,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,4915.56,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6157.24,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,233.76,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1247.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1293.28,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,117.26,14,,,percent of total billed charges,14% of total billed charges,117.26,6157.24,
NM Liver Spect,603565,CDM,340,RC,78803,HCPCS,Outpatient,,,837.56,418.78,,628.17,75,,,percent of total billed charges,75% of total billed charges,628.17,75,,,percent of total billed charges,75% of total billed charges,1247.84,100,,,Fee Schedule,100% of CMS OPPS Rate,233.76,100,,,Fee Schedule,100% of WV Medicaid Rate,2058.94,165,,,Fee Schedule,165% of CMS OPPS Rate,1293.28,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,3584.29,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,4915.56,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6157.24,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,233.76,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1247.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1293.28,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,117.26,14,,,percent of total billed charges,14% of total billed charges,117.26,6157.24,
NM Musculoskeletal Spect,603558,CDM,340,RC,78803,HCPCS,Outpatient,,,837.56,418.78,,628.17,75,,,percent of total billed charges,75% of total billed charges,628.17,75,,,percent of total billed charges,75% of total billed charges,1247.84,100,,,Fee Schedule,100% of CMS OPPS Rate,233.76,100,,,Fee Schedule,100% of WV Medicaid Rate,2058.94,165,,,Fee Schedule,165% of CMS OPPS Rate,1293.28,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,3584.29,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,4915.56,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6157.24,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,233.76,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1247.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1293.28,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,117.26,14,,,percent of total billed charges,14% of total billed charges,117.26,6157.24,
NM PYP with spect,3697194,CDM,341,RC,78803,HCPCS,Outpatient,,,837.56,418.78,,628.17,75,,,percent of total billed charges,75% of total billed charges,628.17,75,,,percent of total billed charges,75% of total billed charges,1247.84,100,,,Fee Schedule,100% of CMS OPPS Rate,233.76,100,,,Fee Schedule,100% of WV Medicaid Rate,2058.94,165,,,Fee Schedule,165% of CMS OPPS Rate,1293.28,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,3584.29,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,4915.56,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6157.24,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,233.76,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1247.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1293.28,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,117.26,14,,,percent of total billed charges,14% of total billed charges,117.26,6157.24,
NM RBC Liver Spect,603566,CDM,340,RC,78803,HCPCS,Outpatient,,,837.56,418.78,,628.17,75,,,percent of total billed charges,75% of total billed charges,628.17,75,,,percent of total billed charges,75% of total billed charges,1247.84,100,,,Fee Schedule,100% of CMS OPPS Rate,233.76,100,,,Fee Schedule,100% of WV Medicaid Rate,2058.94,165,,,Fee Schedule,165% of CMS OPPS Rate,1293.28,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,3584.29,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,4915.56,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6157.24,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,233.76,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1247.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1293.28,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,117.26,14,,,percent of total billed charges,14% of total billed charges,117.26,6157.24,
NM Tumor Loc Spect,603545,CDM,340,RC,78803,HCPCS,Outpatient,,,837.56,418.78,,628.17,75,,,percent of total billed charges,75% of total billed charges,628.17,75,,,percent of total billed charges,75% of total billed charges,1247.84,100,,,Fee Schedule,100% of CMS OPPS Rate,233.76,100,,,Fee Schedule,100% of WV Medicaid Rate,2058.94,165,,,Fee Schedule,165% of CMS OPPS Rate,1293.28,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,3584.29,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,4915.56,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6157.24,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,233.76,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1247.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1293.28,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,117.26,14,,,percent of total billed charges,14% of total billed charges,117.26,6157.24,
NM WBC Imaging Whole Body Spect,3736901,CDM,320,RC,78803,HCPCS,Outpatient,,,837.56,418.78,,628.17,75,,,percent of total billed charges,75% of total billed charges,628.17,75,,,percent of total billed charges,75% of total billed charges,1247.84,100,,,Fee Schedule,100% of CMS OPPS Rate,233.76,100,,,Fee Schedule,100% of WV Medicaid Rate,2058.94,165,,,Fee Schedule,165% of CMS OPPS Rate,1293.28,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,3584.29,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,4915.56,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6157.24,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,233.76,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1247.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1293.28,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,117.26,14,,,percent of total billed charges,14% of total billed charges,117.26,6157.24,
NM Oral Isotope Therapy,3342270,CDM,340,RC,79005,HCPCS,Outpatient,,,336.37,168.19,,252.28,75,,,percent of total billed charges,75% of total billed charges,252.28,75,,,percent of total billed charges,75% of total billed charges,234.78,100,,,Fee Schedule,100% of CMS OPPS Rate,91.44,100,,,Fee Schedule,100% of WV Medicaid Rate,387.39,165,,,Fee Schedule,165% of CMS OPPS Rate,243.33,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,674.39,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,924.87,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1158.5,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,91.44,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,234.78,100,,,Fee Schedule,100% of CMS OPPS Rate,243.33,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,47.09,14,,,percent of total billed charges,14% of total billed charges,47.09,1158.5,
Read,597234,CDM,972,RC,79005,HCPCS,Outpatient,,,134.55,67.28,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
Read,1225041,CDM,972,RC,79005,HCPCS,Outpatient,,,134.55,67.28,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
Read,646054,CDM,972,RC,79101,HCPCS,Outpatient,,,146.47,73.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
Smear Review Pathology,649497,CDM,300,RC,85060,HCPCS,Outpatient,,,55.51,27.76,,41.63,75,,,percent of total billed charges,75% of total billed charges,41.63,75,,,percent of total billed charges,75% of total billed charges,17.76,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.77,14,,,percent of total billed charges,14% of total billed charges,7.77,41.63,
"Pathology Billing Cytopathology NG Thin Prep, with interpretation, except cervical or vaginal",646357,CDM,310,RC,88112,HCPCS,Outpatient,,,144.67,72.34,,108.5,75,,,percent of total billed charges,75% of total billed charges,108.5,75,,,percent of total billed charges,75% of total billed charges,47.13,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,77.78,165,,,Fee Schedule,165% of CMS OPPS Rate,48.85,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,135.4,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,185.69,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,232.6,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,47.13,100,,,Fee Schedule,100% of CMS OPPS Rate,48.85,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,20.25,14,,,percent of total billed charges,14% of total billed charges,20.25,232.6,
Pathology Billing Gyn Cytology with Pathologist Interpretation,295392,CDM,971,RC,88141,HCPCS,Outpatient,,,50.32,25.16,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
Pathology Billing Surgical Pathology Level II Complexity,295348,CDM,310,RC,88302,HCPCS,Outpatient,,,69.93,34.97,,52.45,75,,,percent of total billed charges,75% of total billed charges,52.45,75,,,percent of total billed charges,75% of total billed charges,23.46,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,38.71,165,,,Fee Schedule,165% of CMS OPPS Rate,24.32,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,67.4,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,92.43,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,115.79,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,23.46,100,,,Fee Schedule,100% of CMS OPPS Rate,24.32,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,9.79,14,,,percent of total billed charges,14% of total billed charges,9.79,115.79,
Pathology Billing Surgical Pathology Level III Complexity,295350,CDM,310,RC,88304,HCPCS,Outpatient,,,91.01,45.51,,68.26,75,,,percent of total billed charges,75% of total billed charges,68.26,75,,,percent of total billed charges,75% of total billed charges,47.13,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,77.78,165,,,Fee Schedule,165% of CMS OPPS Rate,48.85,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,135.4,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,185.69,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,232.6,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,47.13,100,,,Fee Schedule,100% of CMS OPPS Rate,48.85,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,12.74,14,,,percent of total billed charges,14% of total billed charges,12.74,232.6,
88305- Tissue exam by pathologist; Level IV,3430541,CDM,310,RC,88305,HCPCS,Outpatient,,,191.73,95.87,,143.8,75,,,percent of total billed charges,75% of total billed charges,143.8,75,,,percent of total billed charges,75% of total billed charges,47.13,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,77.78,165,,,Fee Schedule,165% of CMS OPPS Rate,48.85,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,135.4,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,185.69,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,232.6,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,47.13,100,,,Fee Schedule,100% of CMS OPPS Rate,48.85,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,26.84,14,,,percent of total billed charges,14% of total billed charges,26.84,232.6,
Pathology Billing Surgical Pathology Level IV Complexity,295352,CDM,310,RC,88305,HCPCS,Outpatient,,,155.81,77.91,,116.86,75,,,percent of total billed charges,75% of total billed charges,116.86,75,,,percent of total billed charges,75% of total billed charges,47.13,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,77.78,165,,,Fee Schedule,165% of CMS OPPS Rate,48.85,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,135.4,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,185.69,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,232.6,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,47.13,100,,,Fee Schedule,100% of CMS OPPS Rate,48.85,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,21.81,14,,,percent of total billed charges,14% of total billed charges,21.81,232.6,
Pathology Billing Surgical Pathology Level V Complexity,295354,CDM,310,RC,88307,HCPCS,Outpatient,,,618.39,309.2,,463.79,75,,,percent of total billed charges,75% of total billed charges,463.79,75,,,percent of total billed charges,75% of total billed charges,304.7,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,502.78,165,,,Fee Schedule,165% of CMS OPPS Rate,315.81,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,875.25,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1200.34,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1503.55,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,304.7,100,,,Fee Schedule,100% of CMS OPPS Rate,315.81,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,86.57,14,,,percent of total billed charges,14% of total billed charges,86.57,1503.55,
Pathology Billing Surgical Pathology Level V Complexity Profee,3549253,CDM,971,RC,88307,HCPCS,Outpatient,,,618.39,309.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
Pathology Billing Decalcification,295360,CDM,310,RC,88311,HCPCS,Outpatient,,,13.38,6.69,,10.04,75,,,percent of total billed charges,75% of total billed charges,10.04,75,,,percent of total billed charges,75% of total billed charges,4.28,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.87,14,,,percent of total billed charges,14% of total billed charges,1.87,10.04,
Special Stain HELICO,605636,CDM,310,RC,88312,HCPCS,Outpatient,,,238.55,119.28,,178.91,75,,,percent of total billed charges,75% of total billed charges,178.91,75,,,percent of total billed charges,75% of total billed charges,47.13,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,77.78,165,,,Fee Schedule,165% of CMS OPPS Rate,48.85,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,135.4,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,185.69,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,232.6,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,47.13,100,,,Fee Schedule,100% of CMS OPPS Rate,48.85,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,33.4,14,,,percent of total billed charges,14% of total billed charges,33.4,232.6,
Special Stain HELICO Profee,3549261,CDM,971,RC,88312,HCPCS,Outpatient,,,238.55,119.28,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
Special Stain Pneumocystis,1425138,CDM,310,RC,88312,HCPCS,Outpatient,,,238.55,119.28,,178.91,75,,,percent of total billed charges,75% of total billed charges,178.91,75,,,percent of total billed charges,75% of total billed charges,47.13,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,77.78,165,,,Fee Schedule,165% of CMS OPPS Rate,48.85,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,135.4,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,185.69,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,232.6,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,47.13,100,,,Fee Schedule,100% of CMS OPPS Rate,48.85,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,33.4,14,,,percent of total billed charges,14% of total billed charges,33.4,232.6,
Pathology Billing IHC Additional Stain,3318836,CDM,310,RC,88341,HCPCS,Outpatient,,,63.38,31.69,,47.54,75,,,percent of total billed charges,75% of total billed charges,47.54,75,,,percent of total billed charges,75% of total billed charges,20.28,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.87,14,,,percent of total billed charges,14% of total billed charges,8.87,47.54,
Pathology Billing IHC Additional Stain Profee,3549247,CDM,971,RC,88341,HCPCS,Outpatient,,,184.47,92.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
"Pathology Billing Immuno Cyto Chemistry, tissue,IP,ea ab",295366,CDM,310,RC,88342,HCPCS,Outpatient,,,214.75,107.38,,161.06,75,,,percent of total billed charges,75% of total billed charges,161.06,75,,,percent of total billed charges,75% of total billed charges,147.84,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,243.93,165,,,Fee Schedule,165% of CMS OPPS Rate,153.22,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,424.65,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,582.37,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,729.48,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,147.84,100,,,Fee Schedule,100% of CMS OPPS Rate,153.22,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,30.07,14,,,percent of total billed charges,14% of total billed charges,30.07,729.48,
Pathology Billing Archive tissue selection,1837101,CDM,310,RC,88363,HCPCS,Outpatient,,,51.88,25.94,,38.91,75,,,percent of total billed charges,75% of total billed charges,38.91,75,,,percent of total billed charges,75% of total billed charges,23.46,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,38.71,165,,,Fee Schedule,165% of CMS OPPS Rate,24.32,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,67.4,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,92.43,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,115.79,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,23.46,100,,,Fee Schedule,100% of CMS OPPS Rate,24.32,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,7.26,14,,,percent of total billed charges,14% of total billed charges,7.26,115.79,
90471-PF IM ADM PRQ ID SUBQ/IM NJXS 1 VACCINE,4321579,CDM,981,RC,90471,HCPCS,Outpatient,,,36.86,18.43,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
AMB Admin Oral Immunization Charge -> First Vaccine 90473,3444233,CDM,771,RC,90473,HCPCS,Outpatient,,,41.22,20.61,,30.92,75,,,percent of total billed charges,75% of total billed charges,30.92,75,,,percent of total billed charges,75% of total billed charges,63.43,100,,,Fee Schedule,100% of CMS OPPS Rate,11.06,100,,,Fee Schedule,100% of WV Medicaid Rate,104.66,165,,,Fee Schedule,165% of CMS OPPS Rate,65.74,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,182.2,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,249.87,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,312.99,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,11.06,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,63.43,100,,,Fee Schedule,100% of CMS OPPS Rate,65.74,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,5.77,14,,,percent of total billed charges,14% of total billed charges,5.77,312.99,
0.5 mL MenQuadfi Vaccine,4125120,CDM,636,RC,90619,HCPCS,Outpatient,,,399.39,199.7,,299.54,75,,,percent of total billed charges,75% of total billed charges,299.54,75,,,percent of total billed charges,75% of total billed charges,127.8,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55.91,14,,,percent of total billed charges,14% of total billed charges,55.91,299.54,
91010- Esoph motil/stim/perfus/inter/rep,3431279,CDM,983,RC,91010,HCPCS,Outpatient,,,131.4,65.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
"91035 Esophagus, gastroesophageal reflux test; with mucosal attached telemetry pH electrode pla",3696909,CDM,510,RC,91035,HCPCS,Outpatient,,,876.09,438.05,,657.07,75,,,percent of total billed charges,75% of total billed charges,657.07,75,,,percent of total billed charges,75% of total billed charges,454.5,100,,,Fee Schedule,100% of CMS OPPS Rate,309.22,100,,,Fee Schedule,100% of WV Medicaid Rate,749.91,165,,,Fee Schedule,165% of CMS OPPS Rate,471.04,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1305.49,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1790.39,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,2242.64,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,309.22,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,454.5,100,,,Fee Schedule,100% of CMS OPPS Rate,471.04,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,122.65,14,,,percent of total billed charges,14% of total billed charges,122.65,2242.64,
91035PF Gastroesophageal Reflux Test w/Mucosal Attached Tele,4281208,CDM,960,RC,91035,HCPCS,Outpatient,,,876.09,438.05,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
ENDO CAPSULE ENDOSCOPY,3431296,CDM,983,RC,91110,HCPCS,Outpatient,,,1579.54,789.77,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
92018- Opthal exam/eval/gen anes/complete,3435581,CDM,962,RC,92018,HCPCS,Outpatient,,,273.16,136.58,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
92019- Opthal exam/eval/gen anes/limited,3435582,CDM,962,RC,92019,HCPCS,Outpatient,,,143.16,71.58,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
92100- Serial tonometry/intraoc pres/I&R,3435592,CDM,962,RC,92100,HCPCS,Outpatient,,,63.35,31.68,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
92136- Opthal bio/intraoc lens power calc,3435593,CDM,510,RC,92136,HCPCS,Outpatient,,,46.11,23.06,,34.58,75,,,percent of total billed charges,75% of total billed charges,34.58,75,,,percent of total billed charges,75% of total billed charges,109.16,100,,,Fee Schedule,100% of CMS OPPS Rate,32.69,100,,,Fee Schedule,100% of WV Medicaid Rate,180.11,165,,,Fee Schedule,165% of CMS OPPS Rate,113.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,313.55,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,430.01,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,538.63,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,32.69,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,109.16,100,,,Fee Schedule,100% of CMS OPPS Rate,113.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,6.46,14,,,percent of total billed charges,14% of total billed charges,6.46,538.63,
92225- Opthalmoscopy/drawing/ext/I&R/ini,3435594,CDM,510,RC,92225,HCPCS,Outpatient,,,69.71,34.86,,52.28,75,,,percent of total billed charges,75% of total billed charges,52.28,75,,,percent of total billed charges,75% of total billed charges,22.31,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.76,14,,,percent of total billed charges,14% of total billed charges,9.76,52.28,
92226- Opthalmoscopy/drawing/ext/I&R/subs,3435595,CDM,510,RC,92226,HCPCS,Outpatient,,,64.09,32.05,,48.07,75,,,percent of total billed charges,75% of total billed charges,48.07,75,,,percent of total billed charges,75% of total billed charges,20.51,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.97,14,,,percent of total billed charges,14% of total billed charges,8.97,48.07,
92227- Remote image/analysis/rpt/MD sup,3431348,CDM,510,RC,92227,HCPCS,Outpatient,,,37.42,18.71,,28.07,75,,,percent of total billed charges,75% of total billed charges,28.07,75,,,percent of total billed charges,75% of total billed charges,31.92,100,,,Fee Schedule,100% of CMS OPPS Rate,9.83,100,,,Fee Schedule,100% of WV Medicaid Rate,52.68,165,,,Fee Schedule,165% of CMS OPPS Rate,33.09,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,91.7,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,125.77,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,157.54,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,9.83,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,31.92,100,,,Fee Schedule,100% of CMS OPPS Rate,33.09,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,5.24,14,,,percent of total billed charges,14% of total billed charges,5.24,157.54,
92228- Remote image/monit/manage/MD I & R,3431349,CDM,510,RC,92228,HCPCS,Outpatient,,,30.32,15.16,,22.74,75,,,percent of total billed charges,75% of total billed charges,22.74,75,,,percent of total billed charges,75% of total billed charges,31.92,100,,,Fee Schedule,100% of CMS OPPS Rate,20.16,100,,,Fee Schedule,100% of WV Medicaid Rate,52.68,165,,,Fee Schedule,165% of CMS OPPS Rate,33.09,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,91.7,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,125.77,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,157.54,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,20.16,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,31.92,100,,,Fee Schedule,100% of CMS OPPS Rate,33.09,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4.24,14,,,percent of total billed charges,14% of total billed charges,4.24,157.54,
92230- Fluorescein angioscopy w/I&R,3435596,CDM,510,RC,92230,HCPCS,Outpatient,,,236.49,118.25,,177.37,75,,,percent of total billed charges,75% of total billed charges,177.37,75,,,percent of total billed charges,75% of total billed charges,454.5,100,,,Fee Schedule,100% of CMS OPPS Rate,22.61,100,,,Fee Schedule,100% of WV Medicaid Rate,749.93,165,,,Fee Schedule,165% of CMS OPPS Rate,471.05,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1305.5,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1790.39,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,2242.64,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,22.61,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,454.5,100,,,Fee Schedule,100% of CMS OPPS Rate,471.05,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,33.11,14,,,percent of total billed charges,14% of total billed charges,22.61,2242.64,
92235- Fluorescein angio/imaging/I&R,3435597,CDM,510,RC,92235,HCPCS,Outpatient,,,195.36,97.68,,146.52,75,,,percent of total billed charges,75% of total billed charges,146.52,75,,,percent of total billed charges,75% of total billed charges,263.29,100,,,Fee Schedule,100% of CMS OPPS Rate,80.62,100,,,Fee Schedule,100% of WV Medicaid Rate,434.44,165,,,Fee Schedule,165% of CMS OPPS Rate,272.88,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,756.29,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1037.2,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1299.2,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,80.62,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,263.29,100,,,Fee Schedule,100% of CMS OPPS Rate,272.88,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,27.35,14,,,percent of total billed charges,14% of total billed charges,27.35,1299.2,
92240- Indocyanine-green angio/image/I&R,3435598,CDM,510,RC,92240,HCPCS,Outpatient,,,343.01,171.51,,257.26,75,,,percent of total billed charges,75% of total billed charges,257.26,75,,,percent of total billed charges,75% of total billed charges,263.29,100,,,Fee Schedule,100% of CMS OPPS Rate,124.37,100,,,Fee Schedule,100% of WV Medicaid Rate,434.44,165,,,Fee Schedule,165% of CMS OPPS Rate,272.88,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,756.29,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1037.2,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1299.2,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,124.37,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,263.29,100,,,Fee Schedule,100% of CMS OPPS Rate,272.88,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,48.02,14,,,percent of total billed charges,14% of total billed charges,48.02,1299.2,
92265- Needle oculoelectromyography/I&R,3435601,CDM,510,RC,92265,HCPCS,Outpatient,,,95.87,47.94,,71.9,75,,,percent of total billed charges,75% of total billed charges,71.9,75,,,percent of total billed charges,75% of total billed charges,54.04,100,,,Fee Schedule,100% of CMS OPPS Rate,56.29,100,,,Fee Schedule,100% of WV Medicaid Rate,89.16,165,,,Fee Schedule,165% of CMS OPPS Rate,56,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,155.22,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,212.87,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,266.65,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,56.29,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,54.04,100,,,Fee Schedule,100% of CMS OPPS Rate,56,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,13.42,14,,,percent of total billed charges,14% of total billed charges,13.42,266.65,
92270- Electro-oculography w/I&R,3435602,CDM,510,RC,92270,HCPCS,Outpatient,,,156.19,78.1,,117.14,75,,,percent of total billed charges,75% of total billed charges,117.14,75,,,percent of total billed charges,75% of total billed charges,109.16,100,,,Fee Schedule,100% of CMS OPPS Rate,70.54,100,,,Fee Schedule,100% of WV Medicaid Rate,180.11,165,,,Fee Schedule,165% of CMS OPPS Rate,113.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,313.55,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,430.01,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,538.63,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,70.54,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,109.16,100,,,Fee Schedule,100% of CMS OPPS Rate,113.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,21.87,14,,,percent of total billed charges,14% of total billed charges,21.87,538.63,
92311- Fit/Rx/corneal lens/aphakia/1 eye,3435610,CDM,510,RC,92311,HCPCS,Outpatient,,,261.89,130.95,,196.42,75,,,percent of total billed charges,75% of total billed charges,196.42,75,,,percent of total billed charges,75% of total billed charges,354.97,100,,,Fee Schedule,100% of CMS OPPS Rate,36.13,100,,,Fee Schedule,100% of WV Medicaid Rate,585.71,165,,,Fee Schedule,165% of CMS OPPS Rate,367.9,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1019.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1398.33,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1751.55,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,36.13,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,354.97,100,,,Fee Schedule,100% of CMS OPPS Rate,367.9,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,36.66,14,,,percent of total billed charges,14% of total billed charges,36.13,1751.55,
92312- Fit/Rx/corneal lens/aphakia/OU,3435611,CDM,510,RC,92312,HCPCS,Outpatient,,,303.72,151.86,,227.79,75,,,percent of total billed charges,75% of total billed charges,227.79,75,,,percent of total billed charges,75% of total billed charges,109.16,100,,,Fee Schedule,100% of CMS OPPS Rate,41.79,100,,,Fee Schedule,100% of WV Medicaid Rate,180.11,165,,,Fee Schedule,165% of CMS OPPS Rate,113.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,313.55,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,430.01,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,538.63,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,41.79,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,109.16,100,,,Fee Schedule,100% of CMS OPPS Rate,113.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,42.52,14,,,percent of total billed charges,14% of total billed charges,41.79,538.63,
92313- Fit/Rx/corneoscleral lens,3435612,CDM,510,RC,92313,HCPCS,Outpatient,,,246.07,123.04,,184.55,75,,,percent of total billed charges,75% of total billed charges,184.55,75,,,percent of total billed charges,75% of total billed charges,109.16,100,,,Fee Schedule,100% of CMS OPPS Rate,29.74,100,,,Fee Schedule,100% of WV Medicaid Rate,180.11,165,,,Fee Schedule,165% of CMS OPPS Rate,113.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,313.55,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,430.01,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,538.63,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,29.74,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,109.16,100,,,Fee Schedule,100% of CMS OPPS Rate,113.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,34.45,14,,,percent of total billed charges,14% of total billed charges,29.74,538.63,
92315- Fit/Rx/tech/corn lens/aphakia/1 ey,3435614,CDM,510,RC,92315,HCPCS,Outpatient,,,198.87,99.44,,149.15,75,,,percent of total billed charges,75% of total billed charges,149.15,75,,,percent of total billed charges,75% of total billed charges,109.16,100,,,Fee Schedule,100% of CMS OPPS Rate,14.5,100,,,Fee Schedule,100% of WV Medicaid Rate,180.11,165,,,Fee Schedule,165% of CMS OPPS Rate,113.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,313.55,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,430.01,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,538.63,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,14.5,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,109.16,100,,,Fee Schedule,100% of CMS OPPS Rate,113.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,27.84,14,,,percent of total billed charges,14% of total billed charges,14.5,538.63,
92316- Fit/Rx/tech/corneal lens/aphakia/O,3435615,CDM,510,RC,92316,HCPCS,Outpatient,,,246.86,123.43,,185.15,75,,,percent of total billed charges,75% of total billed charges,185.15,75,,,percent of total billed charges,75% of total billed charges,109.16,100,,,Fee Schedule,100% of CMS OPPS Rate,21.88,100,,,Fee Schedule,100% of WV Medicaid Rate,180.11,165,,,Fee Schedule,165% of CMS OPPS Rate,113.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,313.55,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,430.01,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,538.63,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,21.88,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,109.16,100,,,Fee Schedule,100% of CMS OPPS Rate,113.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,34.56,14,,,percent of total billed charges,14% of total billed charges,21.88,538.63,
92317- Fit/Rx/tech/corneoscleral lens,3435616,CDM,510,RC,92317,HCPCS,Outpatient,,,208.33,104.17,,156.25,75,,,percent of total billed charges,75% of total billed charges,156.25,75,,,percent of total billed charges,75% of total billed charges,31.92,100,,,Fee Schedule,100% of CMS OPPS Rate,14.5,100,,,Fee Schedule,100% of WV Medicaid Rate,52.68,165,,,Fee Schedule,165% of CMS OPPS Rate,33.09,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,91.7,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,125.77,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,157.54,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,14.5,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,31.92,100,,,Fee Schedule,100% of CMS OPPS Rate,33.09,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,29.17,14,,,percent of total billed charges,14% of total billed charges,14.5,157.54,
92325- Modify contact lens/med supervise,3435617,CDM,510,RC,92325,HCPCS,Outpatient,,,107.71,53.86,,80.78,75,,,percent of total billed charges,75% of total billed charges,80.78,75,,,percent of total billed charges,75% of total billed charges,109.16,100,,,Fee Schedule,100% of CMS OPPS Rate,28.76,100,,,Fee Schedule,100% of WV Medicaid Rate,180.11,165,,,Fee Schedule,165% of CMS OPPS Rate,113.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,313.55,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,430.01,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,538.63,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,28.76,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,109.16,100,,,Fee Schedule,100% of CMS OPPS Rate,113.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,15.08,14,,,percent of total billed charges,14% of total billed charges,15.08,538.63,
92326- Replacement of contact lens,3435618,CDM,510,RC,92326,HCPCS,Outpatient,,,91.9,45.95,,68.93,75,,,percent of total billed charges,75% of total billed charges,68.93,75,,,percent of total billed charges,75% of total billed charges,54.04,100,,,Fee Schedule,100% of CMS OPPS Rate,24.58,100,,,Fee Schedule,100% of WV Medicaid Rate,89.16,165,,,Fee Schedule,165% of CMS OPPS Rate,56,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,155.22,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,212.87,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,266.65,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,24.58,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,54.04,100,,,Fee Schedule,100% of CMS OPPS Rate,56,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,12.87,14,,,percent of total billed charges,14% of total billed charges,12.87,266.65,
92502- Otolaryngologic exam/gen anesth,3435632,CDM,510,RC,92502,HCPCS,Outpatient,,,242.37,121.19,,181.78,75,,,percent of total billed charges,75% of total billed charges,181.78,75,,,percent of total billed charges,75% of total billed charges,429.48,100,,,Fee Schedule,100% of CMS OPPS Rate,64.65,100,,,Fee Schedule,100% of WV Medicaid Rate,708.64,165,,,Fee Schedule,165% of CMS OPPS Rate,445.12,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1233.63,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1691.83,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,2119.19,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,64.65,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,429.48,100,,,Fee Schedule,100% of CMS OPPS Rate,445.12,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,33.93,14,,,percent of total billed charges,14% of total billed charges,33.93,2119.19,
92504- Otolaryngo binocular microscopy,3435314,CDM,510,RC,92504,HCPCS,Outpatient,,,70.57,35.29,,52.93,75,,,percent of total billed charges,75% of total billed charges,52.93,75,,,percent of total billed charges,75% of total billed charges,22.58,32,,,percent of total billed charges,32% of total billed charges,6.39,100,,,Fee Schedule,100% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.39,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.88,14,,,percent of total billed charges,14% of total billed charges,6.39,52.93,
92507- Tx speech/lang/voice/aud/ea indiv,3435634,CDM,940,RC,92507,HCPCS,Outpatient,,,197,98.5,,147.75,75,,,percent of total billed charges,75% of total billed charges,147.75,75,,,percent of total billed charges,75% of total billed charges,73.16,100,,,Fee Schedule,100% of CMS OPPS Rate,52.6,100,,,Fee Schedule,100% of WV Medicaid Rate,120.71,165,,,Fee Schedule,165% of CMS OPPS Rate,71.37,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,259.38,354.54,,,Fee Schedule,354.54% of CMS OPPS Fee Schedule Rate,313.64,428.7,,,Fee Schedule,428.7% of CMS OPPS Fee Schedule Rate,329.81,450.81,,,Fee Schedule,450.81% of CMS OPPS Fee Schedule Rate,52.6,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,73.16,100,,,Fee Schedule,100% of CMS OPPS Rate,71.37,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,27.58,14,,,percent of total billed charges,14% of total billed charges,27.58,329.81,
92508- Tx speech/lang/voice/aud/2 > indiv,3435635,CDM,510,RC,92508,HCPCS,Outpatient,,,59.88,29.94,,44.91,75,,,percent of total billed charges,75% of total billed charges,44.91,75,,,percent of total billed charges,75% of total billed charges,22.39,100,,,Fee Schedule,100% of CMS OPPS Rate,15.98,100,,,Fee Schedule,100% of WV Medicaid Rate,36.94,165,,,Fee Schedule,165% of CMS OPPS Rate,21.84,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,79.38,354.54,,,Fee Schedule,354.54% of CMS OPPS Fee Schedule Rate,95.99,428.7,,,Fee Schedule,428.7% of CMS OPPS Fee Schedule Rate,100.94,450.81,,,Fee Schedule,450.81% of CMS OPPS Fee Schedule Rate,15.98,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,22.39,100,,,Fee Schedule,100% of CMS OPPS Rate,21.84,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,8.38,14,,,percent of total billed charges,14% of total billed charges,8.38,100.94,
92511-PF NASOPHARYNGOSCOPY W/ENDOSCOPE SPX,4321577,CDM,981,RC,92511,HCPCS,Outpatient,,,72.16,36.08,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
92512- Nasal function studies,3435637,CDM,510,RC,92512,HCPCS,Outpatient,,,153.73,76.87,,115.3,75,,,percent of total billed charges,75% of total billed charges,115.3,75,,,percent of total billed charges,75% of total billed charges,263.29,100,,,Fee Schedule,100% of CMS OPPS Rate,19.42,100,,,Fee Schedule,100% of WV Medicaid Rate,434.44,165,,,Fee Schedule,165% of CMS OPPS Rate,272.88,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,756.29,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1037.2,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1299.2,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,19.42,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,263.29,100,,,Fee Schedule,100% of CMS OPPS Rate,272.88,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,21.52,14,,,percent of total billed charges,14% of total billed charges,19.42,1299.2,
92520- Laryngeal function studies,3435638,CDM,510,RC,92520,HCPCS,Outpatient,,,202.93,101.47,,152.2,75,,,percent of total billed charges,75% of total billed charges,152.2,75,,,percent of total billed charges,75% of total billed charges,109.16,100,,,Fee Schedule,100% of CMS OPPS Rate,27.53,100,,,Fee Schedule,100% of WV Medicaid Rate,180.11,165,,,Fee Schedule,165% of CMS OPPS Rate,113.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,313.55,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,430.01,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,538.63,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,27.53,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,109.16,100,,,Fee Schedule,100% of CMS OPPS Rate,113.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,28.41,14,,,percent of total billed charges,14% of total billed charges,27.53,538.63,
92522- Speech Sound Production Evaluation,3514660,CDM,940,RC,92522,HCPCS,Outpatient,,,282.33,141.17,,211.75,75,,,percent of total billed charges,75% of total billed charges,211.75,75,,,percent of total billed charges,75% of total billed charges,106.53,100,,,Fee Schedule,100% of CMS OPPS Rate,76.94,100,,,Fee Schedule,100% of WV Medicaid Rate,175.77,165,,,Fee Schedule,165% of CMS OPPS Rate,103.93,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,377.69,354.54,,,Fee Schedule,354.54% of CMS OPPS Fee Schedule Rate,456.69,428.7,,,Fee Schedule,428.7% of CMS OPPS Fee Schedule Rate,480.25,450.81,,,Fee Schedule,450.81% of CMS OPPS Fee Schedule Rate,76.94,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,106.53,100,,,Fee Schedule,100% of CMS OPPS Rate,103.93,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,39.53,14,,,percent of total billed charges,14% of total billed charges,39.53,480.25,
SPEECH SOUND PRODUCTION EVALUATION,3430610,CDM,940,RC,92522,HCPCS,Outpatient,,,282.33,141.17,,211.75,75,,,percent of total billed charges,75% of total billed charges,211.75,75,,,percent of total billed charges,75% of total billed charges,106.53,100,,,Fee Schedule,100% of CMS OPPS Rate,76.94,100,,,Fee Schedule,100% of WV Medicaid Rate,175.77,165,,,Fee Schedule,165% of CMS OPPS Rate,103.93,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,377.69,354.54,,,Fee Schedule,354.54% of CMS OPPS Fee Schedule Rate,456.69,428.7,,,Fee Schedule,428.7% of CMS OPPS Fee Schedule Rate,480.25,450.81,,,Fee Schedule,450.81% of CMS OPPS Fee Schedule Rate,76.94,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,106.53,100,,,Fee Schedule,100% of CMS OPPS Rate,103.93,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,39.53,14,,,percent of total billed charges,14% of total billed charges,39.53,480.25,
92540 Basic vestibular evaluation,3584883,CDM,960,RC,92540,HCPCS,Outpatient,,,78.47,39.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
92542 Positional nystagmus test,3584884,CDM,960,RC,92542,HCPCS,Outpatient,,,10.59,5.3,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
92548 Cdp-sot 6 cond w/i&r,3584885,CDM,960,RC,92548,HCPCS,Outpatient,,,35.04,17.52,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
92550 - Tympanometry and reflux threshold measurements,3715336,CDM,510,RC,92550,HCPCS,Outpatient,,,57.3,28.65,,42.98,75,,,percent of total billed charges,75% of total billed charges,42.98,75,,,percent of total billed charges,75% of total billed charges,136.72,100,,,Fee Schedule,100% of CMS OPPS Rate,15.24,100,,,Fee Schedule,100% of WV Medicaid Rate,225.6,165,,,Fee Schedule,165% of CMS OPPS Rate,141.7,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,392.73,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,538.6,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,674.65,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,15.24,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,136.72,100,,,Fee Schedule,100% of CMS OPPS Rate,141.7,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8.02,14,,,percent of total billed charges,14% of total billed charges,8.02,674.65,
92597- Eval/use/fitting voice prosthesis,3435653,CDM,510,RC,92597,HCPCS,Outpatient,,,186.85,93.43,,140.14,75,,,percent of total billed charges,75% of total billed charges,140.14,75,,,percent of total billed charges,75% of total billed charges,68.89,100,,,Fee Schedule,100% of CMS OPPS Rate,49.9,100,,,Fee Schedule,100% of WV Medicaid Rate,113.67,165,,,Fee Schedule,165% of CMS OPPS Rate,67.21,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,244.24,354.54,,,Fee Schedule,354.54% of CMS OPPS Fee Schedule Rate,295.33,428.7,,,Fee Schedule,428.7% of CMS OPPS Fee Schedule Rate,310.56,450.81,,,Fee Schedule,450.81% of CMS OPPS Fee Schedule Rate,49.9,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,68.89,100,,,Fee Schedule,100% of CMS OPPS Rate,67.21,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,26.16,14,,,percent of total billed charges,14% of total billed charges,26.16,310.56,
92607- Eval/speech-gen device/first hr,3435656,CDM,510,RC,92607,HCPCS,Outpatient,,,315.69,157.85,,236.77,75,,,percent of total billed charges,75% of total billed charges,236.77,75,,,percent of total billed charges,75% of total billed charges,116.86,100,,,Fee Schedule,100% of CMS OPPS Rate,84.31,100,,,Fee Schedule,100% of WV Medicaid Rate,192.82,165,,,Fee Schedule,165% of CMS OPPS Rate,114.01,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,414.32,354.54,,,Fee Schedule,354.54% of CMS OPPS Fee Schedule Rate,500.98,428.7,,,Fee Schedule,428.7% of CMS OPPS Fee Schedule Rate,526.82,450.81,,,Fee Schedule,450.81% of CMS OPPS Fee Schedule Rate,84.31,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,116.86,100,,,Fee Schedule,100% of CMS OPPS Rate,114.01,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,44.2,14,,,percent of total billed charges,14% of total billed charges,44.2,526.82,
92608- Eval/speech-gen device/add 30 min,3435657,CDM,510,RC,92608,HCPCS,Outpatient,,,124.88,62.44,,93.66,75,,,percent of total billed charges,75% of total billed charges,93.66,75,,,percent of total billed charges,75% of total billed charges,45.85,100,,,Fee Schedule,100% of CMS OPPS Rate,33.43,100,,,Fee Schedule,100% of WV Medicaid Rate,75.65,165,,,Fee Schedule,165% of CMS OPPS Rate,44.73,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,162.56,354.54,,,Fee Schedule,354.54% of CMS OPPS Fee Schedule Rate,196.56,428.7,,,Fee Schedule,428.7% of CMS OPPS Fee Schedule Rate,206.7,450.81,,,Fee Schedule,450.81% of CMS OPPS Fee Schedule Rate,33.43,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,45.85,100,,,Fee Schedule,100% of CMS OPPS Rate,44.73,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,17.48,14,,,percent of total billed charges,14% of total billed charges,17.48,206.7,
92613- Endoscop eval/swallow/I & R only,3435661,CDM,510,RC,92613,HCPCS,Outpatient,,,95.02,47.51,,71.27,75,,,percent of total billed charges,75% of total billed charges,71.27,75,,,percent of total billed charges,75% of total billed charges,30.41,32,,,percent of total billed charges,32% of total billed charges,25.32,100,,,Fee Schedule,100% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.32,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.3,14,,,percent of total billed charges,14% of total billed charges,13.3,71.27,
92615- Laryngeal sens test/endo/I & R onl,3435663,CDM,510,RC,92615,HCPCS,Outpatient,,,85.29,42.65,,63.97,75,,,percent of total billed charges,75% of total billed charges,63.97,75,,,percent of total billed charges,75% of total billed charges,27.29,32,,,percent of total billed charges,32% of total billed charges,22.86,100,,,Fee Schedule,100% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.86,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.94,14,,,percent of total billed charges,14% of total billed charges,11.94,63.97,
92616- Endoscop eval/swallow/laryn sense,3435664,CDM,510,RC,92616,HCPCS,Outpatient,,,532.58,266.29,,399.44,75,,,percent of total billed charges,75% of total billed charges,399.44,75,,,percent of total billed charges,75% of total billed charges,95.68,100,,,Fee Schedule,100% of CMS OPPS Rate,68.33,100,,,Fee Schedule,100% of WV Medicaid Rate,157.87,165,,,Fee Schedule,165% of CMS OPPS Rate,93.35,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,339.22,354.54,,,Fee Schedule,354.54% of CMS OPPS Fee Schedule Rate,410.18,428.7,,,Fee Schedule,428.7% of CMS OPPS Fee Schedule Rate,431.34,450.81,,,Fee Schedule,450.81% of CMS OPPS Fee Schedule Rate,68.33,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,95.68,100,,,Fee Schedule,100% of CMS OPPS Rate,93.35,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,74.56,14,,,percent of total billed charges,14% of total billed charges,68.33,431.34,
92640- Analy/prog/aud brainstem implt/hr,3435666,CDM,510,RC,92640,HCPCS,Outpatient,,,284.18,142.09,,213.14,75,,,percent of total billed charges,75% of total billed charges,213.14,75,,,percent of total billed charges,75% of total billed charges,136.72,100,,,Fee Schedule,100% of CMS OPPS Rate,65.38,100,,,Fee Schedule,100% of WV Medicaid Rate,225.58,165,,,Fee Schedule,165% of CMS OPPS Rate,141.69,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,392.72,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,538.59,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,674.64,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,65.38,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,136.72,100,,,Fee Schedule,100% of CMS OPPS Rate,141.69,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,39.79,14,,,percent of total billed charges,14% of total billed charges,39.79,674.64,
"92652 Auditory evoked potentials; for threshold estimation at multiple frequencies, with interpretat",3584893,CDM,960,RC,92652,HCPCS,Outpatient,,,282.81,141.41,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
"92653 Auditory evoked potentials; neurodiagnostic, with interpretation and report",3584894,CDM,960,RC,92653,HCPCS,Outpatient,,,210.02,105.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
92920- PTCA Left Main,3560640,CDM,481,RC,92920,HCPCS,Outpatient,,,1425.4,712.7,,1069.05,75,,,percent of total billed charges,75% of total billed charges,1069.05,75,,,percent of total billed charges,75% of total billed charges,4903.32,100,,,Fee Schedule,100% of CMS OPPS Rate,380.74,100,,,Fee Schedule,100% of WV Medicaid Rate,8090.5,165,,,Fee Schedule,165% of CMS OPPS Rate,5081.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,14084.18,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,19315.33,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,24194.41,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,380.74,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,4903.32,100,,,Fee Schedule,100% of CMS OPPS Rate,5081.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,199.56,14,,,percent of total billed charges,14% of total billed charges,199.56,24194.41,
92920- PTCA single major coronary,3430752,CDM,481,RC,92920,HCPCS,Outpatient,,,1425.4,712.7,,1069.05,75,,,percent of total billed charges,75% of total billed charges,1069.05,75,,,percent of total billed charges,75% of total billed charges,4903.32,100,,,Fee Schedule,100% of CMS OPPS Rate,380.74,100,,,Fee Schedule,100% of WV Medicaid Rate,8090.5,165,,,Fee Schedule,165% of CMS OPPS Rate,5081.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,14084.18,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,19315.33,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,24194.41,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,380.74,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,4903.32,100,,,Fee Schedule,100% of CMS OPPS Rate,5081.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,199.56,14,,,percent of total billed charges,14% of total billed charges,199.56,24194.41,
92920-Coronary Angioplasty - CIRC,4197399,CDM,481,RC,92920,HCPCS,Outpatient,,,1272.68,636.34,,954.51,75,,,percent of total billed charges,75% of total billed charges,954.51,75,,,percent of total billed charges,75% of total billed charges,4903.32,100,,,Fee Schedule,100% of CMS OPPS Rate,380.74,100,,,Fee Schedule,100% of WV Medicaid Rate,8090.5,165,,,Fee Schedule,165% of CMS OPPS Rate,5081.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,14084.18,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,19315.33,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,24194.41,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,380.74,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,4903.32,100,,,Fee Schedule,100% of CMS OPPS Rate,5081.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,178.18,14,,,percent of total billed charges,14% of total billed charges,178.18,24194.41,
92920-Coronary Angioplasty - LAD,4197401,CDM,481,RC,92920,HCPCS,Outpatient,,,1272.68,636.34,,954.51,75,,,percent of total billed charges,75% of total billed charges,954.51,75,,,percent of total billed charges,75% of total billed charges,4903.32,100,,,Fee Schedule,100% of CMS OPPS Rate,380.74,100,,,Fee Schedule,100% of WV Medicaid Rate,8090.5,165,,,Fee Schedule,165% of CMS OPPS Rate,5081.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,14084.18,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,19315.33,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,24194.41,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,380.74,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,4903.32,100,,,Fee Schedule,100% of CMS OPPS Rate,5081.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,178.18,14,,,percent of total billed charges,14% of total billed charges,178.18,24194.41,
92920-Coronary Angioplasty - LT MAIN,4197415,CDM,481,RC,92920,HCPCS,Outpatient,,,1272.68,636.34,,954.51,75,,,percent of total billed charges,75% of total billed charges,954.51,75,,,percent of total billed charges,75% of total billed charges,4903.32,100,,,Fee Schedule,100% of CMS OPPS Rate,380.74,100,,,Fee Schedule,100% of WV Medicaid Rate,8090.5,165,,,Fee Schedule,165% of CMS OPPS Rate,5081.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,14084.18,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,19315.33,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,24194.41,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,380.74,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,4903.32,100,,,Fee Schedule,100% of CMS OPPS Rate,5081.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,178.18,14,,,percent of total billed charges,14% of total billed charges,178.18,24194.41,
92920-Coronary Angioplasty- DIAG,4197409,CDM,481,RC,92920,HCPCS,Outpatient,,,1272.68,636.34,,954.51,75,,,percent of total billed charges,75% of total billed charges,954.51,75,,,percent of total billed charges,75% of total billed charges,4903.32,100,,,Fee Schedule,100% of CMS OPPS Rate,380.74,100,,,Fee Schedule,100% of WV Medicaid Rate,8090.5,165,,,Fee Schedule,165% of CMS OPPS Rate,5081.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,14084.18,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,19315.33,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,24194.41,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,380.74,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,4903.32,100,,,Fee Schedule,100% of CMS OPPS Rate,5081.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,178.18,14,,,percent of total billed charges,14% of total billed charges,178.18,24194.41,
92920-Coronary Angioplasty- OM,4197405,CDM,481,RC,92920,HCPCS,Outpatient,,,1272.68,636.34,,954.51,75,,,percent of total billed charges,75% of total billed charges,954.51,75,,,percent of total billed charges,75% of total billed charges,4903.32,100,,,Fee Schedule,100% of CMS OPPS Rate,380.74,100,,,Fee Schedule,100% of WV Medicaid Rate,8090.5,165,,,Fee Schedule,165% of CMS OPPS Rate,5081.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,14084.18,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,19315.33,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,24194.41,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,380.74,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,4903.32,100,,,Fee Schedule,100% of CMS OPPS Rate,5081.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,178.18,14,,,percent of total billed charges,14% of total billed charges,178.18,24194.41,
92920-Coronary Angioplasty- PDA,4197413,CDM,481,RC,92920,HCPCS,Outpatient,,,1272.68,636.34,,954.51,75,,,percent of total billed charges,75% of total billed charges,954.51,75,,,percent of total billed charges,75% of total billed charges,4903.32,100,,,Fee Schedule,100% of CMS OPPS Rate,380.74,100,,,Fee Schedule,100% of WV Medicaid Rate,8090.5,165,,,Fee Schedule,165% of CMS OPPS Rate,5081.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,14084.18,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,19315.33,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,24194.41,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,380.74,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,4903.32,100,,,Fee Schedule,100% of CMS OPPS Rate,5081.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,178.18,14,,,percent of total billed charges,14% of total billed charges,178.18,24194.41,
92920-Coronary Angioplasty- PLB,4197411,CDM,481,RC,92920,HCPCS,Outpatient,,,1272.68,636.34,,954.51,75,,,percent of total billed charges,75% of total billed charges,954.51,75,,,percent of total billed charges,75% of total billed charges,4903.32,100,,,Fee Schedule,100% of CMS OPPS Rate,380.74,100,,,Fee Schedule,100% of WV Medicaid Rate,8090.5,165,,,Fee Schedule,165% of CMS OPPS Rate,5081.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,14084.18,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,19315.33,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,24194.41,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,380.74,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,4903.32,100,,,Fee Schedule,100% of CMS OPPS Rate,5081.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,178.18,14,,,percent of total billed charges,14% of total billed charges,178.18,24194.41,
92920-Coronary Angioplasty- RAMUS,4197407,CDM,481,RC,92920,HCPCS,Outpatient,,,1272.68,636.34,,954.51,75,,,percent of total billed charges,75% of total billed charges,954.51,75,,,percent of total billed charges,75% of total billed charges,4903.32,100,,,Fee Schedule,100% of CMS OPPS Rate,380.74,100,,,Fee Schedule,100% of WV Medicaid Rate,8090.5,165,,,Fee Schedule,165% of CMS OPPS Rate,5081.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,14084.18,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,19315.33,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,24194.41,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,380.74,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,4903.32,100,,,Fee Schedule,100% of CMS OPPS Rate,5081.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,178.18,14,,,percent of total billed charges,14% of total billed charges,178.18,24194.41,
92920-Coronary Angioplasty- RCA,4197403,CDM,481,RC,92920,HCPCS,Outpatient,,,1272.68,636.34,,954.51,75,,,percent of total billed charges,75% of total billed charges,954.51,75,,,percent of total billed charges,75% of total billed charges,4903.32,100,,,Fee Schedule,100% of CMS OPPS Rate,380.74,100,,,Fee Schedule,100% of WV Medicaid Rate,8090.5,165,,,Fee Schedule,165% of CMS OPPS Rate,5081.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,14084.18,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,19315.33,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,24194.41,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,380.74,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,4903.32,100,,,Fee Schedule,100% of CMS OPPS Rate,5081.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,178.18,14,,,percent of total billed charges,14% of total billed charges,178.18,24194.41,
92920-PF Coronary Angioplasty - CIRC,4197400,CDM,960,RC,92920,HCPCS,Outpatient,,,1272.68,636.34,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
92920-PF Coronary Angioplasty - LAD,4197402,CDM,960,RC,92920,HCPCS,Outpatient,,,1272.68,636.34,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
92920-PF Coronary Angioplasty - LT MAIN,4197416,CDM,960,RC,92920,HCPCS,Outpatient,,,1272.68,636.34,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
92920-PF Coronary Angioplasty- DIAG,4197410,CDM,960,RC,92920,HCPCS,Outpatient,,,1272.68,636.34,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
92920-PF Coronary Angioplasty- OM,4197406,CDM,960,RC,92920,HCPCS,Outpatient,,,1272.68,636.34,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
92920-PF Coronary Angioplasty- PDA,4197414,CDM,960,RC,92920,HCPCS,Outpatient,,,1272.68,636.34,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
92920-PF Coronary Angioplasty- PLB,4197412,CDM,960,RC,92920,HCPCS,Outpatient,,,1272.68,636.34,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
92920-PF Coronary Angioplasty- RAMUS,4197408,CDM,960,RC,92920,HCPCS,Outpatient,,,1272.68,636.34,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
92920-PF Coronary Angioplasty- RCA,4197404,CDM,960,RC,92920,HCPCS,Outpatient,,,1272.68,636.34,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
92920-PF PTCA - LM,3580901,CDM,960,RC,92920,HCPCS,Outpatient,,,1425.4,712.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
92920-PF PTCA CIRC,3580902,CDM,960,RC,92920,HCPCS,Outpatient,,,1425.4,712.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
92920-PF PTCA LAD,3580903,CDM,960,RC,92920,HCPCS,Outpatient,,,1425.4,712.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
92920-PF PTCA Left Main,3580900,CDM,960,RC,92920,HCPCS,Outpatient,,,1425.4,712.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
92920-PF PTCA RCA,3580904,CDM,960,RC,92920,HCPCS,Outpatient,,,1425.4,712.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
92920-PTCA - LM,3552631,CDM,481,RC,92920,HCPCS,Outpatient,,,1425.4,712.7,,1069.05,75,,,percent of total billed charges,75% of total billed charges,1069.05,75,,,percent of total billed charges,75% of total billed charges,4903.32,100,,,Fee Schedule,100% of CMS OPPS Rate,380.74,100,,,Fee Schedule,100% of WV Medicaid Rate,8090.5,165,,,Fee Schedule,165% of CMS OPPS Rate,5081.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,14084.18,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,19315.33,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,24194.41,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,380.74,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,4903.32,100,,,Fee Schedule,100% of CMS OPPS Rate,5081.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,199.56,14,,,percent of total billed charges,14% of total billed charges,199.56,24194.41,
92920-PTCA CIRC,3431979,CDM,481,RC,92920,HCPCS,Outpatient,,,1425.4,712.7,,1069.05,75,,,percent of total billed charges,75% of total billed charges,1069.05,75,,,percent of total billed charges,75% of total billed charges,4903.32,100,,,Fee Schedule,100% of CMS OPPS Rate,380.74,100,,,Fee Schedule,100% of WV Medicaid Rate,8090.5,165,,,Fee Schedule,165% of CMS OPPS Rate,5081.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,14084.18,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,19315.33,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,24194.41,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,380.74,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,4903.32,100,,,Fee Schedule,100% of CMS OPPS Rate,5081.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,199.56,14,,,percent of total billed charges,14% of total billed charges,199.56,24194.41,
92920-PTCA LAD,3431980,CDM,481,RC,92920,HCPCS,Outpatient,,,1425.4,712.7,,1069.05,75,,,percent of total billed charges,75% of total billed charges,1069.05,75,,,percent of total billed charges,75% of total billed charges,4903.32,100,,,Fee Schedule,100% of CMS OPPS Rate,380.74,100,,,Fee Schedule,100% of WV Medicaid Rate,8090.5,165,,,Fee Schedule,165% of CMS OPPS Rate,5081.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,14084.18,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,19315.33,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,24194.41,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,380.74,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,4903.32,100,,,Fee Schedule,100% of CMS OPPS Rate,5081.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,199.56,14,,,percent of total billed charges,14% of total billed charges,199.56,24194.41,
92920-PTCA RCA,3431981,CDM,481,RC,92920,HCPCS,Outpatient,,,1425.4,712.7,,1069.05,75,,,percent of total billed charges,75% of total billed charges,1069.05,75,,,percent of total billed charges,75% of total billed charges,4903.32,100,,,Fee Schedule,100% of CMS OPPS Rate,380.74,100,,,Fee Schedule,100% of WV Medicaid Rate,8090.5,165,,,Fee Schedule,165% of CMS OPPS Rate,5081.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,14084.18,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,19315.33,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,24194.41,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,380.74,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,4903.32,100,,,Fee Schedule,100% of CMS OPPS Rate,5081.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,199.56,14,,,percent of total billed charges,14% of total billed charges,199.56,24194.41,
92921-Coronary Angioplasty add vessel- CIRC,4197417,CDM,481,RC,92921,HCPCS,Outpatient,,,625.65,312.83,,469.24,75,,,percent of total billed charges,75% of total billed charges,469.24,75,,,percent of total billed charges,75% of total billed charges,200.21,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,87.59,14,,,percent of total billed charges,14% of total billed charges,87.59,469.24,
92921-Coronary Angioplasty add vessel- DIAG,4197427,CDM,481,RC,92921,HCPCS,Outpatient,,,625.65,312.83,,469.24,75,,,percent of total billed charges,75% of total billed charges,469.24,75,,,percent of total billed charges,75% of total billed charges,200.21,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,87.59,14,,,percent of total billed charges,14% of total billed charges,87.59,469.24,
92921-Coronary Angioplasty add vessel- LAD,4197419,CDM,481,RC,92921,HCPCS,Outpatient,,,625.65,312.83,,469.24,75,,,percent of total billed charges,75% of total billed charges,469.24,75,,,percent of total billed charges,75% of total billed charges,200.21,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,87.59,14,,,percent of total billed charges,14% of total billed charges,87.59,469.24,
92921-Coronary Angioplasty add vessel- LT MAIN,4197433,CDM,481,RC,92921,HCPCS,Outpatient,,,625.65,312.83,,469.24,75,,,percent of total billed charges,75% of total billed charges,469.24,75,,,percent of total billed charges,75% of total billed charges,200.21,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,87.59,14,,,percent of total billed charges,14% of total billed charges,87.59,469.24,
92921-Coronary Angioplasty add vessel- OM,4197423,CDM,481,RC,92921,HCPCS,Outpatient,,,625.65,312.83,,469.24,75,,,percent of total billed charges,75% of total billed charges,469.24,75,,,percent of total billed charges,75% of total billed charges,200.21,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,87.59,14,,,percent of total billed charges,14% of total billed charges,87.59,469.24,
92921-Coronary Angioplasty add vessel- PDA,4197431,CDM,481,RC,92921,HCPCS,Outpatient,,,625.65,312.83,,469.24,75,,,percent of total billed charges,75% of total billed charges,469.24,75,,,percent of total billed charges,75% of total billed charges,200.21,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,87.59,14,,,percent of total billed charges,14% of total billed charges,87.59,469.24,
92921-Coronary Angioplasty add vessel- PLB,4197429,CDM,481,RC,92921,HCPCS,Outpatient,,,625.65,312.83,,469.24,75,,,percent of total billed charges,75% of total billed charges,469.24,75,,,percent of total billed charges,75% of total billed charges,200.21,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,87.59,14,,,percent of total billed charges,14% of total billed charges,87.59,469.24,
92921-Coronary Angioplasty add vessel- RAMUS,4197425,CDM,481,RC,92921,HCPCS,Outpatient,,,625.65,312.83,,469.24,75,,,percent of total billed charges,75% of total billed charges,469.24,75,,,percent of total billed charges,75% of total billed charges,200.21,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,87.59,14,,,percent of total billed charges,14% of total billed charges,87.59,469.24,
92921-Coronary Angioplasty add vessel- RCA,4197421,CDM,481,RC,92921,HCPCS,Outpatient,,,625.65,312.83,,469.24,75,,,percent of total billed charges,75% of total billed charges,469.24,75,,,percent of total billed charges,75% of total billed charges,200.21,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,87.59,14,,,percent of total billed charges,14% of total billed charges,87.59,469.24,
92921-PF Coronary Angioplasty add vessel- CIRC,4197418,CDM,960,RC,92921,HCPCS,Outpatient,,,625.65,312.83,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
92921-PF Coronary Angioplasty add vessel- DIAG,4197428,CDM,960,RC,92921,HCPCS,Outpatient,,,625.65,312.83,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
92921-PF Coronary Angioplasty add vessel- LAD,4197420,CDM,960,RC,92921,HCPCS,Outpatient,,,625.65,312.83,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
92921-PF Coronary Angioplasty add vessel- LT MAIN,4197434,CDM,960,RC,92921,HCPCS,Outpatient,,,625.65,312.83,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
92921-PF Coronary Angioplasty add vessel- OM,4197424,CDM,960,RC,92921,HCPCS,Outpatient,,,625.65,312.83,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
92921-PF Coronary Angioplasty add vessel- PDA,4197432,CDM,960,RC,92921,HCPCS,Outpatient,,,625.65,312.83,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
92921-PF Coronary Angioplasty add vessel- PLB,4197430,CDM,960,RC,92921,HCPCS,Outpatient,,,625.65,312.83,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
92921-PF Coronary Angioplasty add vessel- RAMUS,4197426,CDM,960,RC,92921,HCPCS,Outpatient,,,625.65,312.83,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
92921-PF Coronary Angioplasty add vessel- RCA,4197422,CDM,960,RC,92921,HCPCS,Outpatient,,,625.65,312.83,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
92924- Athrectomy sg cor/branch,3430754,CDM,481,RC,92924,HCPCS,Outpatient,,,1699.16,849.58,,1274.37,75,,,percent of total billed charges,75% of total billed charges,1274.37,75,,,percent of total billed charges,75% of total billed charges,9980.15,100,,,Fee Schedule,100% of CMS OPPS Rate,453.75,100,,,Fee Schedule,100% of WV Medicaid Rate,16467.25,165,,,Fee Schedule,165% of CMS OPPS Rate,10343.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,28666.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,39314,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,49244.77,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,453.75,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,9980.15,100,,,Fee Schedule,100% of CMS OPPS Rate,10343.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,237.88,14,,,percent of total billed charges,14% of total billed charges,237.88,49244.77,
92924-Ather/Rotablator LAD,3561395,CDM,481,RC,92924,HCPCS,Outpatient,,,1699.16,849.58,,1274.37,75,,,percent of total billed charges,75% of total billed charges,1274.37,75,,,percent of total billed charges,75% of total billed charges,9980.15,100,,,Fee Schedule,100% of CMS OPPS Rate,453.75,100,,,Fee Schedule,100% of WV Medicaid Rate,16467.25,165,,,Fee Schedule,165% of CMS OPPS Rate,10343.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,28666.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,39314,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,49244.77,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,453.75,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,9980.15,100,,,Fee Schedule,100% of CMS OPPS Rate,10343.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,237.88,14,,,percent of total billed charges,14% of total billed charges,237.88,49244.77,
92924-Ather/Rotablator RCA,3560658,CDM,481,RC,92924,HCPCS,Outpatient,,,1699.16,849.58,,1274.37,75,,,percent of total billed charges,75% of total billed charges,1274.37,75,,,percent of total billed charges,75% of total billed charges,9980.15,100,,,Fee Schedule,100% of CMS OPPS Rate,453.75,100,,,Fee Schedule,100% of WV Medicaid Rate,16467.25,165,,,Fee Schedule,165% of CMS OPPS Rate,10343.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,28666.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,39314,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,49244.77,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,453.75,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,9980.15,100,,,Fee Schedule,100% of CMS OPPS Rate,10343.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,237.88,14,,,percent of total billed charges,14% of total billed charges,237.88,49244.77,
92924-Coronary Atherectomy with coronary angioplasty-CIRC,4197345,CDM,481,RC,92924,HCPCS,Outpatient,,,1517.1,758.55,,1137.83,75,,,percent of total billed charges,75% of total billed charges,1137.83,75,,,percent of total billed charges,75% of total billed charges,9980.15,100,,,Fee Schedule,100% of CMS OPPS Rate,453.75,100,,,Fee Schedule,100% of WV Medicaid Rate,16467.25,165,,,Fee Schedule,165% of CMS OPPS Rate,10343.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,28666.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,39314,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,49244.77,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,453.75,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,9980.15,100,,,Fee Schedule,100% of CMS OPPS Rate,10343.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,212.39,14,,,percent of total billed charges,14% of total billed charges,212.39,49244.77,
92924-Coronary Atherectomy with coronary angioplasty-DIAG,4197355,CDM,481,RC,92924,HCPCS,Outpatient,,,1517.1,758.55,,1137.83,75,,,percent of total billed charges,75% of total billed charges,1137.83,75,,,percent of total billed charges,75% of total billed charges,9980.15,100,,,Fee Schedule,100% of CMS OPPS Rate,453.75,100,,,Fee Schedule,100% of WV Medicaid Rate,16467.25,165,,,Fee Schedule,165% of CMS OPPS Rate,10343.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,28666.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,39314,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,49244.77,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,453.75,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,9980.15,100,,,Fee Schedule,100% of CMS OPPS Rate,10343.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,212.39,14,,,percent of total billed charges,14% of total billed charges,212.39,49244.77,
92924-Coronary Atherectomy with coronary angioplasty-LAD,4197347,CDM,481,RC,92924,HCPCS,Outpatient,,,1517.1,758.55,,1137.83,75,,,percent of total billed charges,75% of total billed charges,1137.83,75,,,percent of total billed charges,75% of total billed charges,9980.15,100,,,Fee Schedule,100% of CMS OPPS Rate,453.75,100,,,Fee Schedule,100% of WV Medicaid Rate,16467.25,165,,,Fee Schedule,165% of CMS OPPS Rate,10343.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,28666.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,39314,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,49244.77,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,453.75,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,9980.15,100,,,Fee Schedule,100% of CMS OPPS Rate,10343.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,212.39,14,,,percent of total billed charges,14% of total billed charges,212.39,49244.77,
92924-Coronary Atherectomy with coronary angioplasty-LT MAIN,4197361,CDM,481,RC,92924,HCPCS,Outpatient,,,1517.1,758.55,,1137.83,75,,,percent of total billed charges,75% of total billed charges,1137.83,75,,,percent of total billed charges,75% of total billed charges,9980.15,100,,,Fee Schedule,100% of CMS OPPS Rate,453.75,100,,,Fee Schedule,100% of WV Medicaid Rate,16467.25,165,,,Fee Schedule,165% of CMS OPPS Rate,10343.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,28666.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,39314,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,49244.77,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,453.75,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,9980.15,100,,,Fee Schedule,100% of CMS OPPS Rate,10343.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,212.39,14,,,percent of total billed charges,14% of total billed charges,212.39,49244.77,
92924-Coronary Atherectomy with coronary angioplasty-OM,4197351,CDM,481,RC,92924,HCPCS,Outpatient,,,1517.1,758.55,,1137.83,75,,,percent of total billed charges,75% of total billed charges,1137.83,75,,,percent of total billed charges,75% of total billed charges,9980.15,100,,,Fee Schedule,100% of CMS OPPS Rate,453.75,100,,,Fee Schedule,100% of WV Medicaid Rate,16467.25,165,,,Fee Schedule,165% of CMS OPPS Rate,10343.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,28666.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,39314,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,49244.77,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,453.75,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,9980.15,100,,,Fee Schedule,100% of CMS OPPS Rate,10343.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,212.39,14,,,percent of total billed charges,14% of total billed charges,212.39,49244.77,
92924-Coronary Atherectomy with coronary angioplasty-PDA,4197359,CDM,481,RC,92924,HCPCS,Outpatient,,,1517.1,758.55,,1137.83,75,,,percent of total billed charges,75% of total billed charges,1137.83,75,,,percent of total billed charges,75% of total billed charges,9980.15,100,,,Fee Schedule,100% of CMS OPPS Rate,453.75,100,,,Fee Schedule,100% of WV Medicaid Rate,16467.25,165,,,Fee Schedule,165% of CMS OPPS Rate,10343.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,28666.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,39314,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,49244.77,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,453.75,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,9980.15,100,,,Fee Schedule,100% of CMS OPPS Rate,10343.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,212.39,14,,,percent of total billed charges,14% of total billed charges,212.39,49244.77,
92924-Coronary Atherectomy with coronary angioplasty-PLB,4197357,CDM,481,RC,92924,HCPCS,Outpatient,,,1517.1,758.55,,1137.83,75,,,percent of total billed charges,75% of total billed charges,1137.83,75,,,percent of total billed charges,75% of total billed charges,9980.15,100,,,Fee Schedule,100% of CMS OPPS Rate,453.75,100,,,Fee Schedule,100% of WV Medicaid Rate,16467.25,165,,,Fee Schedule,165% of CMS OPPS Rate,10343.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,28666.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,39314,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,49244.77,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,453.75,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,9980.15,100,,,Fee Schedule,100% of CMS OPPS Rate,10343.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,212.39,14,,,percent of total billed charges,14% of total billed charges,212.39,49244.77,
92924-Coronary Atherectomy with coronary angioplasty-RAMUS,4197353,CDM,481,RC,92924,HCPCS,Outpatient,,,1517.1,758.55,,1137.83,75,,,percent of total billed charges,75% of total billed charges,1137.83,75,,,percent of total billed charges,75% of total billed charges,9980.15,100,,,Fee Schedule,100% of CMS OPPS Rate,453.75,100,,,Fee Schedule,100% of WV Medicaid Rate,16467.25,165,,,Fee Schedule,165% of CMS OPPS Rate,10343.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,28666.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,39314,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,49244.77,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,453.75,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,9980.15,100,,,Fee Schedule,100% of CMS OPPS Rate,10343.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,212.39,14,,,percent of total billed charges,14% of total billed charges,212.39,49244.77,
92924-Coronary Atherectomy with coronary angioplasty-RCA,4197349,CDM,481,RC,92924,HCPCS,Outpatient,,,1517.1,758.55,,1137.83,75,,,percent of total billed charges,75% of total billed charges,1137.83,75,,,percent of total billed charges,75% of total billed charges,9980.15,100,,,Fee Schedule,100% of CMS OPPS Rate,453.75,100,,,Fee Schedule,100% of WV Medicaid Rate,16467.25,165,,,Fee Schedule,165% of CMS OPPS Rate,10343.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,28666.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,39314,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,49244.77,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,453.75,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,9980.15,100,,,Fee Schedule,100% of CMS OPPS Rate,10343.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,212.39,14,,,percent of total billed charges,14% of total billed charges,212.39,49244.77,
92924-PF Ather/Rotablator LAD,3580907,CDM,960,RC,92924,HCPCS,Outpatient,,,1699.16,849.58,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
92924-PF Ather/Rotablator RCA,3580906,CDM,960,RC,92924,HCPCS,Outpatient,,,1699.16,849.58,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
92924-PF Coronary Atherectomy with coronary angioplasty-CIRC,4197346,CDM,960,RC,92924,HCPCS,Outpatient,,,1517.1,758.55,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
92924-PF Coronary Atherectomy with coronary angioplasty-DIAG,4197356,CDM,960,RC,92924,HCPCS,Outpatient,,,1517.1,758.55,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
92924-PF Coronary Atherectomy with coronary angioplasty-LAD,4197348,CDM,960,RC,92924,HCPCS,Outpatient,,,1517.1,758.55,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
92924-PF Coronary Atherectomy with coronary angioplasty-LT MAIN,4197362,CDM,960,RC,92924,HCPCS,Outpatient,,,1517.1,758.55,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
92924-PF Coronary Atherectomy with coronary angioplasty-OM,4197352,CDM,960,RC,92924,HCPCS,Outpatient,,,1517.1,758.55,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
92924-PF Coronary Atherectomy with coronary angioplasty-PDA,4197360,CDM,960,RC,92924,HCPCS,Outpatient,,,1517.1,758.55,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
92924-PF Coronary Atherectomy with coronary angioplasty-PLB,4197358,CDM,960,RC,92924,HCPCS,Outpatient,,,1517.1,758.55,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
92924-PF Coronary Atherectomy with coronary angioplasty-RAMUS,4197354,CDM,960,RC,92924,HCPCS,Outpatient,,,1517.1,758.55,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
92924-PF Coronary Atherectomy with coronary angioplasty-RCA,4197350,CDM,960,RC,92924,HCPCS,Outpatient,,,1517.1,758.55,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
92925 Percutaneous transluminal coronary atherectomy with c,3623286,CDM,510,RC,92925,HCPCS,Outpatient,,,808.89,404.45,,606.67,75,,,percent of total billed charges,75% of total billed charges,606.67,75,,,percent of total billed charges,75% of total billed charges,258.84,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,113.24,14,,,percent of total billed charges,14% of total billed charges,113.24,606.67,
92925-Coronary Atherectomy with coronary angioplasty add vessel-CIRC,4197301,CDM,481,RC,92925,HCPCS,Outpatient,,,723,361.5,,542.25,75,,,percent of total billed charges,75% of total billed charges,542.25,75,,,percent of total billed charges,75% of total billed charges,231.36,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,101.22,14,,,percent of total billed charges,14% of total billed charges,101.22,542.25,
92925-Coronary Atherectomy with coronary angioplasty add vessel-DIAG,4197311,CDM,481,RC,92925,HCPCS,Outpatient,,,723,361.5,,542.25,75,,,percent of total billed charges,75% of total billed charges,542.25,75,,,percent of total billed charges,75% of total billed charges,231.36,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,101.22,14,,,percent of total billed charges,14% of total billed charges,101.22,542.25,
92925-Coronary Atherectomy with coronary angioplasty add vessel-LAD,4197303,CDM,481,RC,92925,HCPCS,Outpatient,,,723,361.5,,542.25,75,,,percent of total billed charges,75% of total billed charges,542.25,75,,,percent of total billed charges,75% of total billed charges,231.36,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,101.22,14,,,percent of total billed charges,14% of total billed charges,101.22,542.25,
92925-Coronary Atherectomy with coronary angioplasty add vessel-LT MAIN,4197317,CDM,481,RC,92925,HCPCS,Outpatient,,,723,361.5,,542.25,75,,,percent of total billed charges,75% of total billed charges,542.25,75,,,percent of total billed charges,75% of total billed charges,231.36,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,101.22,14,,,percent of total billed charges,14% of total billed charges,101.22,542.25,
92925-Coronary Atherectomy with coronary angioplasty add vessel-OM,4197307,CDM,481,RC,92925,HCPCS,Outpatient,,,723,361.5,,542.25,75,,,percent of total billed charges,75% of total billed charges,542.25,75,,,percent of total billed charges,75% of total billed charges,231.36,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,101.22,14,,,percent of total billed charges,14% of total billed charges,101.22,542.25,
92925-Coronary Atherectomy with coronary angioplasty add vessel-PDA,4197315,CDM,481,RC,92925,HCPCS,Outpatient,,,723,361.5,,542.25,75,,,percent of total billed charges,75% of total billed charges,542.25,75,,,percent of total billed charges,75% of total billed charges,231.36,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,101.22,14,,,percent of total billed charges,14% of total billed charges,101.22,542.25,
92925-Coronary Atherectomy with coronary angioplasty add vessel-PLB,4197313,CDM,481,RC,92925,HCPCS,Outpatient,,,723,361.5,,542.25,75,,,percent of total billed charges,75% of total billed charges,542.25,75,,,percent of total billed charges,75% of total billed charges,231.36,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,101.22,14,,,percent of total billed charges,14% of total billed charges,101.22,542.25,
92925-Coronary Atherectomy with coronary angioplasty add vessel-RAMUS,4197309,CDM,481,RC,92925,HCPCS,Outpatient,,,723,361.5,,542.25,75,,,percent of total billed charges,75% of total billed charges,542.25,75,,,percent of total billed charges,75% of total billed charges,231.36,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,101.22,14,,,percent of total billed charges,14% of total billed charges,101.22,542.25,
92925-Coronary Atherectomy with coronary angioplasty add vessel-RCA,4197305,CDM,481,RC,92925,HCPCS,Outpatient,,,723,361.5,,542.25,75,,,percent of total billed charges,75% of total billed charges,542.25,75,,,percent of total billed charges,75% of total billed charges,231.36,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,101.22,14,,,percent of total billed charges,14% of total billed charges,101.22,542.25,
92925-PF Coronary Atherectomy with coronary angioplasty add vessel-CIRC,4197302,CDM,960,RC,92925,HCPCS,Outpatient,,,723,361.5,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
92925-PF Coronary Atherectomy with coronary angioplasty add vessel-DIAG,4197312,CDM,960,RC,92925,HCPCS,Outpatient,,,723,361.5,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
92925-PF Coronary Atherectomy with coronary angioplasty add vessel-LAD,4197304,CDM,960,RC,92925,HCPCS,Outpatient,,,723,361.5,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
92925-PF Coronary Atherectomy with coronary angioplasty add vessel-LT MAIN,4197318,CDM,960,RC,92925,HCPCS,Outpatient,,,723,361.5,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
92925-PF Coronary Atherectomy with coronary angioplasty add vessel-OM,4197308,CDM,960,RC,92925,HCPCS,Outpatient,,,723,361.5,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
92925-PF Coronary Atherectomy with coronary angioplasty add vessel-PDA,4197316,CDM,960,RC,92925,HCPCS,Outpatient,,,723,361.5,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
92925-PF Coronary Atherectomy with coronary angioplasty add vessel-PLB,4197314,CDM,960,RC,92925,HCPCS,Outpatient,,,723,361.5,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
92925-PF Coronary Atherectomy with coronary angioplasty add vessel-RAMUS,4197310,CDM,960,RC,92925,HCPCS,Outpatient,,,723,361.5,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
92925-PF Coronary Atherectomy with coronary angioplasty add vessel-RCA,4197306,CDM,960,RC,92925,HCPCS,Outpatient,,,723,361.5,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
92928- Coronary stent/single cor art,3430756,CDM,481,RC,92928,HCPCS,Outpatient,,,1586.21,793.11,,1189.66,75,,,percent of total billed charges,75% of total billed charges,1189.66,75,,,percent of total billed charges,75% of total billed charges,9980.15,100,,,Fee Schedule,100% of CMS OPPS Rate,423.76,100,,,Fee Schedule,100% of WV Medicaid Rate,16467.25,165,,,Fee Schedule,165% of CMS OPPS Rate,10343.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,28666.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,39314,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,49244.77,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,423.76,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,9980.15,100,,,Fee Schedule,100% of CMS OPPS Rate,10343.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,222.07,14,,,percent of total billed charges,14% of total billed charges,222.07,49244.77,
92928-Coronary Angioplasty with coronary stent- CIRC,4217108,CDM,481,RC,92928,HCPCS,Outpatient,,,1241.6,620.8,,931.2,75,,,percent of total billed charges,75% of total billed charges,931.2,75,,,percent of total billed charges,75% of total billed charges,9980.15,100,,,Fee Schedule,100% of CMS OPPS Rate,423.76,100,,,Fee Schedule,100% of WV Medicaid Rate,16467.25,165,,,Fee Schedule,165% of CMS OPPS Rate,10343.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,28666.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,39314,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,49244.77,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,423.76,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,9980.15,100,,,Fee Schedule,100% of CMS OPPS Rate,10343.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,173.82,14,,,percent of total billed charges,14% of total billed charges,173.82,49244.77,
92928-Coronary Angioplasty with coronary stent- DIAG,4217135,CDM,481,RC,92928,HCPCS,Outpatient,,,1241.6,620.8,,931.2,75,,,percent of total billed charges,75% of total billed charges,931.2,75,,,percent of total billed charges,75% of total billed charges,9980.15,100,,,Fee Schedule,100% of CMS OPPS Rate,423.76,100,,,Fee Schedule,100% of WV Medicaid Rate,16467.25,165,,,Fee Schedule,165% of CMS OPPS Rate,10343.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,28666.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,39314,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,49244.77,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,423.76,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,9980.15,100,,,Fee Schedule,100% of CMS OPPS Rate,10343.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,173.82,14,,,percent of total billed charges,14% of total billed charges,173.82,49244.77,
92928-Coronary Angioplasty with coronary stent- LAD,4217111,CDM,481,RC,92928,HCPCS,Outpatient,,,1241.6,620.8,,931.2,75,,,percent of total billed charges,75% of total billed charges,931.2,75,,,percent of total billed charges,75% of total billed charges,9980.15,100,,,Fee Schedule,100% of CMS OPPS Rate,423.76,100,,,Fee Schedule,100% of WV Medicaid Rate,16467.25,165,,,Fee Schedule,165% of CMS OPPS Rate,10343.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,28666.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,39314,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,49244.77,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,423.76,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,9980.15,100,,,Fee Schedule,100% of CMS OPPS Rate,10343.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,173.82,14,,,percent of total billed charges,14% of total billed charges,173.82,49244.77,
92928-Coronary Angioplasty with coronary stent- LEFT MAIN,4217114,CDM,481,RC,92928,HCPCS,Outpatient,,,1241.6,620.8,,931.2,75,,,percent of total billed charges,75% of total billed charges,931.2,75,,,percent of total billed charges,75% of total billed charges,9980.15,100,,,Fee Schedule,100% of CMS OPPS Rate,423.76,100,,,Fee Schedule,100% of WV Medicaid Rate,16467.25,165,,,Fee Schedule,165% of CMS OPPS Rate,10343.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,28666.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,39314,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,49244.77,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,423.76,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,9980.15,100,,,Fee Schedule,100% of CMS OPPS Rate,10343.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,173.82,14,,,percent of total billed charges,14% of total billed charges,173.82,49244.77,
92928-Coronary Angioplasty with coronary stent- RAMUS,4217120,CDM,481,RC,92928,HCPCS,Outpatient,,,1241.6,620.8,,931.2,75,,,percent of total billed charges,75% of total billed charges,931.2,75,,,percent of total billed charges,75% of total billed charges,9980.15,100,,,Fee Schedule,100% of CMS OPPS Rate,423.76,100,,,Fee Schedule,100% of WV Medicaid Rate,16467.25,165,,,Fee Schedule,165% of CMS OPPS Rate,10343.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,28666.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,39314,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,49244.77,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,423.76,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,9980.15,100,,,Fee Schedule,100% of CMS OPPS Rate,10343.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,173.82,14,,,percent of total billed charges,14% of total billed charges,173.82,49244.77,
92928-Coronary Angioplasty with coronary stent- RCA,4217117,CDM,481,RC,92928,HCPCS,Outpatient,,,1241.6,620.8,,931.2,75,,,percent of total billed charges,75% of total billed charges,931.2,75,,,percent of total billed charges,75% of total billed charges,9980.15,100,,,Fee Schedule,100% of CMS OPPS Rate,423.76,100,,,Fee Schedule,100% of WV Medicaid Rate,16467.25,165,,,Fee Schedule,165% of CMS OPPS Rate,10343.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,28666.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,39314,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,49244.77,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,423.76,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,9980.15,100,,,Fee Schedule,100% of CMS OPPS Rate,10343.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,173.82,14,,,percent of total billed charges,14% of total billed charges,173.82,49244.77,
92928-PF Coronary Angioplasty with coronary stent- CIRC,4217109,CDM,960,RC,92928,HCPCS,Outpatient,,,1241.6,620.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
92928-PF Coronary Angioplasty with coronary stent- DIAG,4217136,CDM,960,RC,92928,HCPCS,Outpatient,,,1241.6,620.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
92928-PF Coronary Angioplasty with coronary stent- LAD,4217112,CDM,960,RC,92928,HCPCS,Outpatient,,,1241.6,620.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
92928-PF Coronary Angioplasty with coronary stent- LEFT MAIN,4217115,CDM,960,RC,92928,HCPCS,Outpatient,,,1241.6,620.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
92928-PF Coronary Angioplasty with coronary stent- RAMUS,4217121,CDM,960,RC,92928,HCPCS,Outpatient,,,1241.6,620.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
92928-PF Coronary Angioplasty with coronary stent- RCA,4217118,CDM,960,RC,92928,HCPCS,Outpatient,,,1241.6,620.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
Coronary Angioplasty with coronary stent- CIRC,,,480,RC,92928,HCPCS,Outpatient,,,1241.6,620.8,,931.2,75,,,percent of total billed charges,75% of total billed charges,931.2,75,,,percent of total billed charges,75% of total billed charges,9980.15,100,,,Fee Schedule,100% of CMS OPPS Rate,423.76,100,,,Fee Schedule,100% of WV Medicaid Rate,16467.25,165,,,Fee Schedule,165% of CMS OPPS Rate,10343.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,28666.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,39314,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,49244.77,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,423.76,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,9980.15,100,,,Fee Schedule,100% of CMS OPPS Rate,10343.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,173.82,14,,,percent of total billed charges,14% of total billed charges,173.82,49244.77,
Coronary Angioplasty with coronary stent- DIAG,,,480,RC,92928,HCPCS,Outpatient,,,1241.6,620.8,,931.2,75,,,percent of total billed charges,75% of total billed charges,931.2,75,,,percent of total billed charges,75% of total billed charges,9980.15,100,,,Fee Schedule,100% of CMS OPPS Rate,423.76,100,,,Fee Schedule,100% of WV Medicaid Rate,16467.25,165,,,Fee Schedule,165% of CMS OPPS Rate,10343.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,28666.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,39314,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,49244.77,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,423.76,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,9980.15,100,,,Fee Schedule,100% of CMS OPPS Rate,10343.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,173.82,14,,,percent of total billed charges,14% of total billed charges,173.82,49244.77,
Coronary Angioplasty with coronary stent- LAD,,,480,RC,92928,HCPCS,Outpatient,,,1241.6,620.8,,931.2,75,,,percent of total billed charges,75% of total billed charges,931.2,75,,,percent of total billed charges,75% of total billed charges,9980.15,100,,,Fee Schedule,100% of CMS OPPS Rate,423.76,100,,,Fee Schedule,100% of WV Medicaid Rate,16467.25,165,,,Fee Schedule,165% of CMS OPPS Rate,10343.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,28666.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,39314,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,49244.77,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,423.76,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,9980.15,100,,,Fee Schedule,100% of CMS OPPS Rate,10343.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,173.82,14,,,percent of total billed charges,14% of total billed charges,173.82,49244.77,
Coronary Angioplasty with coronary stent- LEFT MAIN,,,480,RC,92928,HCPCS,Outpatient,,,1241.6,620.8,,931.2,75,,,percent of total billed charges,75% of total billed charges,931.2,75,,,percent of total billed charges,75% of total billed charges,9980.15,100,,,Fee Schedule,100% of CMS OPPS Rate,423.76,100,,,Fee Schedule,100% of WV Medicaid Rate,16467.25,165,,,Fee Schedule,165% of CMS OPPS Rate,10343.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,28666.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,39314,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,49244.77,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,423.76,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,9980.15,100,,,Fee Schedule,100% of CMS OPPS Rate,10343.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,173.82,14,,,percent of total billed charges,14% of total billed charges,173.82,49244.77,
Coronary Angioplasty with coronary stent- RAMUS,,,480,RC,92928,HCPCS,Outpatient,,,1241.6,620.8,,931.2,75,,,percent of total billed charges,75% of total billed charges,931.2,75,,,percent of total billed charges,75% of total billed charges,9980.15,100,,,Fee Schedule,100% of CMS OPPS Rate,423.76,100,,,Fee Schedule,100% of WV Medicaid Rate,16467.25,165,,,Fee Schedule,165% of CMS OPPS Rate,10343.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,28666.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,39314,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,49244.77,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,423.76,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,9980.15,100,,,Fee Schedule,100% of CMS OPPS Rate,10343.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,173.82,14,,,percent of total billed charges,14% of total billed charges,173.82,49244.77,
Coronary Angioplasty with coronary stent- RCA,,,480,RC,92928,HCPCS,Outpatient,,,1241.6,620.8,,931.2,75,,,percent of total billed charges,75% of total billed charges,931.2,75,,,percent of total billed charges,75% of total billed charges,9980.15,100,,,Fee Schedule,100% of CMS OPPS Rate,423.76,100,,,Fee Schedule,100% of WV Medicaid Rate,16467.25,165,,,Fee Schedule,165% of CMS OPPS Rate,10343.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,28666.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,39314,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,49244.77,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,423.76,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,9980.15,100,,,Fee Schedule,100% of CMS OPPS Rate,10343.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,173.82,14,,,percent of total billed charges,14% of total billed charges,173.82,49244.77,
92929 Percutaneous transcatheter placement of intracoronary,3623279,CDM,510,RC,92929,HCPCS,Outpatient,,,794.67,397.34,,596,75,,,percent of total billed charges,75% of total billed charges,596,75,,,percent of total billed charges,75% of total billed charges,254.29,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,111.25,14,,,percent of total billed charges,14% of total billed charges,111.25,596,
92929 PF -Coronary Angioplasty with coronary stent add vesse,4217133,CDM,960,RC,92929,HCPCS,Outpatient,,,794.67,397.34,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
92929-Coronary Angioplasty with coronary stent add vessel- C,4217123,CDM,481,RC,92929,HCPCS,Outpatient,,,794.67,397.34,,596,75,,,percent of total billed charges,75% of total billed charges,596,75,,,percent of total billed charges,75% of total billed charges,254.29,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,111.25,14,,,percent of total billed charges,14% of total billed charges,111.25,596,
92929-Coronary Angioplasty with coronary stent add vessel- D,4217138,CDM,481,RC,92929,HCPCS,Outpatient,,,794.67,397.34,,596,75,,,percent of total billed charges,75% of total billed charges,596,75,,,percent of total billed charges,75% of total billed charges,254.29,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,111.25,14,,,percent of total billed charges,14% of total billed charges,111.25,596,
92929-Coronary Angioplasty with coronary stent add vessel- L,4217126,CDM,481,RC,92929,HCPCS,Outpatient,,,794.67,397.34,,596,75,,,percent of total billed charges,75% of total billed charges,596,75,,,percent of total billed charges,75% of total billed charges,254.29,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,111.25,14,,,percent of total billed charges,14% of total billed charges,111.25,596,
92929-Coronary Angioplasty with coronary stent add vessel- L,4217129,CDM,481,RC,92929,HCPCS,Outpatient,,,794.67,397.34,,596,75,,,percent of total billed charges,75% of total billed charges,596,75,,,percent of total billed charges,75% of total billed charges,254.29,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,111.25,14,,,percent of total billed charges,14% of total billed charges,111.25,596,
92929-Coronary Angioplasty with coronary stent add vessel- R,4217132,CDM,481,RC,92929,HCPCS,Outpatient,,,794.67,397.34,,596,75,,,percent of total billed charges,75% of total billed charges,596,75,,,percent of total billed charges,75% of total billed charges,254.29,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,111.25,14,,,percent of total billed charges,14% of total billed charges,111.25,596,
92929-PF Coronary Angioplasty with coronary stent add vessel,4217124,CDM,960,RC,92929,HCPCS,Outpatient,,,794.67,397.34,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
92929-PF Coronary Angioplasty with coronary stent add vessel,4217127,CDM,960,RC,92929,HCPCS,Outpatient,,,794.67,397.34,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
92929-PF Coronary Angioplasty with coronary stent add vessel,4217130,CDM,960,RC,92929,HCPCS,Outpatient,,,794.67,397.34,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
92929-PF Coronary Angioplasty with coronary stent add vessel,4217139,CDM,960,RC,92929,HCPCS,Outpatient,,,794.67,397.34,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
Coronary Angioplasty with coronary stent add vessel- CIRC,,,480,RC,92929,HCPCS,Outpatient,,,794.67,397.34,,596,75,,,percent of total billed charges,75% of total billed charges,596,75,,,percent of total billed charges,75% of total billed charges,254.29,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,111.25,14,,,percent of total billed charges,14% of total billed charges,111.25,596,
Coronary Angioplasty with coronary stent add vessel- DIAG,,,480,RC,92929,HCPCS,Outpatient,,,794.67,397.34,,596,75,,,percent of total billed charges,75% of total billed charges,596,75,,,percent of total billed charges,75% of total billed charges,254.29,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,111.25,14,,,percent of total billed charges,14% of total billed charges,111.25,596,
Coronary Angioplasty with coronary stent add vessel- LAD,,,480,RC,92929,HCPCS,Outpatient,,,794.67,397.34,,596,75,,,percent of total billed charges,75% of total billed charges,596,75,,,percent of total billed charges,75% of total billed charges,254.29,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,111.25,14,,,percent of total billed charges,14% of total billed charges,111.25,596,
Coronary Angioplasty with coronary stent add vessel- LEFT MAIN,,,480,RC,92929,HCPCS,Outpatient,,,794.67,397.34,,596,75,,,percent of total billed charges,75% of total billed charges,596,75,,,percent of total billed charges,75% of total billed charges,254.29,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,111.25,14,,,percent of total billed charges,14% of total billed charges,111.25,596,
Coronary Angioplasty with coronary stent add vessel- RCA,,,480,RC,92929,HCPCS,Outpatient,,,794.67,397.34,,596,75,,,percent of total billed charges,75% of total billed charges,596,75,,,percent of total billed charges,75% of total billed charges,254.29,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,111.25,14,,,percent of total billed charges,14% of total billed charges,111.25,596,
92933 - ATHERECTOMY W DES LC,4165504,CDM,481,RC,92933,HCPCS,Outpatient,,,3177.56,1588.78,,2383.17,75,,,percent of total billed charges,75% of total billed charges,2383.17,75,,,percent of total billed charges,75% of total billed charges,16149.79,100,,,Fee Schedule,100% of CMS OPPS Rate,475.38,100,,,Fee Schedule,100% of WV Medicaid Rate,26647.16,165,,,Fee Schedule,165% of CMS OPPS Rate,16737.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,46388.09,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,63617.56,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,79687.45,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,475.38,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,16149.79,100,,,Fee Schedule,100% of CMS OPPS Rate,16737.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,444.86,14,,,percent of total billed charges,14% of total billed charges,444.86,79687.45,
92933 -ATHERECTOMY W DES LAD,4167144,CDM,481,RC,92933,HCPCS,Outpatient,,,3177.56,1588.78,,2383.17,75,,,percent of total billed charges,75% of total billed charges,2383.17,75,,,percent of total billed charges,75% of total billed charges,16149.79,100,,,Fee Schedule,100% of CMS OPPS Rate,475.38,100,,,Fee Schedule,100% of WV Medicaid Rate,26647.16,165,,,Fee Schedule,165% of CMS OPPS Rate,16737.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,46388.09,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,63617.56,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,79687.45,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,475.38,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,16149.79,100,,,Fee Schedule,100% of CMS OPPS Rate,16737.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,444.86,14,,,percent of total billed charges,14% of total billed charges,444.86,79687.45,
92933- ATHERECTOMY W DES LT MAIN,4167146,CDM,481,RC,92933,HCPCS,Outpatient,,,3177.56,1588.78,,2383.17,75,,,percent of total billed charges,75% of total billed charges,2383.17,75,,,percent of total billed charges,75% of total billed charges,16149.79,100,,,Fee Schedule,100% of CMS OPPS Rate,475.38,100,,,Fee Schedule,100% of WV Medicaid Rate,26647.16,165,,,Fee Schedule,165% of CMS OPPS Rate,16737.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,46388.09,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,63617.56,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,79687.45,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,475.38,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,16149.79,100,,,Fee Schedule,100% of CMS OPPS Rate,16737.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,444.86,14,,,percent of total billed charges,14% of total billed charges,444.86,79687.45,
92933- ATHERECTOMY W DES RAMUS,4167145,CDM,481,RC,92933,HCPCS,Outpatient,,,3177.56,1588.78,,2383.17,75,,,percent of total billed charges,75% of total billed charges,2383.17,75,,,percent of total billed charges,75% of total billed charges,16149.79,100,,,Fee Schedule,100% of CMS OPPS Rate,475.38,100,,,Fee Schedule,100% of WV Medicaid Rate,26647.16,165,,,Fee Schedule,165% of CMS OPPS Rate,16737.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,46388.09,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,63617.56,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,79687.45,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,475.38,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,16149.79,100,,,Fee Schedule,100% of CMS OPPS Rate,16737.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,444.86,14,,,percent of total billed charges,14% of total billed charges,444.86,79687.45,
92933- Athrectomy/stent sg cor/branch,3430758,CDM,510,RC,92933,HCPCS,Outpatient,,,1779.43,889.72,,1334.57,75,,,percent of total billed charges,75% of total billed charges,1334.57,75,,,percent of total billed charges,75% of total billed charges,16149.79,100,,,Fee Schedule,100% of CMS OPPS Rate,475.38,100,,,Fee Schedule,100% of WV Medicaid Rate,26647.16,165,,,Fee Schedule,165% of CMS OPPS Rate,16737.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,46388.09,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,63617.56,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,79687.45,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,475.38,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,16149.79,100,,,Fee Schedule,100% of CMS OPPS Rate,16737.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,249.12,14,,,percent of total billed charges,14% of total billed charges,249.12,79687.45,
92933-Athrectomy W/PTA/Stent,3552627,CDM,481,RC,92933,HCPCS,Outpatient,,,1779.43,889.72,,1334.57,75,,,percent of total billed charges,75% of total billed charges,1334.57,75,,,percent of total billed charges,75% of total billed charges,16149.79,100,,,Fee Schedule,100% of CMS OPPS Rate,475.38,100,,,Fee Schedule,100% of WV Medicaid Rate,26647.16,165,,,Fee Schedule,165% of CMS OPPS Rate,16737.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,46388.09,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,63617.56,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,79687.45,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,475.38,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,16149.79,100,,,Fee Schedule,100% of CMS OPPS Rate,16737.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,249.12,14,,,percent of total billed charges,14% of total billed charges,249.12,79687.45,
92933-Coronary Atherectomy with coronary stent- LT MAIN,4197379,CDM,481,RC,92933,HCPCS,Outpatient,,,1588.78,794.39,,1191.59,75,,,percent of total billed charges,75% of total billed charges,1191.59,75,,,percent of total billed charges,75% of total billed charges,16149.79,100,,,Fee Schedule,100% of CMS OPPS Rate,475.38,100,,,Fee Schedule,100% of WV Medicaid Rate,26647.16,165,,,Fee Schedule,165% of CMS OPPS Rate,16737.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,46388.09,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,63617.56,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,79687.45,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,475.38,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,16149.79,100,,,Fee Schedule,100% of CMS OPPS Rate,16737.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,222.43,14,,,percent of total billed charges,14% of total billed charges,222.43,79687.45,
92933-Coronary Atherectomy with coronary stent-CIRC,4197363,CDM,481,RC,92933,HCPCS,Outpatient,,,1588.78,794.39,,1191.59,75,,,percent of total billed charges,75% of total billed charges,1191.59,75,,,percent of total billed charges,75% of total billed charges,16149.79,100,,,Fee Schedule,100% of CMS OPPS Rate,475.38,100,,,Fee Schedule,100% of WV Medicaid Rate,26647.16,165,,,Fee Schedule,165% of CMS OPPS Rate,16737.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,46388.09,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,63617.56,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,79687.45,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,475.38,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,16149.79,100,,,Fee Schedule,100% of CMS OPPS Rate,16737.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,222.43,14,,,percent of total billed charges,14% of total billed charges,222.43,79687.45,
92933-Coronary Atherectomy with coronary stent-DIAG,4197373,CDM,481,RC,92933,HCPCS,Outpatient,,,1588.78,794.39,,1191.59,75,,,percent of total billed charges,75% of total billed charges,1191.59,75,,,percent of total billed charges,75% of total billed charges,16149.79,100,,,Fee Schedule,100% of CMS OPPS Rate,475.38,100,,,Fee Schedule,100% of WV Medicaid Rate,26647.16,165,,,Fee Schedule,165% of CMS OPPS Rate,16737.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,46388.09,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,63617.56,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,79687.45,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,475.38,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,16149.79,100,,,Fee Schedule,100% of CMS OPPS Rate,16737.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,222.43,14,,,percent of total billed charges,14% of total billed charges,222.43,79687.45,
92933-Coronary Atherectomy with coronary stent-LAD,4197365,CDM,481,RC,92933,HCPCS,Outpatient,,,1588.78,794.39,,1191.59,75,,,percent of total billed charges,75% of total billed charges,1191.59,75,,,percent of total billed charges,75% of total billed charges,16149.79,100,,,Fee Schedule,100% of CMS OPPS Rate,475.38,100,,,Fee Schedule,100% of WV Medicaid Rate,26647.16,165,,,Fee Schedule,165% of CMS OPPS Rate,16737.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,46388.09,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,63617.56,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,79687.45,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,475.38,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,16149.79,100,,,Fee Schedule,100% of CMS OPPS Rate,16737.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,222.43,14,,,percent of total billed charges,14% of total billed charges,222.43,79687.45,
92933-Coronary Atherectomy with coronary stent-OM,4197369,CDM,481,RC,92933,HCPCS,Outpatient,,,1588.78,794.39,,1191.59,75,,,percent of total billed charges,75% of total billed charges,1191.59,75,,,percent of total billed charges,75% of total billed charges,16149.79,100,,,Fee Schedule,100% of CMS OPPS Rate,475.38,100,,,Fee Schedule,100% of WV Medicaid Rate,26647.16,165,,,Fee Schedule,165% of CMS OPPS Rate,16737.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,46388.09,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,63617.56,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,79687.45,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,475.38,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,16149.79,100,,,Fee Schedule,100% of CMS OPPS Rate,16737.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,222.43,14,,,percent of total billed charges,14% of total billed charges,222.43,79687.45,
92933-Coronary Atherectomy with coronary stent-PDA,4197377,CDM,481,RC,92933,HCPCS,Outpatient,,,1588.78,794.39,,1191.59,75,,,percent of total billed charges,75% of total billed charges,1191.59,75,,,percent of total billed charges,75% of total billed charges,16149.79,100,,,Fee Schedule,100% of CMS OPPS Rate,475.38,100,,,Fee Schedule,100% of WV Medicaid Rate,26647.16,165,,,Fee Schedule,165% of CMS OPPS Rate,16737.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,46388.09,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,63617.56,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,79687.45,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,475.38,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,16149.79,100,,,Fee Schedule,100% of CMS OPPS Rate,16737.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,222.43,14,,,percent of total billed charges,14% of total billed charges,222.43,79687.45,
92933-Coronary Atherectomy with coronary stent-PLB,4197375,CDM,481,RC,92933,HCPCS,Outpatient,,,1588.78,794.39,,1191.59,75,,,percent of total billed charges,75% of total billed charges,1191.59,75,,,percent of total billed charges,75% of total billed charges,16149.79,100,,,Fee Schedule,100% of CMS OPPS Rate,475.38,100,,,Fee Schedule,100% of WV Medicaid Rate,26647.16,165,,,Fee Schedule,165% of CMS OPPS Rate,16737.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,46388.09,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,63617.56,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,79687.45,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,475.38,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,16149.79,100,,,Fee Schedule,100% of CMS OPPS Rate,16737.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,222.43,14,,,percent of total billed charges,14% of total billed charges,222.43,79687.45,
92933-Coronary Atherectomy with coronary stent-RAMUS,4197371,CDM,481,RC,92933,HCPCS,Outpatient,,,1588.78,794.39,,1191.59,75,,,percent of total billed charges,75% of total billed charges,1191.59,75,,,percent of total billed charges,75% of total billed charges,16149.79,100,,,Fee Schedule,100% of CMS OPPS Rate,475.38,100,,,Fee Schedule,100% of WV Medicaid Rate,26647.16,165,,,Fee Schedule,165% of CMS OPPS Rate,16737.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,46388.09,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,63617.56,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,79687.45,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,475.38,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,16149.79,100,,,Fee Schedule,100% of CMS OPPS Rate,16737.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,222.43,14,,,percent of total billed charges,14% of total billed charges,222.43,79687.45,
92933-Coronary Atherectomy with coronary stent-RCA,4197367,CDM,481,RC,92933,HCPCS,Outpatient,,,1588.78,794.39,,1191.59,75,,,percent of total billed charges,75% of total billed charges,1191.59,75,,,percent of total billed charges,75% of total billed charges,16149.79,100,,,Fee Schedule,100% of CMS OPPS Rate,475.38,100,,,Fee Schedule,100% of WV Medicaid Rate,26647.16,165,,,Fee Schedule,165% of CMS OPPS Rate,16737.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,46388.09,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,63617.56,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,79687.45,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,475.38,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,16149.79,100,,,Fee Schedule,100% of CMS OPPS Rate,16737.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,222.43,14,,,percent of total billed charges,14% of total billed charges,222.43,79687.45,
92933-PF ATHERECTOMY W DES LAD,4167147,CDM,960,RC,92933,HCPCS,Outpatient,,,3177.56,1588.78,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
92933-PF ATHERECTOMY W DES LC,4165505,CDM,960,RC,92933,HCPCS,Outpatient,,,3177.56,1588.78,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
92933-PF ATHERECTOMY W DES LT MAIN,4165506,CDM,960,RC,92933,HCPCS,Outpatient,,,3177.56,1588.78,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
92933-PF ATHERECTOMY W DES RAMUS,4167148,CDM,960,RC,92933,HCPCS,Outpatient,,,3177.56,1588.78,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
92933-PF Athrectomy W/PTA/Stent,3580909,CDM,960,RC,92933,HCPCS,Outpatient,,,1779.43,889.72,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
92933-PF Coronary Atherectomy with coronary stent- LT MAIN,4197380,CDM,960,RC,92933,HCPCS,Outpatient,,,1588.78,794.39,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
92933-PF Coronary Atherectomy with coronary stent-CIRC,4197364,CDM,960,RC,92933,HCPCS,Outpatient,,,1588.78,794.39,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
92933-PF Coronary Atherectomy with coronary stent-DIAG,4197374,CDM,960,RC,92933,HCPCS,Outpatient,,,1588.78,794.39,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
92933-PF Coronary Atherectomy with coronary stent-LAD,4197366,CDM,960,RC,92933,HCPCS,Outpatient,,,1588.78,794.39,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
92933-PF Coronary Atherectomy with coronary stent-OM,4197370,CDM,960,RC,92933,HCPCS,Outpatient,,,1588.78,794.39,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
92933-PF Coronary Atherectomy with coronary stent-PDA,4197378,CDM,960,RC,92933,HCPCS,Outpatient,,,1588.78,794.39,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
92933-PF Coronary Atherectomy with coronary stent-PLB,4197376,CDM,960,RC,92933,HCPCS,Outpatient,,,1588.78,794.39,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
92933-PF Coronary Atherectomy with coronary stent-RAMUS,4197372,CDM,960,RC,92933,HCPCS,Outpatient,,,1588.78,794.39,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
92933-PF Coronary Atherectomy with coronary stent-RCA,4197368,CDM,960,RC,92933,HCPCS,Outpatient,,,1588.78,794.39,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
ATHERECTOMY W DES LAD,,,480,RC,92933,HCPCS,Outpatient,,,1739.17,869.59,,1304.38,75,,,percent of total billed charges,75% of total billed charges,1304.38,75,,,percent of total billed charges,75% of total billed charges,16149.79,100,,,Fee Schedule,100% of CMS OPPS Rate,475.38,100,,,Fee Schedule,100% of WV Medicaid Rate,26647.16,165,,,Fee Schedule,165% of CMS OPPS Rate,16737.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,46388.09,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,63617.56,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,79687.45,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,475.38,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,16149.79,100,,,Fee Schedule,100% of CMS OPPS Rate,16737.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,243.48,14,,,percent of total billed charges,14% of total billed charges,243.48,79687.45,
ATHERECTOMY W DES LC,,,480,RC,92933,HCPCS,Outpatient,,,1739.17,869.59,,1304.38,75,,,percent of total billed charges,75% of total billed charges,1304.38,75,,,percent of total billed charges,75% of total billed charges,16149.79,100,,,Fee Schedule,100% of CMS OPPS Rate,475.38,100,,,Fee Schedule,100% of WV Medicaid Rate,26647.16,165,,,Fee Schedule,165% of CMS OPPS Rate,16737.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,46388.09,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,63617.56,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,79687.45,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,475.38,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,16149.79,100,,,Fee Schedule,100% of CMS OPPS Rate,16737.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,243.48,14,,,percent of total billed charges,14% of total billed charges,243.48,79687.45,
ATHERECTOMY W DES LT MAIN,,,480,RC,92933,HCPCS,Outpatient,,,1739.17,869.59,,1304.38,75,,,percent of total billed charges,75% of total billed charges,1304.38,75,,,percent of total billed charges,75% of total billed charges,16149.79,100,,,Fee Schedule,100% of CMS OPPS Rate,475.38,100,,,Fee Schedule,100% of WV Medicaid Rate,26647.16,165,,,Fee Schedule,165% of CMS OPPS Rate,16737.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,46388.09,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,63617.56,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,79687.45,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,475.38,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,16149.79,100,,,Fee Schedule,100% of CMS OPPS Rate,16737.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,243.48,14,,,percent of total billed charges,14% of total billed charges,243.48,79687.45,
ATHERECTOMY W DES RAMUS,,,480,RC,92933,HCPCS,Outpatient,,,1739.17,869.59,,1304.38,75,,,percent of total billed charges,75% of total billed charges,1304.38,75,,,percent of total billed charges,75% of total billed charges,16149.79,100,,,Fee Schedule,100% of CMS OPPS Rate,475.38,100,,,Fee Schedule,100% of WV Medicaid Rate,26647.16,165,,,Fee Schedule,165% of CMS OPPS Rate,16737.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,46388.09,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,63617.56,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,79687.45,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,475.38,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,16149.79,100,,,Fee Schedule,100% of CMS OPPS Rate,16737.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,243.48,14,,,percent of total billed charges,14% of total billed charges,243.48,79687.45,
92934-Coronary Atherectomy with coronary stent  add vessel-DIAG,4197391,CDM,481,RC,92934,HCPCS,Outpatient,,,725.38,362.69,,544.04,75,,,percent of total billed charges,75% of total billed charges,544.04,75,,,percent of total billed charges,75% of total billed charges,232.12,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,101.55,14,,,percent of total billed charges,14% of total billed charges,101.55,544.04,
92934-Coronary Atherectomy with coronary stent  add vessel-LT MAIN,4197397,CDM,481,RC,92934,HCPCS,Outpatient,,,725.38,362.69,,544.04,75,,,percent of total billed charges,75% of total billed charges,544.04,75,,,percent of total billed charges,75% of total billed charges,232.12,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,101.55,14,,,percent of total billed charges,14% of total billed charges,101.55,544.04,
92934-Coronary Atherectomy with coronary stent  add vessel-PDA,4197395,CDM,481,RC,92934,HCPCS,Outpatient,,,725.38,362.69,,544.04,75,,,percent of total billed charges,75% of total billed charges,544.04,75,,,percent of total billed charges,75% of total billed charges,232.12,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,101.55,14,,,percent of total billed charges,14% of total billed charges,101.55,544.04,
92934-Coronary Atherectomy with coronary stent  add vessel-PLB,4197393,CDM,481,RC,92934,HCPCS,Outpatient,,,725.38,362.69,,544.04,75,,,percent of total billed charges,75% of total billed charges,544.04,75,,,percent of total billed charges,75% of total billed charges,232.12,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,101.55,14,,,percent of total billed charges,14% of total billed charges,101.55,544.04,
92934-Coronary Atherectomy with coronary stent  add vessel-RAMUS,4197389,CDM,481,RC,92934,HCPCS,Outpatient,,,725.38,362.69,,544.04,75,,,percent of total billed charges,75% of total billed charges,544.04,75,,,percent of total billed charges,75% of total billed charges,232.12,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,101.55,14,,,percent of total billed charges,14% of total billed charges,101.55,544.04,
92934-Coronary Atherectomy with coronary stent add vessel-CIRC,4197381,CDM,481,RC,92934,HCPCS,Outpatient,,,725.38,362.69,,544.04,75,,,percent of total billed charges,75% of total billed charges,544.04,75,,,percent of total billed charges,75% of total billed charges,232.12,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,101.55,14,,,percent of total billed charges,14% of total billed charges,101.55,544.04,
92934-Coronary Atherectomy with coronary stent add vessel-LAD,4197383,CDM,481,RC,92934,HCPCS,Outpatient,,,725.38,362.69,,544.04,75,,,percent of total billed charges,75% of total billed charges,544.04,75,,,percent of total billed charges,75% of total billed charges,232.12,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,101.55,14,,,percent of total billed charges,14% of total billed charges,101.55,544.04,
92934-Coronary Atherectomy with coronary stent add vessel-OM,4197387,CDM,481,RC,92934,HCPCS,Outpatient,,,725.38,362.69,,544.04,75,,,percent of total billed charges,75% of total billed charges,544.04,75,,,percent of total billed charges,75% of total billed charges,232.12,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,101.55,14,,,percent of total billed charges,14% of total billed charges,101.55,544.04,
92934-Coronary Atherectomy with coronary stent add vessel-RCA,4197385,CDM,481,RC,92934,HCPCS,Outpatient,,,725.38,362.69,,544.04,75,,,percent of total billed charges,75% of total billed charges,544.04,75,,,percent of total billed charges,75% of total billed charges,232.12,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,101.55,14,,,percent of total billed charges,14% of total billed charges,101.55,544.04,
92934-PF Coronary Atherectomy with coronary stent  add vessel-DIAG,4197392,CDM,960,RC,92934,HCPCS,Outpatient,,,725.38,362.69,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
92934-PF Coronary Atherectomy with coronary stent  add vessel-LT MAIN,4197398,CDM,960,RC,92934,HCPCS,Outpatient,,,725.38,362.69,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
92934-PF Coronary Atherectomy with coronary stent  add vessel-PDA,4197396,CDM,960,RC,92934,HCPCS,Outpatient,,,725.38,362.69,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
92934-PF Coronary Atherectomy with coronary stent  add vessel-PLB,4197394,CDM,960,RC,92934,HCPCS,Outpatient,,,725.38,362.69,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
92934-PF Coronary Atherectomy with coronary stent  add vessel-RAMUS,4197390,CDM,960,RC,92934,HCPCS,Outpatient,,,725.38,362.69,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
92934-PF Coronary Atherectomy with coronary stent add vessel-CIRC,4197382,CDM,960,RC,92934,HCPCS,Outpatient,,,725.38,362.69,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
92934-PF Coronary Atherectomy with coronary stent add vessel-LAD,4197384,CDM,960,RC,92934,HCPCS,Outpatient,,,725.38,362.69,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
92934-PF Coronary Atherectomy with coronary stent add vessel-OM,4197388,CDM,960,RC,92934,HCPCS,Outpatient,,,725.38,362.69,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
92934-PF Coronary Atherectomy with coronary stent add vessel-RCA,4197386,CDM,960,RC,92934,HCPCS,Outpatient,,,725.38,362.69,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
92937- PCI of/through CABG single vessel,3430760,CDM,510,RC,92937,HCPCS,Outpatient,,,1584.51,792.26,,1188.38,75,,,percent of total billed charges,75% of total billed charges,1188.38,75,,,percent of total billed charges,75% of total billed charges,9980.15,100,,,Fee Schedule,100% of CMS OPPS Rate,423.27,100,,,Fee Schedule,100% of WV Medicaid Rate,16467.25,165,,,Fee Schedule,165% of CMS OPPS Rate,10343.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,28666.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,39314,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,49244.77,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,423.27,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,9980.15,100,,,Fee Schedule,100% of CMS OPPS Rate,10343.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,221.83,14,,,percent of total billed charges,14% of total billed charges,221.83,49244.77,
92938 Percutaneous transluminal revascularization of or thro,3622807,CDM,510,RC,92938,HCPCS,Outpatient,,,793.82,396.91,,595.37,75,,,percent of total billed charges,75% of total billed charges,595.37,75,,,percent of total billed charges,75% of total billed charges,254.02,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,111.13,14,,,percent of total billed charges,14% of total billed charges,111.13,595.37,
92941- PCI total/subto occ/AMI/single cor,3430762,CDM,510,RC,92941,HCPCS,Outpatient,,,1782.85,891.43,,1337.14,75,,,percent of total billed charges,75% of total billed charges,1337.14,75,,,percent of total billed charges,75% of total billed charges,1782.85,100,,,Fee Schedule,Pays at line item charges based on APC Setting,476.11,100,,,Fee Schedule,100% of WV Medicaid Rate,1782.85,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1782.85,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1782.85,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1782.85,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1782.85,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,476.11,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1782.85,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1782.85,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,249.6,14,,,percent of total billed charges,14% of total billed charges,249.6,1782.85,
92941-PF Prq Trluml Coronr Tot Occlus Revasc Mi One Vsl,4361225,CDM,960,RC,92941,HCPCS,Outpatient,,,1286.5,643.25,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
92941-Prq Trluml Coronr Tot Occlus Revasc Mi One Vsl,4361224,CDM,481,RC,92941,HCPCS,Outpatient,,,1286.5,643.25,,964.88,75,,,percent of total billed charges,75% of total billed charges,964.88,75,,,percent of total billed charges,75% of total billed charges,1286.5,100,,,Fee Schedule,Pays at line item charges based on APC Setting,476.11,100,,,Fee Schedule,100% of WV Medicaid Rate,1286.5,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1286.5,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1286.5,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1286.5,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1286.5,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,476.11,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1286.5,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1286.5,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,180.11,14,,,percent of total billed charges,14% of total billed charges,180.11,1286.5,
92943 - PCI CTO DES LAD,4141219,CDM,481,RC,92943,HCPCS,Outpatient,,,1592.11,796.06,,1194.08,75,,,percent of total billed charges,75% of total billed charges,1194.08,75,,,percent of total billed charges,75% of total billed charges,9980.15,100,,,Fee Schedule,100% of CMS OPPS Rate,476.11,100,,,Fee Schedule,100% of WV Medicaid Rate,16467.25,165,,,Fee Schedule,165% of CMS OPPS Rate,10343.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,28666.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,39314,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,49244.77,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,476.11,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,9980.15,100,,,Fee Schedule,100% of CMS OPPS Rate,10343.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,222.9,14,,,percent of total billed charges,14% of total billed charges,222.9,49244.77,
92943 - PCI CTO DES LC,4141220,CDM,481,RC,92943,HCPCS,Outpatient,,,1592.11,796.06,,1194.08,75,,,percent of total billed charges,75% of total billed charges,1194.08,75,,,percent of total billed charges,75% of total billed charges,9980.15,100,,,Fee Schedule,100% of CMS OPPS Rate,476.11,100,,,Fee Schedule,100% of WV Medicaid Rate,16467.25,165,,,Fee Schedule,165% of CMS OPPS Rate,10343.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,28666.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,39314,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,49244.77,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,476.11,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,9980.15,100,,,Fee Schedule,100% of CMS OPPS Rate,10343.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,222.9,14,,,percent of total billed charges,14% of total billed charges,222.9,49244.77,
92943 - PCI CTO DES LT MAIN,4141223,CDM,481,RC,92943,HCPCS,Outpatient,,,1592.11,796.06,,1194.08,75,,,percent of total billed charges,75% of total billed charges,1194.08,75,,,percent of total billed charges,75% of total billed charges,9980.15,100,,,Fee Schedule,100% of CMS OPPS Rate,476.11,100,,,Fee Schedule,100% of WV Medicaid Rate,16467.25,165,,,Fee Schedule,165% of CMS OPPS Rate,10343.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,28666.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,39314,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,49244.77,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,476.11,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,9980.15,100,,,Fee Schedule,100% of CMS OPPS Rate,10343.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,222.9,14,,,percent of total billed charges,14% of total billed charges,222.9,49244.77,
92943 - PCI CTO DES RAMUS,4141221,CDM,481,RC,92943,HCPCS,Outpatient,,,1592.11,796.06,,1194.08,75,,,percent of total billed charges,75% of total billed charges,1194.08,75,,,percent of total billed charges,75% of total billed charges,9980.15,100,,,Fee Schedule,100% of CMS OPPS Rate,476.11,100,,,Fee Schedule,100% of WV Medicaid Rate,16467.25,165,,,Fee Schedule,165% of CMS OPPS Rate,10343.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,28666.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,39314,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,49244.77,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,476.11,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,9980.15,100,,,Fee Schedule,100% of CMS OPPS Rate,10343.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,222.9,14,,,percent of total billed charges,14% of total billed charges,222.9,49244.77,
92943 - PF  PCI CTO DES RAMUS,4141225,CDM,960,RC,92943,HCPCS,Outpatient,,,1592.11,796.06,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
92943 - PF PCI CTO DES LAD,4141227,CDM,960,RC,92943,HCPCS,Outpatient,,,1592.11,796.06,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
92943 - PF PCI CTO DES LC,4141226,CDM,960,RC,92943,HCPCS,Outpatient,,,1592.11,796.06,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
92943 - PF PCI CTO DES LT MAIN,4141224,CDM,960,RC,92943,HCPCS,Outpatient,,,1592.11,796.06,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
92943- PCI of CTO single coronary,3430763,CDM,360,RC,92943,HCPCS,Outpatient,,,1783.16,891.58,,1337.37,75,,,percent of total billed charges,75% of total billed charges,1337.37,75,,,percent of total billed charges,75% of total billed charges,9980.15,100,,,Fee Schedule,100% of CMS OPPS Rate,476.11,100,,,Fee Schedule,100% of WV Medicaid Rate,16467.25,165,,,Fee Schedule,165% of CMS OPPS Rate,10343.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,28666.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,39314,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,49244.77,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,476.11,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,9980.15,100,,,Fee Schedule,100% of CMS OPPS Rate,10343.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,249.64,14,,,percent of total billed charges,14% of total billed charges,249.64,49244.77,
92943-CTO-Revasc/PTCA,3552629,CDM,481,RC,92943,HCPCS,Outpatient,,,1783.16,891.58,,1337.37,75,,,percent of total billed charges,75% of total billed charges,1337.37,75,,,percent of total billed charges,75% of total billed charges,9980.15,100,,,Fee Schedule,100% of CMS OPPS Rate,476.11,100,,,Fee Schedule,100% of WV Medicaid Rate,16467.25,165,,,Fee Schedule,165% of CMS OPPS Rate,10343.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,28666.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,39314,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,49244.77,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,476.11,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,9980.15,100,,,Fee Schedule,100% of CMS OPPS Rate,10343.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,249.64,14,,,percent of total billed charges,14% of total billed charges,249.64,49244.77,
92943-PF CTO-Revasc/PTCA,3580910,CDM,960,RC,92943,HCPCS,Outpatient,,,1783.16,891.58,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
"92944 - (PF) Percutaneous transluminal revascularization of chronic total occlusion, coronary artery",3635238,CDM,510,RC,92944,HCPCS,Outpatient,,,893.79,446.9,,670.34,75,,,percent of total billed charges,75% of total billed charges,670.34,75,,,percent of total billed charges,75% of total billed charges,286.01,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,125.13,14,,,percent of total billed charges,14% of total billed charges,125.13,670.34,
92944-CTO Revasc- additional vessel- DIAG,4197337,CDM,481,RC,92944,HCPCS,Outpatient,,,909.4,454.7,,682.05,75,,,percent of total billed charges,75% of total billed charges,682.05,75,,,percent of total billed charges,75% of total billed charges,291.01,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,127.32,14,,,percent of total billed charges,14% of total billed charges,127.32,682.05,
92944-CTO Revasc- additional vessel- LAD,4197329,CDM,481,RC,92944,HCPCS,Outpatient,,,909.4,454.7,,682.05,75,,,percent of total billed charges,75% of total billed charges,682.05,75,,,percent of total billed charges,75% of total billed charges,291.01,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,127.32,14,,,percent of total billed charges,14% of total billed charges,127.32,682.05,
92944-CTO Revasc- additional vessel- LT MAIN,4197343,CDM,481,RC,92944,HCPCS,Outpatient,,,909.4,454.7,,682.05,75,,,percent of total billed charges,75% of total billed charges,682.05,75,,,percent of total billed charges,75% of total billed charges,291.01,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,127.32,14,,,percent of total billed charges,14% of total billed charges,127.32,682.05,
92944-CTO Revasc- additional vessel- OM,4197333,CDM,481,RC,92944,HCPCS,Outpatient,,,909.4,454.7,,682.05,75,,,percent of total billed charges,75% of total billed charges,682.05,75,,,percent of total billed charges,75% of total billed charges,291.01,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,127.32,14,,,percent of total billed charges,14% of total billed charges,127.32,682.05,
92944-CTO Revasc- additional vessel- PDA,4197341,CDM,481,RC,92944,HCPCS,Outpatient,,,909.4,454.7,,682.05,75,,,percent of total billed charges,75% of total billed charges,682.05,75,,,percent of total billed charges,75% of total billed charges,291.01,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,127.32,14,,,percent of total billed charges,14% of total billed charges,127.32,682.05,
92944-CTO Revasc- additional vessel- PLB,4197339,CDM,481,RC,92944,HCPCS,Outpatient,,,909.4,454.7,,682.05,75,,,percent of total billed charges,75% of total billed charges,682.05,75,,,percent of total billed charges,75% of total billed charges,291.01,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,127.32,14,,,percent of total billed charges,14% of total billed charges,127.32,682.05,
92944-CTO Revasc- additional vessel- RAMUS,4197335,CDM,481,RC,92944,HCPCS,Outpatient,,,909.4,454.7,,682.05,75,,,percent of total billed charges,75% of total billed charges,682.05,75,,,percent of total billed charges,75% of total billed charges,291.01,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,127.32,14,,,percent of total billed charges,14% of total billed charges,127.32,682.05,
92944-CTO Revasc- additional vessel- RCA,4197331,CDM,481,RC,92944,HCPCS,Outpatient,,,909.4,454.7,,682.05,75,,,percent of total billed charges,75% of total billed charges,682.05,75,,,percent of total billed charges,75% of total billed charges,291.01,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,127.32,14,,,percent of total billed charges,14% of total billed charges,127.32,682.05,
92944-PF CTO Revasc- additional vessel- CIRC,4197328,CDM,960,RC,92944,HCPCS,Outpatient,,,909.4,454.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
92944-PF CTO Revasc- additional vessel- DIAG,4197338,CDM,960,RC,92944,HCPCS,Outpatient,,,909.4,454.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
92944-PF CTO Revasc- additional vessel- LAD,4197330,CDM,960,RC,92944,HCPCS,Outpatient,,,909.4,454.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
92944-PF CTO Revasc- additional vessel- LT MAIN,4197344,CDM,960,RC,92944,HCPCS,Outpatient,,,909.4,454.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
92944-PF CTO Revasc- additional vessel- OM,4197334,CDM,960,RC,92944,HCPCS,Outpatient,,,909.4,454.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
92944-PF CTO Revasc- additional vessel- PDA,4197342,CDM,960,RC,92944,HCPCS,Outpatient,,,909.4,454.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
92944-PF CTO Revasc- additional vessel- PLB,4197340,CDM,960,RC,92944,HCPCS,Outpatient,,,909.4,454.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
92944-PF CTO Revasc- additional vessel- RAMUS,4197336,CDM,960,RC,92944,HCPCS,Outpatient,,,909.4,454.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
92944-PF CTO Revasc- additional vessel- RCA,4197332,CDM,960,RC,92944,HCPCS,Outpatient,,,909.4,454.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
"CTO with PTA, Stent, artherectomy; add'l vessel",4197327,CDM,481,RC,92944,HCPCS,Outpatient,,,909.4,454.7,,682.05,75,,,percent of total billed charges,75% of total billed charges,682.05,75,,,percent of total billed charges,75% of total billed charges,291.01,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,127.32,14,,,percent of total billed charges,14% of total billed charges,127.32,682.05,
92950- Cardiopulmonary resuscitation,3430765,CDM,450,RC,92950,HCPCS,Outpatient,,,841.76,420.88,,631.32,75,,,percent of total billed charges,75% of total billed charges,631.32,75,,,percent of total billed charges,75% of total billed charges,263.29,100,,,Fee Schedule,100% of CMS OPPS Rate,131.01,100,,,Fee Schedule,100% of WV Medicaid Rate,434.44,165,,,Fee Schedule,165% of CMS OPPS Rate,272.88,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,756.29,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1037.2,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1299.2,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,131.01,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,263.29,100,,,Fee Schedule,100% of CMS OPPS Rate,272.88,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,117.85,14,,,percent of total billed charges,14% of total billed charges,117.85,1299.2,
92950-PF Cardiopulmonary Resuscitation,4321576,CDM,981,RC,92950,HCPCS,Outpatient,,,361.98,180.99,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
92953- Temporary transcutaneous pacing,3430926,CDM,480,RC,92953,HCPCS,Outpatient,,,2.81,1.41,,2.11,75,,,percent of total billed charges,75% of total billed charges,2.11,75,,,percent of total billed charges,75% of total billed charges,552.94,100,,,Fee Schedule,100% of CMS OPPS Rate,0.74,100,,,Fee Schedule,100% of WV Medicaid Rate,912.36,165,,,Fee Schedule,165% of CMS OPPS Rate,573.08,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1588.26,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2178.17,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,2728.39,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,552.94,100,,,Fee Schedule,100% of CMS OPPS Rate,573.08,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,0.74,2728.39,
92953-PF TEMPORARY TRANSCUTANEOUS PACING,4321575,CDM,981,RC,92953,HCPCS,Outpatient,,,2.12,1.06,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
92953-TEMPORARY TRANSCUTANEOUS PACING,3431983,CDM,481,RC,92953,HCPCS,Outpatient,,,2.81,1.41,,2.11,75,,,percent of total billed charges,75% of total billed charges,2.11,75,,,percent of total billed charges,75% of total billed charges,552.94,100,,,Fee Schedule,100% of CMS OPPS Rate,0.74,100,,,Fee Schedule,100% of WV Medicaid Rate,912.36,165,,,Fee Schedule,165% of CMS OPPS Rate,573.08,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1588.26,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2178.17,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,2728.39,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,552.94,100,,,Fee Schedule,100% of CMS OPPS Rate,573.08,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,0.74,2728.39,
"Transcutaneous PCNG, Temp",3428533,CDM,981,RC,92953,HCPCS,Outpatient,,,2.81,1.41,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
92960- Cardioversion/elective/external,3430927,CDM,960,RC,92960,HCPCS,Outpatient,,,214.35,107.18,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
92960-EXTERNAL ELECTIVE CARDIOVERSION,3431984,CDM,481,RC,92960,HCPCS,Outpatient,,,190.02,95.01,,142.52,75,,,percent of total billed charges,75% of total billed charges,142.52,75,,,percent of total billed charges,75% of total billed charges,552.94,100,,,Fee Schedule,100% of CMS OPPS Rate,74.97,100,,,Fee Schedule,100% of WV Medicaid Rate,912.36,165,,,Fee Schedule,165% of CMS OPPS Rate,573.08,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1588.26,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2178.17,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,2728.39,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,74.97,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,552.94,100,,,Fee Schedule,100% of CMS OPPS Rate,573.08,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,26.6,14,,,percent of total billed charges,14% of total billed charges,26.6,2728.39,
92960-PF CARDIOVERSION ELECTIVE ARRHYTHMIA EXTERNAL,4321574,CDM,981,RC,92960,HCPCS,Outpatient,,,209.58,104.79,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
92960-PF EXTERNAL ELECTIVE CARDIOVERSION,3580911,CDM,960,RC,92960,HCPCS,Outpatient,,,190.02,95.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
Cardioversion,604545,CDM,480,RC,92960,HCPCS,Outpatient,,,214.35,107.18,,160.76,75,,,percent of total billed charges,75% of total billed charges,160.76,75,,,percent of total billed charges,75% of total billed charges,552.94,100,,,Fee Schedule,100% of CMS OPPS Rate,74.97,100,,,Fee Schedule,100% of WV Medicaid Rate,912.36,165,,,Fee Schedule,165% of CMS OPPS Rate,573.08,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1588.26,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2178.17,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,2728.39,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,74.97,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,552.94,100,,,Fee Schedule,100% of CMS OPPS Rate,573.08,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,30.01,14,,,percent of total billed charges,14% of total billed charges,30.01,2728.39,
Ext Cardioversion - Elec,3428428,CDM,981,RC,92960,HCPCS,Outpatient,,,190.02,95.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
92961- Cardioversion/elective/internal,3430928,CDM,510,RC,92961,HCPCS,Outpatient,,,512.55,256.28,,384.41,75,,,percent of total billed charges,75% of total billed charges,384.41,75,,,percent of total billed charges,75% of total billed charges,552.94,100,,,Fee Schedule,100% of CMS OPPS Rate,175.26,100,,,Fee Schedule,100% of WV Medicaid Rate,912.36,165,,,Fee Schedule,165% of CMS OPPS Rate,573.08,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1588.26,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2178.17,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,2728.39,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,175.26,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,552.94,100,,,Fee Schedule,100% of CMS OPPS Rate,573.08,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,71.76,14,,,percent of total billed charges,14% of total billed charges,71.76,2728.39,
92970- Cardioassist/circ assist/internal,3430929,CDM,510,RC,92970,HCPCS,Outpatient,,,510.86,255.43,,383.15,75,,,percent of total billed charges,75% of total billed charges,383.15,75,,,percent of total billed charges,75% of total billed charges,510.86,100,,,Fee Schedule,Pays at line item charges based on APC Setting,136.41,100,,,Fee Schedule,100% of WV Medicaid Rate,510.86,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,510.86,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,510.86,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,510.86,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,510.86,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,136.41,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,510.86,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,510.86,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,71.52,14,,,percent of total billed charges,14% of total billed charges,71.52,510.86,
92971- Cardioassist/circ assist/external,3430930,CDM,510,RC,92971,HCPCS,Outpatient,,,267.31,133.66,,200.48,75,,,percent of total billed charges,75% of total billed charges,200.48,75,,,percent of total billed charges,75% of total billed charges,267.31,100,,,Fee Schedule,Pays at line item charges based on APC Setting,71.28,100,,,Fee Schedule,100% of WV Medicaid Rate,267.31,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,267.31,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,267.31,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,267.31,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,267.31,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,71.28,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,267.31,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,267.31,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,37.42,14,,,percent of total billed charges,14% of total billed charges,37.42,267.31,
0715T-PF Shockwave additional vessel 1,4197322,CDM,960,RC,92972,HCPCS,Outpatient,,,540.18,270.09,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
0715T-PF Shockwave additional vessel 2,4197324,CDM,960,RC,92972,HCPCS,Outpatient,,,540.18,270.09,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
0715T-PF Shockwave additional vessel 3,4197326,CDM,960,RC,92972,HCPCS,Outpatient,,,540.18,270.09,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
0715T-PF Shockwave- Primary Vessel,4197320,CDM,960,RC,92972,HCPCS,Outpatient,,,540.18,270.09,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
0715T-Shockwave additional vessel 1,4197321,CDM,481,RC,92972,HCPCS,Outpatient,,,540.18,270.09,,405.14,75,,,percent of total billed charges,75% of total billed charges,405.14,75,,,percent of total billed charges,75% of total billed charges,172.86,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,75.63,14,,,percent of total billed charges,14% of total billed charges,75.63,405.14,
0715T-Shockwave additional vessel 2,4197323,CDM,481,RC,92972,HCPCS,Outpatient,,,540.18,270.09,,405.14,75,,,percent of total billed charges,75% of total billed charges,405.14,75,,,percent of total billed charges,75% of total billed charges,172.86,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,75.63,14,,,percent of total billed charges,14% of total billed charges,75.63,405.14,
0715T-Shockwave additional vessel 3,4197325,CDM,481,RC,92972,HCPCS,Outpatient,,,540.18,270.09,,405.14,75,,,percent of total billed charges,75% of total billed charges,405.14,75,,,percent of total billed charges,75% of total billed charges,172.86,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,75.63,14,,,percent of total billed charges,14% of total billed charges,75.63,405.14,
0715T-Shockwave- Primary Vessel,4197319,CDM,481,RC,92972,HCPCS,Outpatient,,,540.18,270.09,,405.14,75,,,percent of total billed charges,75% of total billed charges,405.14,75,,,percent of total billed charges,75% of total billed charges,172.86,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,75.63,14,,,percent of total billed charges,14% of total billed charges,75.63,405.14,
92972-PF Shockwave - Primary Vessel,4361243,CDM,960,RC,92972,HCPCS,Outpatient,,,276.16,138.08,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
92972-PF Shockwave additional vessel 1,4361237,CDM,960,RC,92972,HCPCS,Outpatient,,,276.16,138.08,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
92972-PF Shockwave additional vessel 2,4361239,CDM,960,RC,92972,HCPCS,Outpatient,,,276.16,138.08,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
92972-PF Shockwave additional vessel 3,4361241,CDM,960,RC,92972,HCPCS,Outpatient,,,276.16,138.08,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
92972-Shockwave - Primary Vessel,4361242,CDM,481,RC,92972,HCPCS,Outpatient,,,276.16,138.08,,207.12,75,,,percent of total billed charges,75% of total billed charges,207.12,75,,,percent of total billed charges,75% of total billed charges,88.37,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.66,14,,,percent of total billed charges,14% of total billed charges,38.66,207.12,
92972-Shockwave additional vessel 1,4361236,CDM,481,RC,92972,HCPCS,Outpatient,,,276.16,138.08,,207.12,75,,,percent of total billed charges,75% of total billed charges,207.12,75,,,percent of total billed charges,75% of total billed charges,88.37,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.66,14,,,percent of total billed charges,14% of total billed charges,38.66,207.12,
92972-Shockwave additional vessel 2,4361238,CDM,481,RC,92972,HCPCS,Outpatient,,,276.16,138.08,,207.12,75,,,percent of total billed charges,75% of total billed charges,207.12,75,,,percent of total billed charges,75% of total billed charges,88.37,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.66,14,,,percent of total billed charges,14% of total billed charges,38.66,207.12,
92972-Shockwave additional vessel 3,4361240,CDM,481,RC,92972,HCPCS,Outpatient,,,276.16,138.08,,207.12,75,,,percent of total billed charges,75% of total billed charges,207.12,75,,,percent of total billed charges,75% of total billed charges,88.37,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.66,14,,,percent of total billed charges,14% of total billed charges,38.66,207.12,
92973- Coronary thrombectomy/mechanical,3430931,CDM,481,RC,92973,HCPCS,Outpatient,,,475.36,237.68,,356.52,75,,,percent of total billed charges,75% of total billed charges,356.52,75,,,percent of total billed charges,75% of total billed charges,152.12,32,,,percent of total billed charges,32% of total billed charges,127.08,100,,,Fee Schedule,100% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,127.08,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.55,14,,,percent of total billed charges,14% of total billed charges,66.55,356.52,
92973-INTRACORONARY TRANSCATHER THROMBECT,3431985,CDM,481,RC,92973,HCPCS,Outpatient,,,475.36,237.68,,356.52,75,,,percent of total billed charges,75% of total billed charges,356.52,75,,,percent of total billed charges,75% of total billed charges,152.12,32,,,percent of total billed charges,32% of total billed charges,127.08,100,,,Fee Schedule,100% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,127.08,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.55,14,,,percent of total billed charges,14% of total billed charges,66.55,356.52,
Percutaneous Trasluminal Coronary Thrombectomy,646459,CDM,481,RC,92973,HCPCS,Outpatient,,,462.9,231.45,,347.18,75,,,percent of total billed charges,75% of total billed charges,347.18,75,,,percent of total billed charges,75% of total billed charges,148.13,32,,,percent of total billed charges,32% of total billed charges,127.08,100,,,Fee Schedule,100% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,127.08,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.81,14,,,percent of total billed charges,14% of total billed charges,64.81,347.18,
92974- Brachytherapy/transcath/coronary,3430932,CDM,510,RC,92974,HCPCS,Outpatient,,,433.99,217,,325.49,75,,,percent of total billed charges,75% of total billed charges,325.49,75,,,percent of total billed charges,75% of total billed charges,138.88,32,,,percent of total billed charges,32% of total billed charges,115.77,100,,,Fee Schedule,100% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,115.77,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.76,14,,,percent of total billed charges,14% of total billed charges,60.76,325.49,
92975- Coronary thrombolysis/IC infusion,3430933,CDM,510,RC,92975,HCPCS,Outpatient,,,1014.4,507.2,,760.8,75,,,percent of total billed charges,75% of total billed charges,760.8,75,,,percent of total billed charges,75% of total billed charges,1014.4,100,,,Fee Schedule,Pays at line item charges based on APC Setting,270.87,100,,,Fee Schedule,100% of WV Medicaid Rate,1014.4,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1014.4,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1014.4,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1014.4,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1014.4,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,270.87,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1014.4,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1014.4,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,142.02,14,,,percent of total billed charges,14% of total billed charges,142.02,1014.4,
"92975-Coronary Thrombolysis; by intracoronary infusion, including coronary angiography",4271260,CDM,481,RC,92975,HCPCS,Outpatient,,,792.63,396.32,,594.47,75,,,percent of total billed charges,75% of total billed charges,594.47,75,,,percent of total billed charges,75% of total billed charges,792.63,100,,,Fee Schedule,Pays at line item charges based on APC Setting,270.87,100,,,Fee Schedule,100% of WV Medicaid Rate,792.63,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,792.63,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,792.63,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,792.63,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,792.63,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,270.87,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,792.63,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,792.63,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,110.97,14,,,percent of total billed charges,14% of total billed charges,110.97,792.63,
"92975-PF Coronary Thrombolysis; by intracoronary infusion, including coronary angiography",4271261,CDM,960,RC,92975,HCPCS,Outpatient,,,792.63,396.32,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
92977- Coronary thrombolysis/IV infusion,3430934,CDM,510,RC,92977,HCPCS,Outpatient,,,124.24,62.12,,93.18,75,,,percent of total billed charges,75% of total billed charges,93.18,75,,,percent of total billed charges,75% of total billed charges,312.7,100,,,Fee Schedule,100% of CMS OPPS Rate,33.18,100,,,Fee Schedule,100% of WV Medicaid Rate,515.97,165,,,Fee Schedule,165% of CMS OPPS Rate,324.08,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,898.23,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1231.85,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1543.03,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,33.18,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,312.7,100,,,Fee Schedule,100% of CMS OPPS Rate,324.08,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,17.39,14,,,percent of total billed charges,14% of total billed charges,17.39,1543.03,
92977-PF THROMBOLYSIS CORONARY INTRAVENOUS INFUSION,4321573,CDM,981,RC,92977,HCPCS,Outpatient,,,95.4,47.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
92978 - PF Endoluminal imaging of coronary vessel or graft using intravascular ultrasound (IVUS) or,3715284,CDM,510,RC,92978,HCPCS,Outpatient,,,252.87,126.44,,189.65,75,,,percent of total billed charges,75% of total billed charges,189.65,75,,,percent of total billed charges,75% of total billed charges,80.92,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.4,14,,,percent of total billed charges,14% of total billed charges,35.4,189.65,
92978 (26) Endoluminal imaging of coronary vessel or graft using intravascular ultrasound (IVUS) or,3621299,CDM,510,RC,92978,HCPCS,Outpatient,,,252.87,126.44,,189.65,75,,,percent of total billed charges,75% of total billed charges,189.65,75,,,percent of total billed charges,75% of total billed charges,80.92,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.4,14,,,percent of total billed charges,14% of total billed charges,35.4,189.65,
92978 PF IVUS CIRC,3580912,CDM,960,RC,92978,HCPCS,Outpatient,,,252.87,126.44,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
92978-IVUS CIRC,3431986,CDM,480,RC,92978,HCPCS,Outpatient,,,252.87,126.44,,189.65,75,,,percent of total billed charges,75% of total billed charges,189.65,75,,,percent of total billed charges,75% of total billed charges,80.92,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.4,14,,,percent of total billed charges,14% of total billed charges,35.4,189.65,
92978-IVUS LAD,3431987,CDM,481,RC,92978,HCPCS,Outpatient,,,252.87,126.44,,189.65,75,,,percent of total billed charges,75% of total billed charges,189.65,75,,,percent of total billed charges,75% of total billed charges,80.92,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.4,14,,,percent of total billed charges,14% of total billed charges,35.4,189.65,
92978-IVUS LEFT MAIN,3431988,CDM,481,RC,92978,HCPCS,Outpatient,,,252.87,126.44,,189.65,75,,,percent of total billed charges,75% of total billed charges,189.65,75,,,percent of total billed charges,75% of total billed charges,80.92,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.4,14,,,percent of total billed charges,14% of total billed charges,35.4,189.65,
92978-IVUS RCA,3431989,CDM,480,RC,92978,HCPCS,Outpatient,,,252.87,126.44,,189.65,75,,,percent of total billed charges,75% of total billed charges,189.65,75,,,percent of total billed charges,75% of total billed charges,80.92,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.4,14,,,percent of total billed charges,14% of total billed charges,35.4,189.65,
IVUS -Ramus,3840968,CDM,480,RC,92978,HCPCS,Outpatient,,,252.87,126.44,,189.65,75,,,percent of total billed charges,75% of total billed charges,189.65,75,,,percent of total billed charges,75% of total billed charges,80.92,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.4,14,,,percent of total billed charges,14% of total billed charges,35.4,189.65,
92979 - PF Endoluminal imaging of coronary vessel or graft using intravascular ultrasound (IVUS) or,3715285,CDM,510,RC,92979,HCPCS,Outpatient,,,201.76,100.88,,151.32,75,,,percent of total billed charges,75% of total billed charges,151.32,75,,,percent of total billed charges,75% of total billed charges,64.56,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.25,14,,,percent of total billed charges,14% of total billed charges,28.25,151.32,
92979 (26) Endoluminal imaging of coronary vessel or graft using intravascular ultrasound (IVUS) or,3623711,CDM,510,RC,92979,HCPCS,Outpatient,,,201.76,100.88,,151.32,75,,,percent of total billed charges,75% of total billed charges,151.32,75,,,percent of total billed charges,75% of total billed charges,64.56,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.25,14,,,percent of total billed charges,14% of total billed charges,28.25,151.32,
92979- IVUS LAD Additional,3560639,CDM,481,RC,92979,HCPCS,Outpatient,,,201.76,100.88,,151.32,75,,,percent of total billed charges,75% of total billed charges,151.32,75,,,percent of total billed charges,75% of total billed charges,64.56,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.25,14,,,percent of total billed charges,14% of total billed charges,28.25,151.32,
92979-IVUS CIRC ADDITIONAL,3431990,CDM,481,RC,92979,HCPCS,Outpatient,,,201.76,100.88,,151.32,75,,,percent of total billed charges,75% of total billed charges,151.32,75,,,percent of total billed charges,75% of total billed charges,64.56,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.25,14,,,percent of total billed charges,14% of total billed charges,28.25,151.32,
92979-IVUS LAD ADDITIONAL,3431991,CDM,480,RC,92979,HCPCS,Outpatient,,,201.76,100.88,,151.32,75,,,percent of total billed charges,75% of total billed charges,151.32,75,,,percent of total billed charges,75% of total billed charges,64.56,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.25,14,,,percent of total billed charges,14% of total billed charges,28.25,151.32,
92979-IVUS LEFT MAIN ADD,3431992,CDM,481,RC,92979,HCPCS,Outpatient,,,201.76,100.88,,151.32,75,,,percent of total billed charges,75% of total billed charges,151.32,75,,,percent of total billed charges,75% of total billed charges,64.56,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.25,14,,,percent of total billed charges,14% of total billed charges,28.25,151.32,
92979-IVUS RCA ADDITIONAL,3431993,CDM,480,RC,92979,HCPCS,Outpatient,,,201.76,100.88,,151.32,75,,,percent of total billed charges,75% of total billed charges,151.32,75,,,percent of total billed charges,75% of total billed charges,64.56,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.25,14,,,percent of total billed charges,14% of total billed charges,28.25,151.32,
92979-PF IVUS LAD Additional,3580913,CDM,960,RC,92979,HCPCS,Outpatient,,,201.76,100.88,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
92986- Perc valvuloplasty/aortic valve,3430940,CDM,481,RC,92986,HCPCS,Outpatient,,,3523.15,1761.58,,2642.36,75,,,percent of total billed charges,75% of total billed charges,2642.36,75,,,percent of total billed charges,75% of total billed charges,4903.32,100,,,Fee Schedule,100% of CMS OPPS Rate,940.92,100,,,Fee Schedule,100% of WV Medicaid Rate,8090.5,165,,,Fee Schedule,165% of CMS OPPS Rate,5081.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,14084.18,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,19315.33,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,24194.41,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,940.92,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,4903.32,100,,,Fee Schedule,100% of CMS OPPS Rate,5081.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,493.24,14,,,percent of total billed charges,14% of total billed charges,493.24,24194.41,
92986-Aortic Valvuloplasty,3431994,CDM,481,RC,92986,HCPCS,Outpatient,,,3523.15,1761.58,,2642.36,75,,,percent of total billed charges,75% of total billed charges,2642.36,75,,,percent of total billed charges,75% of total billed charges,4903.32,100,,,Fee Schedule,100% of CMS OPPS Rate,940.92,100,,,Fee Schedule,100% of WV Medicaid Rate,8090.5,165,,,Fee Schedule,165% of CMS OPPS Rate,5081.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,14084.18,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,19315.33,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,24194.41,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,940.92,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,4903.32,100,,,Fee Schedule,100% of CMS OPPS Rate,5081.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,493.24,14,,,percent of total billed charges,14% of total billed charges,493.24,24194.41,
92986-Balloon Valvuloplasty Aortic,3431995,CDM,481,RC,92986,HCPCS,Outpatient,,,3523.15,1761.58,,2642.36,75,,,percent of total billed charges,75% of total billed charges,2642.36,75,,,percent of total billed charges,75% of total billed charges,4903.32,100,,,Fee Schedule,100% of CMS OPPS Rate,940.92,100,,,Fee Schedule,100% of WV Medicaid Rate,8090.5,165,,,Fee Schedule,165% of CMS OPPS Rate,5081.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,14084.18,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,19315.33,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,24194.41,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,940.92,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,4903.32,100,,,Fee Schedule,100% of CMS OPPS Rate,5081.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,493.24,14,,,percent of total billed charges,14% of total billed charges,493.24,24194.41,
Balloon Valvuloplasty Aortic,,,480,RC,92986,HCPCS,Outpatient,,,3451.73,1725.87,,2588.8,75,,,percent of total billed charges,75% of total billed charges,2588.8,75,,,percent of total billed charges,75% of total billed charges,4903.32,100,,,Fee Schedule,100% of CMS OPPS Rate,940.92,100,,,Fee Schedule,100% of WV Medicaid Rate,8090.5,165,,,Fee Schedule,165% of CMS OPPS Rate,5081.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,14084.18,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,19315.33,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,24194.41,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,940.92,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,4903.32,100,,,Fee Schedule,100% of CMS OPPS Rate,5081.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,483.24,14,,,percent of total billed charges,14% of total billed charges,483.24,24194.41,
92987- Perc valvuloplasty/mitral valve,3430941,CDM,510,RC,92987,HCPCS,Outpatient,,,3645.75,1822.88,,2734.31,75,,,percent of total billed charges,75% of total billed charges,2734.31,75,,,percent of total billed charges,75% of total billed charges,9980.15,100,,,Fee Schedule,100% of CMS OPPS Rate,973.86,100,,,Fee Schedule,100% of WV Medicaid Rate,16467.25,165,,,Fee Schedule,165% of CMS OPPS Rate,10343.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,28666.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,39314,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,49244.77,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,973.86,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,9980.15,100,,,Fee Schedule,100% of CMS OPPS Rate,10343.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,510.41,14,,,percent of total billed charges,14% of total billed charges,510.41,49244.77,
92987-Balloon Valuloplasty Mitral,3431996,CDM,481,RC,92987,HCPCS,Outpatient,,,3645.75,1822.88,,2734.31,75,,,percent of total billed charges,75% of total billed charges,2734.31,75,,,percent of total billed charges,75% of total billed charges,9980.15,100,,,Fee Schedule,100% of CMS OPPS Rate,973.86,100,,,Fee Schedule,100% of WV Medicaid Rate,16467.25,165,,,Fee Schedule,165% of CMS OPPS Rate,10343.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,28666.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,39314,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,49244.77,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,973.86,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,9980.15,100,,,Fee Schedule,100% of CMS OPPS Rate,10343.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,510.41,14,,,percent of total billed charges,14% of total billed charges,510.41,49244.77,
92987-Mitral Valvuloplasty,3431997,CDM,481,RC,92987,HCPCS,Outpatient,,,3645.75,1822.88,,2734.31,75,,,percent of total billed charges,75% of total billed charges,2734.31,75,,,percent of total billed charges,75% of total billed charges,9980.15,100,,,Fee Schedule,100% of CMS OPPS Rate,973.86,100,,,Fee Schedule,100% of WV Medicaid Rate,16467.25,165,,,Fee Schedule,165% of CMS OPPS Rate,10343.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,28666.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,39314,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,49244.77,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,973.86,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,9980.15,100,,,Fee Schedule,100% of CMS OPPS Rate,10343.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,510.41,14,,,percent of total billed charges,14% of total billed charges,510.41,49244.77,
Balloon Valuloplasty Mitral,,,480,RC,92987,HCPCS,Outpatient,,,3571.54,1785.77,,2678.66,75,,,percent of total billed charges,75% of total billed charges,2678.66,75,,,percent of total billed charges,75% of total billed charges,9980.15,100,,,Fee Schedule,100% of CMS OPPS Rate,973.86,100,,,Fee Schedule,100% of WV Medicaid Rate,16467.25,165,,,Fee Schedule,165% of CMS OPPS Rate,10343.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,28666.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,39314,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,49244.77,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,973.86,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,9980.15,100,,,Fee Schedule,100% of CMS OPPS Rate,10343.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,500.02,14,,,percent of total billed charges,14% of total billed charges,500.02,49244.77,
92990- Perc balloon valvuloplas/pul valve,3430942,CDM,510,RC,92990,HCPCS,Outpatient,,,2898.8,1449.4,,2174.1,75,,,percent of total billed charges,75% of total billed charges,2174.1,75,,,percent of total billed charges,75% of total billed charges,9980.15,100,,,Fee Schedule,100% of CMS OPPS Rate,774.27,100,,,Fee Schedule,100% of WV Medicaid Rate,16467.25,165,,,Fee Schedule,165% of CMS OPPS Rate,10343.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,28666.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,39314,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,49244.77,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,774.27,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,9980.15,100,,,Fee Schedule,100% of CMS OPPS Rate,10343.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,405.83,14,,,percent of total billed charges,14% of total billed charges,405.83,49244.77,
92990-Balloon Valvuloplasty Pulmonic,3431998,CDM,481,RC,92990,HCPCS,Outpatient,,,2898.8,1449.4,,2174.1,75,,,percent of total billed charges,75% of total billed charges,2174.1,75,,,percent of total billed charges,75% of total billed charges,9980.15,100,,,Fee Schedule,100% of CMS OPPS Rate,774.27,100,,,Fee Schedule,100% of WV Medicaid Rate,16467.25,165,,,Fee Schedule,165% of CMS OPPS Rate,10343.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,28666.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,39314,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,49244.77,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,774.27,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,9980.15,100,,,Fee Schedule,100% of CMS OPPS Rate,10343.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,405.83,14,,,percent of total billed charges,14% of total billed charges,405.83,49244.77,
92990-Pulmonary Valvuloplasty,3431999,CDM,481,RC,92990,HCPCS,Outpatient,,,2898.8,1449.4,,2174.1,75,,,percent of total billed charges,75% of total billed charges,2174.1,75,,,percent of total billed charges,75% of total billed charges,9980.15,100,,,Fee Schedule,100% of CMS OPPS Rate,774.27,100,,,Fee Schedule,100% of WV Medicaid Rate,16467.25,165,,,Fee Schedule,165% of CMS OPPS Rate,10343.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,28666.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,39314,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,49244.77,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,774.27,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,9980.15,100,,,Fee Schedule,100% of CMS OPPS Rate,10343.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,405.83,14,,,percent of total billed charges,14% of total billed charges,405.83,49244.77,
Balloon Valvuloplasty Pulmonic,,,480,RC,92990,HCPCS,Outpatient,,,2846.18,1423.09,,2134.64,75,,,percent of total billed charges,75% of total billed charges,2134.64,75,,,percent of total billed charges,75% of total billed charges,9980.15,100,,,Fee Schedule,100% of CMS OPPS Rate,774.27,100,,,Fee Schedule,100% of WV Medicaid Rate,16467.25,165,,,Fee Schedule,165% of CMS OPPS Rate,10343.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,28666.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,39314,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,49244.77,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,774.27,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,9980.15,100,,,Fee Schedule,100% of CMS OPPS Rate,10343.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,398.47,14,,,percent of total billed charges,14% of total billed charges,398.47,49244.77,
92997- Pulm art angioplasty/init vessel,3430945,CDM,360,RC,92997,HCPCS,Outpatient,,,1706.32,853.16,,1279.74,75,,,percent of total billed charges,75% of total billed charges,1279.74,75,,,percent of total billed charges,75% of total billed charges,9980.15,100,,,Fee Schedule,100% of CMS OPPS Rate,455.71,100,,,Fee Schedule,100% of WV Medicaid Rate,16467.25,165,,,Fee Schedule,165% of CMS OPPS Rate,10343.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,28666.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,39314,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,49244.77,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,455.71,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,9980.15,100,,,Fee Schedule,100% of CMS OPPS Rate,10343.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,238.88,14,,,percent of total billed charges,14% of total billed charges,238.88,49244.77,
92997-Pulmonary Angiography  w  Angioplasty,3432000,CDM,481,RC,92997,HCPCS,Outpatient,,,1706.32,853.16,,1279.74,75,,,percent of total billed charges,75% of total billed charges,1279.74,75,,,percent of total billed charges,75% of total billed charges,9980.15,100,,,Fee Schedule,100% of CMS OPPS Rate,455.71,100,,,Fee Schedule,100% of WV Medicaid Rate,16467.25,165,,,Fee Schedule,165% of CMS OPPS Rate,10343.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,28666.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,39314,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,49244.77,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,455.71,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,9980.15,100,,,Fee Schedule,100% of CMS OPPS Rate,10343.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,238.88,14,,,percent of total billed charges,14% of total billed charges,238.88,49244.77,
Pulmonary Angiography  w  Angioplasty,,,480,RC,92997,HCPCS,Outpatient,,,1672.34,836.17,,1254.26,75,,,percent of total billed charges,75% of total billed charges,1254.26,75,,,percent of total billed charges,75% of total billed charges,9980.15,100,,,Fee Schedule,100% of CMS OPPS Rate,455.71,100,,,Fee Schedule,100% of WV Medicaid Rate,16467.25,165,,,Fee Schedule,165% of CMS OPPS Rate,10343.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,28666.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,39314,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,49244.77,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,455.71,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,9980.15,100,,,Fee Schedule,100% of CMS OPPS Rate,10343.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,234.13,14,,,percent of total billed charges,14% of total billed charges,234.13,49244.77,
92998- Pulm art angioplasty/ea add vessel,3430946,CDM,510,RC,92998,HCPCS,Outpatient,,,852.98,426.49,,639.74,75,,,percent of total billed charges,75% of total billed charges,639.74,75,,,percent of total billed charges,75% of total billed charges,272.95,32,,,percent of total billed charges,32% of total billed charges,227.86,100,,,Fee Schedule,100% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,227.86,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,119.42,14,,,percent of total billed charges,14% of total billed charges,119.42,639.74,
92998-Pulmonary Angio w Angioplasty add,3432001,CDM,481,RC,92998,HCPCS,Outpatient,,,852.98,426.49,,639.74,75,,,percent of total billed charges,75% of total billed charges,639.74,75,,,percent of total billed charges,75% of total billed charges,272.95,32,,,percent of total billed charges,32% of total billed charges,227.86,100,,,Fee Schedule,100% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,227.86,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,119.42,14,,,percent of total billed charges,14% of total billed charges,119.42,639.74,
Pulmonary Angio w Angioplasty add,,,480,RC,92998,HCPCS,Outpatient,,,837.17,418.59,,627.88,75,,,percent of total billed charges,75% of total billed charges,627.88,75,,,percent of total billed charges,75% of total billed charges,267.89,32,,,percent of total billed charges,32% of total billed charges,227.86,100,,,Fee Schedule,100% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,227.86,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,117.2,14,,,percent of total billed charges,14% of total billed charges,117.2,627.88,
Clinic EKG,3527352,CDM,730,RC,93000,HCPCS,Outpatient,,,28.01,14.01,,21.01,75,,,percent of total billed charges,75% of total billed charges,21.01,75,,,percent of total billed charges,75% of total billed charges,8.96,32,,,percent of total billed charges,32% of total billed charges,9.59,100,,,Fee Schedule,100% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.59,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.92,14,,,percent of total billed charges,14% of total billed charges,3.92,21.01,
Electrocardiogram with Magnet,1955109,CDM,960,RC,93000,HCPCS,Outpatient,,,28.01,14.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
EKG Pre/Post Unit,645285,CDM,730,RC,93005,HCPCS,Outpatient,,,21.49,10.75,,16.12,75,,,percent of total billed charges,75% of total billed charges,16.12,75,,,percent of total billed charges,75% of total billed charges,54.04,100,,,Fee Schedule,100% of CMS OPPS Rate,3.93,100,,,Fee Schedule,100% of WV Medicaid Rate,89.16,165,,,Fee Schedule,165% of CMS OPPS Rate,56,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,155.22,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,212.87,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,266.65,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,3.93,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,54.04,100,,,Fee Schedule,100% of CMS OPPS Rate,56,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,3.01,14,,,percent of total billed charges,14% of total billed charges,3.01,266.65,
EKG-Inpatient,617637,CDM,730,RC,93005,HCPCS,Outpatient,,,14.52,7.26,,10.89,75,,,percent of total billed charges,75% of total billed charges,10.89,75,,,percent of total billed charges,75% of total billed charges,54.04,100,,,Fee Schedule,100% of CMS OPPS Rate,3.93,100,,,Fee Schedule,100% of WV Medicaid Rate,89.16,165,,,Fee Schedule,165% of CMS OPPS Rate,56,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,155.22,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,212.87,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,266.65,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,3.93,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,54.04,100,,,Fee Schedule,100% of CMS OPPS Rate,56,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,2.03,14,,,percent of total billed charges,14% of total billed charges,2.03,266.65,
PAT EKG,653557,CDM,730,RC,93005,HCPCS,Outpatient,,,21.49,10.75,,16.12,75,,,percent of total billed charges,75% of total billed charges,16.12,75,,,percent of total billed charges,75% of total billed charges,54.04,100,,,Fee Schedule,100% of CMS OPPS Rate,3.93,100,,,Fee Schedule,100% of WV Medicaid Rate,89.16,165,,,Fee Schedule,165% of CMS OPPS Rate,56,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,155.22,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,212.87,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,266.65,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,3.93,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,54.04,100,,,Fee Schedule,100% of CMS OPPS Rate,56,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,3.01,14,,,percent of total billed charges,14% of total billed charges,3.01,266.65,
93010-EKG Interpretation,3561120,CDM,960,RC,93010,HCPCS,Outpatient,,,21.49,10.75,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
93010-PF ECG ROUTINE ECG W/LEAST 12 LDS I&R ONLY,4321508,CDM,981,RC,93010,HCPCS,Outpatient,,,21.49,10.75,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
93016- Cardio stress/supervision only,3430950,CDM,960,RC,93016,HCPCS,Outpatient,,,56.25,28.13,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
Stress Test,,,480,RC,93017,HCPCS,Outpatient,,,68.26,34.13,,51.2,75,,,percent of total billed charges,75% of total billed charges,51.2,75,,,percent of total billed charges,75% of total billed charges,263.3,100,,,Fee Schedule,100% of CMS OPPS Rate,22.12,100,,,Fee Schedule,100% of WV Medicaid Rate,434.45,165,,,Fee Schedule,165% of CMS OPPS Rate,272.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,756.3,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1037.2,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1299.2,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,22.12,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,263.3,100,,,Fee Schedule,100% of CMS OPPS Rate,272.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,9.56,14,,,percent of total billed charges,14% of total billed charges,9.56,1299.2,
93018- CV stress test/interp/report only,3430952,CDM,960,RC,93018,HCPCS,Outpatient,,,27.73,13.87,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
93040- ECG/1-3 leads/w interp & report,3430954,CDM,510,RC,93040,HCPCS,Outpatient,,,31.8,15.9,,23.85,75,,,percent of total billed charges,75% of total billed charges,23.85,75,,,percent of total billed charges,75% of total billed charges,10.18,32,,,percent of total billed charges,32% of total billed charges,8.36,100,,,Fee Schedule,100% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.36,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.45,14,,,percent of total billed charges,14% of total billed charges,4.45,23.85,
93042- ECG/1-3 leads/interp & report only,3430956,CDM,510,RC,93042,HCPCS,Outpatient,,,18.06,9.03,,13.55,75,,,percent of total billed charges,75% of total billed charges,13.55,75,,,percent of total billed charges,75% of total billed charges,5.78,32,,,percent of total billed charges,32% of total billed charges,4.67,100,,,Fee Schedule,100% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.67,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.53,14,,,percent of total billed charges,14% of total billed charges,2.53,13.55,
93224- Xtrnl Ecg Less than 48 Hr Record Scan Stor w/Phy R+I,3430957,CDM,960,RC,93224,HCPCS,Outpatient,,,133.96,66.98,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
CL Holter Monitor 24-48 hour,3430958,CDM,731,RC,93225,HCPCS,Outpatient,,,33.24,16.62,,24.93,75,,,percent of total billed charges,75% of total billed charges,24.93,75,,,percent of total billed charges,75% of total billed charges,109.16,100,,,Fee Schedule,100% of CMS OPPS Rate,12.04,100,,,Fee Schedule,100% of WV Medicaid Rate,180.11,165,,,Fee Schedule,165% of CMS OPPS Rate,113.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,313.55,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,430.01,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,538.63,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,12.04,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,109.16,100,,,Fee Schedule,100% of CMS OPPS Rate,113.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4.65,14,,,percent of total billed charges,14% of total billed charges,4.65,538.63,
Holter Monitor Scanning,604597,CDM,731,RC,93225,HCPCS,Outpatient,,,33.24,16.62,,24.93,75,,,percent of total billed charges,75% of total billed charges,24.93,75,,,percent of total billed charges,75% of total billed charges,109.16,100,,,Fee Schedule,100% of CMS OPPS Rate,12.04,100,,,Fee Schedule,100% of WV Medicaid Rate,180.11,165,,,Fee Schedule,165% of CMS OPPS Rate,113.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,313.55,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,430.01,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,538.63,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,12.04,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,109.16,100,,,Fee Schedule,100% of CMS OPPS Rate,113.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4.65,14,,,percent of total billed charges,14% of total billed charges,4.65,538.63,
93226- Holter/to 48 hrs/scan analy/w rpt,3430959,CDM,960,RC,93226,HCPCS,Outpatient,,,64.36,32.18,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
93227- Holter/to 48 hrs/review/interp,3430960,CDM,960,RC,93227,HCPCS,Outpatient,,,36.38,18.19,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
93228- MCT/rec/to 30 days/interp/rept,3430961,CDM,730,RC,93228,HCPCS,Outpatient,,,49.86,24.93,,37.4,75,,,percent of total billed charges,75% of total billed charges,37.4,75,,,percent of total billed charges,75% of total billed charges,15.96,32,,,percent of total billed charges,32% of total billed charges,17.94,100,,,Fee Schedule,100% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.94,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.98,14,,,percent of total billed charges,14% of total billed charges,6.98,37.4,
93229- MCT to 30 days/tech support,3430962,CDM,731,RC,93229,HCPCS,Outpatient,,,2083.74,1041.87,,1562.81,75,,,percent of total billed charges,75% of total billed charges,1562.81,75,,,percent of total billed charges,75% of total billed charges,136.72,100,,,Fee Schedule,100% of CMS OPPS Rate,556.49,100,,,Fee Schedule,100% of WV Medicaid Rate,225.58,165,,,Fee Schedule,165% of CMS OPPS Rate,141.69,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,392.72,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,538.59,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,674.64,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,556.49,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,136.72,100,,,Fee Schedule,100% of CMS OPPS Rate,141.69,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,291.72,14,,,percent of total billed charges,14% of total billed charges,136.72,1562.81,
93242 - Ext ECG >48HR <7D Recording,3896947,CDM,510,RC,93242,HCPCS,Outpatient,,,21.88,10.94,,16.41,75,,,percent of total billed charges,75% of total billed charges,16.41,75,,,percent of total billed charges,75% of total billed charges,31.92,100,,,Fee Schedule,100% of CMS OPPS Rate,8.85,100,,,Fee Schedule,100% of WV Medicaid Rate,52.68,165,,,Fee Schedule,165% of CMS OPPS Rate,33.09,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,91.7,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,125.77,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,157.54,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,8.85,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,31.92,100,,,Fee Schedule,100% of CMS OPPS Rate,33.09,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,3.06,14,,,percent of total billed charges,14% of total billed charges,3.06,157.54,
93244 - External electrocardiographic recording for more than 48 hours up to 7 days by continuous rh,3635239,CDM,510,RC,93244,HCPCS,Outpatient,,,46.13,23.07,,34.6,75,,,percent of total billed charges,75% of total billed charges,34.6,75,,,percent of total billed charges,75% of total billed charges,14.76,32,,,percent of total billed charges,32% of total billed charges,16.71,100,,,Fee Schedule,100% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.71,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.46,14,,,percent of total billed charges,14% of total billed charges,6.46,34.6,
93244 CardioKey 48hrs to 7days,3594862,CDM,960,RC,93244,HCPCS,Outpatient,,,46.13,23.07,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
93246 - EXT ECG>7D<15D RECORDING,3997218,CDM,510,RC,93246,HCPCS,Outpatient,,,21.88,10.94,,16.41,75,,,percent of total billed charges,75% of total billed charges,16.41,75,,,percent of total billed charges,75% of total billed charges,54.04,100,,,Fee Schedule,100% of CMS OPPS Rate,8.85,100,,,Fee Schedule,100% of WV Medicaid Rate,89.16,165,,,Fee Schedule,165% of CMS OPPS Rate,56,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,155.22,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,212.87,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,266.65,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,8.85,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,54.04,100,,,Fee Schedule,100% of CMS OPPS Rate,56,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,3.06,14,,,percent of total billed charges,14% of total billed charges,3.06,266.65,
93248 - External electrocardiographic recording for more than 7 days up to 15 days by continuous rhy,3635240,CDM,960,RC,93248,HCPCS,Outpatient,,,50.8,25.4,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
93248 CardioKey 7days to 15 days,3594863,CDM,960,RC,93248,HCPCS,Outpatient,,,50.8,25.4,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
93260-Programming device evaluation (in person) with iterative adjustment of the implantable device,3783565,CDM,510,RC,93260,HCPCS,Outpatient,,,84.01,42.01,,63.01,75,,,percent of total billed charges,75% of total billed charges,63.01,75,,,percent of total billed charges,75% of total billed charges,32.9,100,,,Fee Schedule,100% of CMS OPPS Rate,51.86,100,,,Fee Schedule,100% of WV Medicaid Rate,54.29,165,,,Fee Schedule,165% of CMS OPPS Rate,34.1,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,94.51,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,129.62,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,162.36,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,51.86,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,32.9,100,,,Fee Schedule,100% of CMS OPPS Rate,34.1,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,11.76,14,,,percent of total billed charges,14% of total billed charges,11.76,162.36,
"93261-Interrogation device evaluation (in person) with analysis, review and report by a physician or",3783563,CDM,510,RC,93261,HCPCS,Outpatient,,,83.21,41.61,,62.41,75,,,percent of total billed charges,75% of total billed charges,62.41,75,,,percent of total billed charges,75% of total billed charges,32.9,100,,,Fee Schedule,100% of CMS OPPS Rate,47.93,100,,,Fee Schedule,100% of WV Medicaid Rate,54.29,165,,,Fee Schedule,165% of CMS OPPS Rate,34.1,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,94.51,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,129.62,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,162.36,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,47.93,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,32.9,100,,,Fee Schedule,100% of CMS OPPS Rate,34.1,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,11.65,14,,,percent of total billed charges,14% of total billed charges,11.65,162.36,
93264-CardioMEMS recalibration,3432003,CDM,960,RC,93264,HCPCS,Outpatient,,,72.14,36.07,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
93264-CardioMems Recalibration.,4131431,CDM,481,RC,93264,HCPCS,Outpatient,,,72.14,36.07,,54.11,75,,,percent of total billed charges,75% of total billed charges,54.11,75,,,percent of total billed charges,75% of total billed charges,23.08,32,,,percent of total billed charges,32% of total billed charges,24.58,100,,,Fee Schedule,100% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.58,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.1,14,,,percent of total billed charges,14% of total billed charges,10.1,54.11,
93264-CAVA MONITOR WRLESS PULM ART PRESS,3430963,CDM,960,RC,93264,HCPCS,Outpatient,,,72.14,36.07,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
93264-PF CardioMems Recalibration,4131346,CDM,960,RC,93264,HCPCS,Outpatient,,,72.14,36.07,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
CardioMEMS recalibration,3427124,CDM,480,RC,93264,HCPCS,Outpatient,,,72.14,36.07,,54.11,75,,,percent of total billed charges,75% of total billed charges,54.11,75,,,percent of total billed charges,75% of total billed charges,23.08,32,,,percent of total billed charges,32% of total billed charges,24.58,100,,,Fee Schedule,100% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.58,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.1,14,,,percent of total billed charges,14% of total billed charges,10.1,54.11,
93268- Event recorder/to 30 days/global,3430964,CDM,731,RC,93268,HCPCS,Outpatient,,,439.96,219.98,,329.97,75,,,percent of total billed charges,75% of total billed charges,329.97,75,,,percent of total billed charges,75% of total billed charges,140.79,32,,,percent of total billed charges,32% of total billed charges,117.49,100,,,Fee Schedule,100% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,117.49,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.59,14,,,percent of total billed charges,14% of total billed charges,61.59,329.97,
93270- Ext pt/auto ECG/30 day/MD interp,3430766,CDM,731,RC,93270,HCPCS,Outpatient,,,15.29,7.65,,11.47,75,,,percent of total billed charges,75% of total billed charges,11.47,75,,,percent of total billed charges,75% of total billed charges,32.9,100,,,Fee Schedule,100% of CMS OPPS Rate,5.41,100,,,Fee Schedule,100% of WV Medicaid Rate,54.29,165,,,Fee Schedule,165% of CMS OPPS Rate,34.1,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,94.51,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,129.62,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,162.36,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,5.41,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,32.9,100,,,Fee Schedule,100% of CMS OPPS Rate,34.1,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,2.14,14,,,percent of total billed charges,14% of total billed charges,2.14,162.36,
Event Monitoring,604570,CDM,731,RC,93270,HCPCS,Outpatient,,,15.29,7.65,,11.47,75,,,percent of total billed charges,75% of total billed charges,11.47,75,,,percent of total billed charges,75% of total billed charges,32.9,100,,,Fee Schedule,100% of CMS OPPS Rate,5.41,100,,,Fee Schedule,100% of WV Medicaid Rate,54.29,165,,,Fee Schedule,165% of CMS OPPS Rate,34.1,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,94.51,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,129.62,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,162.36,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,5.41,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,32.9,100,,,Fee Schedule,100% of CMS OPPS Rate,34.1,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,2.14,14,,,percent of total billed charges,14% of total billed charges,2.14,162.36,
93272- Event rec/to 30 days/review/interp,3430966,CDM,960,RC,93272,HCPCS,Outpatient,,,48.12,24.06,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
93279- PPM eval/test/program/sgn lead,3430968,CDM,480,RC,93279,HCPCS,Outpatient,,,61.33,30.67,,46,75,,,percent of total billed charges,75% of total billed charges,46,75,,,percent of total billed charges,75% of total billed charges,32.9,100,,,Fee Schedule,100% of CMS OPPS Rate,45.96,100,,,Fee Schedule,100% of WV Medicaid Rate,54.29,165,,,Fee Schedule,165% of CMS OPPS Rate,34.1,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,94.51,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,129.62,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,162.36,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,45.96,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,32.9,100,,,Fee Schedule,100% of CMS OPPS Rate,34.1,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8.59,14,,,percent of total billed charges,14% of total billed charges,8.59,162.36,
93280- PPM eval/test/program/dual lead,3430969,CDM,480,RC,93280,HCPCS,Outpatient,,,72.65,36.33,,54.49,75,,,percent of total billed charges,75% of total billed charges,54.49,75,,,percent of total billed charges,75% of total billed charges,32.9,100,,,Fee Schedule,100% of CMS OPPS Rate,54.32,100,,,Fee Schedule,100% of WV Medicaid Rate,54.29,165,,,Fee Schedule,165% of CMS OPPS Rate,34.1,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,94.51,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,129.62,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,162.36,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,54.32,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,32.9,100,,,Fee Schedule,100% of CMS OPPS Rate,34.1,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,10.17,14,,,percent of total billed charges,14% of total billed charges,10.17,162.36,
93280-In Person programming/eval W/adjustments to test function of the device and select optimal pro,4271187,CDM,481,RC,93280,HCPCS,Outpatient,,,72.65,36.33,,54.49,75,,,percent of total billed charges,75% of total billed charges,54.49,75,,,percent of total billed charges,75% of total billed charges,32.9,100,,,Fee Schedule,100% of CMS OPPS Rate,54.32,100,,,Fee Schedule,100% of WV Medicaid Rate,54.29,165,,,Fee Schedule,165% of CMS OPPS Rate,34.1,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,94.51,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,129.62,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,162.36,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,54.32,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,32.9,100,,,Fee Schedule,100% of CMS OPPS Rate,34.1,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,10.17,14,,,percent of total billed charges,14% of total billed charges,10.17,162.36,
93280-PF In Person programming/eval W/adjustments to test function of the device and select optimal,4271188,CDM,960,RC,93280,HCPCS,Outpatient,,,72.65,36.33,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
93281- PPM eval/test/program/multi lead,3430970,CDM,480,RC,93281,HCPCS,Outpatient,,,81.54,40.77,,61.16,75,,,percent of total billed charges,75% of total billed charges,61.16,75,,,percent of total billed charges,75% of total billed charges,32.9,100,,,Fee Schedule,100% of CMS OPPS Rate,57.52,100,,,Fee Schedule,100% of WV Medicaid Rate,54.29,165,,,Fee Schedule,165% of CMS OPPS Rate,34.1,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,94.51,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,129.62,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,162.36,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,57.52,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,32.9,100,,,Fee Schedule,100% of CMS OPPS Rate,34.1,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,11.42,14,,,percent of total billed charges,14% of total billed charges,11.42,162.36,
93282- ICD eval/test/program/single lead,3430971,CDM,480,RC,93282,HCPCS,Outpatient,,,80.92,40.46,,60.69,75,,,percent of total billed charges,75% of total billed charges,60.69,75,,,percent of total billed charges,75% of total billed charges,32.9,100,,,Fee Schedule,100% of CMS OPPS Rate,55.06,100,,,Fee Schedule,100% of WV Medicaid Rate,54.29,165,,,Fee Schedule,165% of CMS OPPS Rate,34.1,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,94.51,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,129.62,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,162.36,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,55.06,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,32.9,100,,,Fee Schedule,100% of CMS OPPS Rate,34.1,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,11.33,14,,,percent of total billed charges,14% of total billed charges,11.33,162.36,
93283- ICD eval/test/program/dual lead,3430972,CDM,480,RC,93283,HCPCS,Outpatient,,,109.86,54.93,,82.4,75,,,percent of total billed charges,75% of total billed charges,82.4,75,,,percent of total billed charges,75% of total billed charges,32.9,100,,,Fee Schedule,100% of CMS OPPS Rate,67.34,100,,,Fee Schedule,100% of WV Medicaid Rate,54.29,165,,,Fee Schedule,165% of CMS OPPS Rate,34.1,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,94.51,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,129.62,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,162.36,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,67.34,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,32.9,100,,,Fee Schedule,100% of CMS OPPS Rate,34.1,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,15.38,14,,,percent of total billed charges,14% of total billed charges,15.38,162.36,
93284- ICD eval/test/program/mult lead,3430973,CDM,480,RC,93284,HCPCS,Outpatient,,,119.19,59.6,,89.39,75,,,percent of total billed charges,75% of total billed charges,89.39,75,,,percent of total billed charges,75% of total billed charges,32.9,100,,,Fee Schedule,100% of CMS OPPS Rate,72.51,100,,,Fee Schedule,100% of WV Medicaid Rate,54.29,165,,,Fee Schedule,165% of CMS OPPS Rate,34.1,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,94.51,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,129.62,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,162.36,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,72.51,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,32.9,100,,,Fee Schedule,100% of CMS OPPS Rate,34.1,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,16.69,14,,,percent of total billed charges,14% of total billed charges,16.69,162.36,
93285- ILR eval/test/program,3430974,CDM,480,RC,93285,HCPCS,Outpatient,,,49.93,24.97,,37.45,75,,,percent of total billed charges,75% of total billed charges,37.45,75,,,percent of total billed charges,75% of total billed charges,32.9,100,,,Fee Schedule,100% of CMS OPPS Rate,41.29,100,,,Fee Schedule,100% of WV Medicaid Rate,54.29,165,,,Fee Schedule,165% of CMS OPPS Rate,34.1,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,94.51,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,129.62,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,162.36,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,41.29,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,32.9,100,,,Fee Schedule,100% of CMS OPPS Rate,34.1,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,6.99,14,,,percent of total billed charges,14% of total billed charges,6.99,162.36,
93286- PPM eval/peri-proc/sng/dual/multi,3430975,CDM,510,RC,93286,HCPCS,Outpatient,,,77.7,38.85,,58.28,75,,,percent of total billed charges,75% of total billed charges,58.28,75,,,percent of total billed charges,75% of total billed charges,24.86,32,,,percent of total billed charges,32% of total billed charges,30.97,100,,,Fee Schedule,100% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.97,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.88,14,,,percent of total billed charges,14% of total billed charges,10.88,58.28,
Pre/Post MRI Pacemaker Interrogation,4231171,CDM,480,RC,93286,HCPCS,Outpatient,,,31.08,15.54,,23.31,75,,,percent of total billed charges,75% of total billed charges,23.31,75,,,percent of total billed charges,75% of total billed charges,9.95,32,,,percent of total billed charges,32% of total billed charges,30.97,100,,,Fee Schedule,100% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.97,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.35,14,,,percent of total billed charges,14% of total billed charges,4.35,30.97,
Pre/Post MRI Pacemaker Interrogation,4231197,CDM,480,RC,93286,HCPCS,Outpatient,,,31.08,15.54,,23.31,75,,,percent of total billed charges,75% of total billed charges,23.31,75,,,percent of total billed charges,75% of total billed charges,9.95,32,,,percent of total billed charges,32% of total billed charges,30.97,100,,,Fee Schedule,100% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.97,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.35,14,,,percent of total billed charges,14% of total billed charges,4.35,30.97,
93287- ICD eval/peri-proc/sng/dual/multi,3430976,CDM,510,RC,93287,HCPCS,Outpatient,,,77.7,38.85,,58.28,75,,,percent of total billed charges,75% of total billed charges,58.28,75,,,percent of total billed charges,75% of total billed charges,24.86,32,,,percent of total billed charges,32% of total billed charges,36.61,100,,,Fee Schedule,100% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.61,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.88,14,,,percent of total billed charges,14% of total billed charges,10.88,58.28,
Pre/Post MRI Defibrillator Interrogation,4231172,CDM,480,RC,93287,HCPCS,Outpatient,,,46.72,23.36,,35.04,75,,,percent of total billed charges,75% of total billed charges,35.04,75,,,percent of total billed charges,75% of total billed charges,14.95,32,,,percent of total billed charges,32% of total billed charges,36.61,100,,,Fee Schedule,100% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.61,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.54,14,,,percent of total billed charges,14% of total billed charges,6.54,36.61,
93288 - Interrogation Eval in Person 1/Dual/Mlt Lead Pm,3430977,CDM,480,RC,93288,HCPCS,Outpatient,,,40.34,20.17,,30.26,75,,,percent of total billed charges,75% of total billed charges,30.26,75,,,percent of total billed charges,75% of total billed charges,32.9,100,,,Fee Schedule,100% of CMS OPPS Rate,38.34,100,,,Fee Schedule,100% of WV Medicaid Rate,54.29,165,,,Fee Schedule,165% of CMS OPPS Rate,34.1,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,94.51,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,129.62,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,162.36,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,38.34,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,32.9,100,,,Fee Schedule,100% of CMS OPPS Rate,34.1,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,5.65,14,,,percent of total billed charges,14% of total billed charges,5.65,162.36,
93289- ICD interr/in person/sng/dual/mult,3430978,CDM,480,RC,93289,HCPCS,Outpatient,,,71.59,35.8,,53.69,75,,,percent of total billed charges,75% of total billed charges,53.69,75,,,percent of total billed charges,75% of total billed charges,32.9,100,,,Fee Schedule,100% of CMS OPPS Rate,49.65,100,,,Fee Schedule,100% of WV Medicaid Rate,54.29,165,,,Fee Schedule,165% of CMS OPPS Rate,34.1,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,94.51,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,129.62,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,162.36,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,49.65,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,32.9,100,,,Fee Schedule,100% of CMS OPPS Rate,34.1,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,10.02,14,,,percent of total billed charges,14% of total billed charges,10.02,162.36,
93289-ICD Generator Testing,3432004,CDM,481,RC,93289,HCPCS,Outpatient,,,71.59,35.8,,53.69,75,,,percent of total billed charges,75% of total billed charges,53.69,75,,,percent of total billed charges,75% of total billed charges,32.9,100,,,Fee Schedule,100% of CMS OPPS Rate,49.65,100,,,Fee Schedule,100% of WV Medicaid Rate,54.29,165,,,Fee Schedule,165% of CMS OPPS Rate,34.1,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,94.51,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,129.62,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,162.36,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,49.65,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,32.9,100,,,Fee Schedule,100% of CMS OPPS Rate,34.1,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,10.02,14,,,percent of total billed charges,14% of total billed charges,10.02,162.36,
ICD Generator Testing,3427177,CDM,480,RC,93289,HCPCS,Outpatient,,,71.59,35.8,,53.69,75,,,percent of total billed charges,75% of total billed charges,53.69,75,,,percent of total billed charges,75% of total billed charges,32.9,100,,,Fee Schedule,100% of CMS OPPS Rate,49.65,100,,,Fee Schedule,100% of WV Medicaid Rate,54.29,165,,,Fee Schedule,165% of CMS OPPS Rate,34.1,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,94.51,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,129.62,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,162.36,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,49.65,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,32.9,100,,,Fee Schedule,100% of CMS OPPS Rate,34.1,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,10.02,14,,,percent of total billed charges,14% of total billed charges,10.02,162.36,
93290- Internal card mon/interr/in person,3430979,CDM,510,RC,93290,HCPCS,Outpatient,,,81.64,40.82,,61.23,75,,,percent of total billed charges,75% of total billed charges,61.23,75,,,percent of total billed charges,75% of total billed charges,32.9,100,,,Fee Schedule,100% of CMS OPPS Rate,36.61,100,,,Fee Schedule,100% of WV Medicaid Rate,54.29,165,,,Fee Schedule,165% of CMS OPPS Rate,34.1,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,94.51,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,129.62,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,162.36,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,36.61,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,32.9,100,,,Fee Schedule,100% of CMS OPPS Rate,34.1,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,11.43,14,,,percent of total billed charges,14% of total billed charges,11.43,162.36,
93291- Internal loop rec/interr/in person,3430980,CDM,480,RC,93291,HCPCS,Outpatient,,,34.98,17.49,,26.24,75,,,percent of total billed charges,75% of total billed charges,26.24,75,,,percent of total billed charges,75% of total billed charges,23.46,100,,,Fee Schedule,100% of CMS OPPS Rate,33.43,100,,,Fee Schedule,100% of WV Medicaid Rate,38.71,165,,,Fee Schedule,165% of CMS OPPS Rate,24.32,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,67.4,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,92.43,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,115.79,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,33.43,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,23.46,100,,,Fee Schedule,100% of CMS OPPS Rate,24.32,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4.9,14,,,percent of total billed charges,14% of total billed charges,4.9,115.79,
93292- Wearable defib sys/inter/in person,3430981,CDM,510,RC,93292,HCPCS,Outpatient,,,73.74,36.87,,55.31,75,,,percent of total billed charges,75% of total billed charges,55.31,75,,,percent of total billed charges,75% of total billed charges,32.9,100,,,Fee Schedule,100% of CMS OPPS Rate,34.4,100,,,Fee Schedule,100% of WV Medicaid Rate,54.29,165,,,Fee Schedule,165% of CMS OPPS Rate,34.1,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,94.51,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,129.62,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,162.36,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,34.4,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,32.9,100,,,Fee Schedule,100% of CMS OPPS Rate,34.1,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,10.32,14,,,percent of total billed charges,14% of total billed charges,10.32,162.36,
93293- TTM/90 day/PPM/sg/dual/mult,3430982,CDM,732,RC,93293,HCPCS,Outpatient,,,77.7,38.85,,58.28,75,,,percent of total billed charges,75% of total billed charges,58.28,75,,,percent of total billed charges,75% of total billed charges,32.9,100,,,Fee Schedule,100% of CMS OPPS Rate,30.97,100,,,Fee Schedule,100% of WV Medicaid Rate,54.29,165,,,Fee Schedule,165% of CMS OPPS Rate,34.1,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,94.51,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,129.62,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,162.36,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,30.97,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,32.9,100,,,Fee Schedule,100% of CMS OPPS Rate,34.1,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,10.88,14,,,percent of total billed charges,14% of total billed charges,10.88,162.36,
93294- PM remote eval/90 day/sg/dual/mult,3430983,CDM,960,RC,93294,HCPCS,Outpatient,,,59.11,29.56,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
93295- ICD remote eval/90 day/sg/dual/mul,3430984,CDM,960,RC,93295,HCPCS,Outpatient,,,73.35,36.68,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
93296- PM remote trans/90 day/tech review,3430985,CDM,480,RC,93296,HCPCS,Outpatient,,,38.63,19.32,,28.97,75,,,percent of total billed charges,75% of total billed charges,28.97,75,,,percent of total billed charges,75% of total billed charges,32.9,100,,,Fee Schedule,100% of CMS OPPS Rate,14.5,100,,,Fee Schedule,100% of WV Medicaid Rate,54.29,165,,,Fee Schedule,165% of CMS OPPS Rate,34.1,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,94.51,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,129.62,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,162.36,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,14.5,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,32.9,100,,,Fee Schedule,100% of CMS OPPS Rate,34.1,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,5.41,14,,,percent of total billed charges,14% of total billed charges,5.41,162.36,
93297- ICM remote eval/30 day,3430986,CDM,510,RC,93297,HCPCS,Outpatient,,,68.85,34.43,,51.64,75,,,percent of total billed charges,75% of total billed charges,51.64,75,,,percent of total billed charges,75% of total billed charges,22.03,32,,,percent of total billed charges,32% of total billed charges,18.44,100,,,Fee Schedule,100% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.44,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.64,14,,,percent of total billed charges,14% of total billed charges,9.64,51.64,
93298- ILR remote eval/30 day,3430987,CDM,960,RC,93298,HCPCS,Outpatient,,,49.31,24.66,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
93303- TTE/congenital anomalies/complete,3430989,CDM,510,RC,93303,HCPCS,Outpatient,,,385.17,192.59,,288.88,75,,,percent of total billed charges,75% of total billed charges,288.88,75,,,percent of total billed charges,75% of total billed charges,473.01,100,,,Fee Schedule,100% of CMS OPPS Rate,145.76,100,,,Fee Schedule,100% of WV Medicaid Rate,780.48,165,,,Fee Schedule,165% of CMS OPPS Rate,490.24,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1358.69,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1863.34,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,2334.03,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,145.76,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,473.01,100,,,Fee Schedule,100% of CMS OPPS Rate,490.24,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,53.92,14,,,percent of total billed charges,14% of total billed charges,53.92,2334.03,
93304- TTE/congen/anom/follow up/limited,3430990,CDM,510,RC,93304,HCPCS,Outpatient,,,288.83,144.42,,216.62,75,,,percent of total billed charges,75% of total billed charges,216.62,75,,,percent of total billed charges,75% of total billed charges,473.01,100,,,Fee Schedule,100% of CMS OPPS Rate,102.5,100,,,Fee Schedule,100% of WV Medicaid Rate,780.48,165,,,Fee Schedule,165% of CMS OPPS Rate,490.24,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1358.69,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1863.34,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,2334.03,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,102.5,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,473.01,100,,,Fee Schedule,100% of CMS OPPS Rate,490.24,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,40.44,14,,,percent of total billed charges,14% of total billed charges,40.44,2334.03,
"93306- Transthoracic Echo (TTE) Complete, w/2D, Doppler & Color (PRO FEE)",3430991,CDM,960,RC,93306,HCPCS,Outpatient,,,136.49,68.25,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
93306- TTE/2D/M-mode/spec dop/color flow,3430992,CDM,483,RC,93306,HCPCS,Outpatient,,,136.49,68.25,,102.37,75,,,percent of total billed charges,75% of total billed charges,102.37,75,,,percent of total billed charges,75% of total billed charges,473.01,100,,,Fee Schedule,100% of CMS OPPS Rate,130.52,100,,,Fee Schedule,100% of WV Medicaid Rate,780.48,165,,,Fee Schedule,165% of CMS OPPS Rate,490.24,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1358.69,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1863.34,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,2334.03,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,130.52,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,473.01,100,,,Fee Schedule,100% of CMS OPPS Rate,490.24,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,19.11,14,,,percent of total billed charges,14% of total billed charges,19.11,2334.03,
CL Adult Echocardiogram,3334933,CDM,483,RC,93306,HCPCS,Outpatient,,,136.49,68.25,,102.37,75,,,percent of total billed charges,75% of total billed charges,102.37,75,,,percent of total billed charges,75% of total billed charges,473.01,100,,,Fee Schedule,100% of CMS OPPS Rate,130.52,100,,,Fee Schedule,100% of WV Medicaid Rate,780.48,165,,,Fee Schedule,165% of CMS OPPS Rate,490.24,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1358.69,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1863.34,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,2334.03,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,130.52,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,473.01,100,,,Fee Schedule,100% of CMS OPPS Rate,490.24,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,19.11,14,,,percent of total billed charges,14% of total billed charges,19.11,2334.03,
Echocardiogram,604555,CDM,483,RC,93306,HCPCS,Outpatient,,,136.49,68.25,,102.37,75,,,percent of total billed charges,75% of total billed charges,102.37,75,,,percent of total billed charges,75% of total billed charges,473.01,100,,,Fee Schedule,100% of CMS OPPS Rate,130.52,100,,,Fee Schedule,100% of WV Medicaid Rate,780.48,165,,,Fee Schedule,165% of CMS OPPS Rate,490.24,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1358.69,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1863.34,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,2334.03,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,130.52,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,473.01,100,,,Fee Schedule,100% of CMS OPPS Rate,490.24,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,19.11,14,,,percent of total billed charges,14% of total billed charges,19.11,2334.03,
MCNH Echo Transthoracic Complete,3805223,CDM,483,RC,93306,HCPCS,Outpatient,,,136.49,68.25,,102.37,75,,,percent of total billed charges,75% of total billed charges,102.37,75,,,percent of total billed charges,75% of total billed charges,473.01,100,,,Fee Schedule,100% of CMS OPPS Rate,130.52,100,,,Fee Schedule,100% of WV Medicaid Rate,780.48,165,,,Fee Schedule,165% of CMS OPPS Rate,490.24,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1358.69,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1863.34,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,2334.03,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,130.52,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,473.01,100,,,Fee Schedule,100% of CMS OPPS Rate,490.24,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,19.11,14,,,percent of total billed charges,14% of total billed charges,19.11,2334.03,
93307- TTE/2D/M-mode/w/o spec/color dop,3430993,CDM,483,RC,93307,HCPCS,Outpatient,,,226.47,113.24,,169.85,75,,,percent of total billed charges,75% of total billed charges,169.85,75,,,percent of total billed charges,75% of total billed charges,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,91.19,100,,,Fee Schedule,100% of WV Medicaid Rate,362.24,165,,,Fee Schedule,165% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,630.61,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,864.84,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1083.29,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,91.19,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,31.71,14,,,percent of total billed charges,14% of total billed charges,31.71,1083.29,
CVS Charge 2D Echo,645298,CDM,483,RC,93307,HCPCS,Outpatient,,,329.64,164.82,,247.23,75,,,percent of total billed charges,75% of total billed charges,247.23,75,,,percent of total billed charges,75% of total billed charges,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,91.19,100,,,Fee Schedule,100% of WV Medicaid Rate,362.24,165,,,Fee Schedule,165% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,630.61,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,864.84,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1083.29,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,91.19,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,46.15,14,,,percent of total billed charges,14% of total billed charges,46.15,1083.29,
93308 - Limited Echocardiogram Pro Fee,3635415,CDM,960,RC,93308,HCPCS,Outpatient,,,49.42,24.71,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
93308- TTE/2D/M-mode/follow-up/limited  (GLOBAL),3430994,CDM,483,RC,93308,HCPCS,Outpatient,,,49.42,24.71,,37.07,75,,,percent of total billed charges,75% of total billed charges,37.07,75,,,percent of total billed charges,75% of total billed charges,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,49.42,100,,,Fee Schedule,100% of WV Medicaid Rate,362.24,165,,,Fee Schedule,165% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,630.61,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,864.84,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1083.29,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,49.42,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,6.92,14,,,percent of total billed charges,14% of total billed charges,6.92,1083.29,
93308-Dobutamine Valve Study,4061205,CDM,482,RC,93308,HCPCS,Outpatient,,,49.42,24.71,,37.07,75,,,percent of total billed charges,75% of total billed charges,37.07,75,,,percent of total billed charges,75% of total billed charges,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,49.42,100,,,Fee Schedule,100% of WV Medicaid Rate,362.24,165,,,Fee Schedule,165% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,630.61,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,864.84,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1083.29,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,49.42,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,6.92,14,,,percent of total billed charges,14% of total billed charges,6.92,1083.29,
93308-PF Dobutamine Valve Study,4061208,CDM,960,RC,93308,HCPCS,Outpatient,,,49.42,24.71,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
93308-PF ECHO TRANSTHORC R-T 2D W/WO M-MODE REC F-UP/LMTD,4321509,CDM,981,RC,93308,HCPCS,Outpatient,,,49.42,24.71,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
CL Limited Echocardiogram,3334936,CDM,483,RC,93308,HCPCS,Outpatient,,,49.42,24.71,,37.07,75,,,percent of total billed charges,75% of total billed charges,37.07,75,,,percent of total billed charges,75% of total billed charges,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,49.42,100,,,Fee Schedule,100% of WV Medicaid Rate,362.24,165,,,Fee Schedule,165% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,630.61,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,864.84,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1083.29,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,49.42,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,6.92,14,,,percent of total billed charges,14% of total billed charges,6.92,1083.29,
Dobutamine Valve Study,4179565,CDM,483,RC,93308,HCPCS,Outpatient,,,49.42,24.71,,37.07,75,,,percent of total billed charges,75% of total billed charges,37.07,75,,,percent of total billed charges,75% of total billed charges,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,49.42,100,,,Fee Schedule,100% of WV Medicaid Rate,362.24,165,,,Fee Schedule,165% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,630.61,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,864.84,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1083.29,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,49.42,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,6.92,14,,,percent of total billed charges,14% of total billed charges,6.92,1083.29,
Limited Study-Echo,645295,CDM,483,RC,93308,HCPCS,Outpatient,,,49.42,24.71,,37.07,75,,,percent of total billed charges,75% of total billed charges,37.07,75,,,percent of total billed charges,75% of total billed charges,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,49.42,100,,,Fee Schedule,100% of WV Medicaid Rate,362.24,165,,,Fee Schedule,165% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,630.61,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,864.84,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1083.29,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,49.42,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,6.92,14,,,percent of total billed charges,14% of total billed charges,6.92,1083.29,
93312- TEE/2D/probe place/image/int/rep,3430995,CDM,483,RC,93312,HCPCS,Outpatient,,,316.46,158.23,,237.35,75,,,percent of total billed charges,75% of total billed charges,237.35,75,,,percent of total billed charges,75% of total billed charges,473.01,100,,,Fee Schedule,100% of CMS OPPS Rate,159.52,100,,,Fee Schedule,100% of WV Medicaid Rate,780.48,165,,,Fee Schedule,165% of CMS OPPS Rate,490.24,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1358.69,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1863.34,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,2334.03,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,159.52,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,473.01,100,,,Fee Schedule,100% of CMS OPPS Rate,490.24,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,44.3,14,,,percent of total billed charges,14% of total billed charges,44.3,2334.03,
"93312- Transesophageal Echo (TEE) 2D, Includes Probe Plcmt, Image Acq, I&R (PRO FEE)",3430996,CDM,483,RC,93312,HCPCS,Outpatient,,,316.46,158.23,,237.35,75,,,percent of total billed charges,75% of total billed charges,237.35,75,,,percent of total billed charges,75% of total billed charges,473.01,100,,,Fee Schedule,100% of CMS OPPS Rate,159.52,100,,,Fee Schedule,100% of WV Medicaid Rate,780.48,165,,,Fee Schedule,165% of CMS OPPS Rate,490.24,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1358.69,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1863.34,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,2334.03,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,159.52,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,473.01,100,,,Fee Schedule,100% of CMS OPPS Rate,490.24,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,44.3,14,,,percent of total billed charges,14% of total billed charges,44.3,2334.03,
Echocardiogram Transeso,604557,CDM,483,RC,93312,HCPCS,Outpatient,,,577.81,288.91,,433.36,75,,,percent of total billed charges,75% of total billed charges,433.36,75,,,percent of total billed charges,75% of total billed charges,473.01,100,,,Fee Schedule,100% of CMS OPPS Rate,159.52,100,,,Fee Schedule,100% of WV Medicaid Rate,780.48,165,,,Fee Schedule,165% of CMS OPPS Rate,490.24,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1358.69,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1863.34,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,2334.03,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,159.52,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,473.01,100,,,Fee Schedule,100% of CMS OPPS Rate,490.24,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,80.89,14,,,percent of total billed charges,14% of total billed charges,80.89,2334.03,
Echocardiogram Transeso in OR,1345096,CDM,483,RC,93312,HCPCS,Outpatient,,,577.81,288.91,,433.36,75,,,percent of total billed charges,75% of total billed charges,433.36,75,,,percent of total billed charges,75% of total billed charges,473.01,100,,,Fee Schedule,100% of CMS OPPS Rate,159.52,100,,,Fee Schedule,100% of WV Medicaid Rate,780.48,165,,,Fee Schedule,165% of CMS OPPS Rate,490.24,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1358.69,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1863.34,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,2334.03,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,159.52,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,473.01,100,,,Fee Schedule,100% of CMS OPPS Rate,490.24,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,80.89,14,,,percent of total billed charges,14% of total billed charges,80.89,2334.03,
MCNH Echo Transthoracic TTE Limited,3805224,CDM,483,RC,93312,HCPCS,Outpatient,,,577.81,288.91,,433.36,75,,,percent of total billed charges,75% of total billed charges,433.36,75,,,percent of total billed charges,75% of total billed charges,473.01,100,,,Fee Schedule,100% of CMS OPPS Rate,159.52,100,,,Fee Schedule,100% of WV Medicaid Rate,780.48,165,,,Fee Schedule,165% of CMS OPPS Rate,490.24,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1358.69,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1863.34,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,2334.03,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,159.52,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,473.01,100,,,Fee Schedule,100% of CMS OPPS Rate,490.24,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,80.89,14,,,percent of total billed charges,14% of total billed charges,80.89,2334.03,
93313- TEE/probe place only,3430997,CDM,510,RC,93313,HCPCS,Outpatient,,,30.07,15.04,,22.55,75,,,percent of total billed charges,75% of total billed charges,22.55,75,,,percent of total billed charges,75% of total billed charges,473.01,100,,,Fee Schedule,100% of CMS OPPS Rate,7.87,100,,,Fee Schedule,100% of WV Medicaid Rate,780.48,165,,,Fee Schedule,165% of CMS OPPS Rate,490.24,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1358.69,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1863.34,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,2334.03,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,7.87,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,473.01,100,,,Fee Schedule,100% of CMS OPPS Rate,490.24,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4.21,14,,,percent of total billed charges,14% of total billed charges,4.21,2334.03,
93314- TEE/image acquisition/int/rep only,3430998,CDM,510,RC,93314,HCPCS,Outpatient,,,334.62,167.31,,250.97,75,,,percent of total billed charges,75% of total billed charges,250.97,75,,,percent of total billed charges,75% of total billed charges,107.08,32,,,percent of total billed charges,32% of total billed charges,152.88,100,,,Fee Schedule,100% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,152.88,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.85,14,,,percent of total billed charges,14% of total billed charges,46.85,250.97,
93315- TEE/congen/prob plac/image/int/rep,3430999,CDM,510,RC,93315,HCPCS,Outpatient,,,329.33,164.67,,247,75,,,percent of total billed charges,75% of total billed charges,247,75,,,percent of total billed charges,75% of total billed charges,473.01,100,,,Fee Schedule,100% of CMS OPPS Rate,329.33,100,,,Fee Schedule,100% of WV Medicaid Rate,780.48,165,,,Fee Schedule,165% of CMS OPPS Rate,490.24,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1358.69,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1863.34,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,2334.03,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,329.33,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,473.01,100,,,Fee Schedule,100% of CMS OPPS Rate,490.24,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,46.11,14,,,percent of total billed charges,14% of total billed charges,46.11,2334.03,
93316- TEE/congenital/probe place only,3431000,CDM,510,RC,93316,HCPCS,Outpatient,,,69.41,34.71,,52.06,75,,,percent of total billed charges,75% of total billed charges,52.06,75,,,percent of total billed charges,75% of total billed charges,473.01,100,,,Fee Schedule,100% of CMS OPPS Rate,18.44,100,,,Fee Schedule,100% of WV Medicaid Rate,780.48,165,,,Fee Schedule,165% of CMS OPPS Rate,490.24,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1358.69,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1863.34,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,2334.03,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,18.44,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,473.01,100,,,Fee Schedule,100% of CMS OPPS Rate,490.24,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,9.72,14,,,percent of total billed charges,14% of total billed charges,9.72,2334.03,
93317- TEE/congenital/image/int/rep only,3431001,CDM,510,RC,93317,HCPCS,Outpatient,,,232.48,116.24,,174.36,75,,,percent of total billed charges,75% of total billed charges,174.36,75,,,percent of total billed charges,75% of total billed charges,74.39,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.55,14,,,percent of total billed charges,14% of total billed charges,32.55,174.36,
93318- TEE/real time 2D/image/cont mon,3431002,CDM,480,RC,93318,HCPCS,Outpatient,,,268.72,134.36,,201.54,75,,,percent of total billed charges,75% of total billed charges,201.54,75,,,percent of total billed charges,75% of total billed charges,473.01,100,,,Fee Schedule,100% of CMS OPPS Rate,268.72,100,,,Fee Schedule,100% of WV Medicaid Rate,780.48,165,,,Fee Schedule,165% of CMS OPPS Rate,490.24,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1358.69,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1863.34,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,2334.03,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,268.72,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,473.01,100,,,Fee Schedule,100% of CMS OPPS Rate,490.24,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,37.62,14,,,percent of total billed charges,14% of total billed charges,37.62,2334.03,
3D Echocardiographic imaging and postprocessing during TEE o,3938898,CDM,483,RC,93319,HCPCS,Outpatient,,,135.18,67.59,,101.39,75,,,percent of total billed charges,75% of total billed charges,101.39,75,,,percent of total billed charges,75% of total billed charges,43.26,32,,,percent of total billed charges,32% of total billed charges,17.45,102,,,Fee Schedule,102% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.45,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.93,14,,,percent of total billed charges,14% of total billed charges,17.45,101.39,
93319 - 3D Echo Img Cgen Car Anomol,4113120,CDM,972,RC,93319,HCPCS,Outpatient,,,133.42,66.71,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
93320 (26) - Doppler Echo Spectral Display,4113123,CDM,972,RC,93320,HCPCS,Outpatient,,,112.86,56.43,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
93320- Doppler echo spectral display,3431003,CDM,483,RC,93320,HCPCS,Outpatient,,,80.07,40.04,,60.05,75,,,percent of total billed charges,75% of total billed charges,60.05,75,,,percent of total billed charges,75% of total billed charges,25.62,32,,,percent of total billed charges,32% of total billed charges,33.67,100,,,Fee Schedule,100% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.67,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.21,14,,,percent of total billed charges,14% of total billed charges,11.21,60.05,
93320-Spectral Doppler,3554696,CDM,481,RC,93320,HCPCS,Outpatient,,,80.07,40.04,,60.05,75,,,percent of total billed charges,75% of total billed charges,60.05,75,,,percent of total billed charges,75% of total billed charges,25.62,32,,,percent of total billed charges,32% of total billed charges,33.67,100,,,Fee Schedule,100% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.67,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.21,14,,,percent of total billed charges,14% of total billed charges,11.21,60.05,
Spectral Doppler,3558607,CDM,483,RC,93320,HCPCS,Outpatient,,,122.11,61.06,,91.58,75,,,percent of total billed charges,75% of total billed charges,91.58,75,,,percent of total billed charges,75% of total billed charges,39.08,32,,,percent of total billed charges,32% of total billed charges,33.67,100,,,Fee Schedule,100% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.67,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.1,14,,,percent of total billed charges,14% of total billed charges,17.1,91.58,
93321- Dop echo/pulse/cont wave/spec/lim,3431005,CDM,483,RC,93321,HCPCS,Outpatient,,,46.64,23.32,,34.98,75,,,percent of total billed charges,75% of total billed charges,34.98,75,,,percent of total billed charges,75% of total billed charges,14.92,32,,,percent of total billed charges,32% of total billed charges,16.47,100,,,Fee Schedule,100% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.47,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.53,14,,,percent of total billed charges,14% of total billed charges,6.53,34.98,
93321 Doppler echo pulsed wave,4061246,CDM,483,RC,93321,HCPCS,Outpatient,,,46.64,23.32,,34.98,75,,,percent of total billed charges,75% of total billed charges,34.98,75,,,percent of total billed charges,75% of total billed charges,14.92,32,,,percent of total billed charges,32% of total billed charges,16.47,100,,,Fee Schedule,100% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.47,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.53,14,,,percent of total billed charges,14% of total billed charges,6.53,34.98,
"93321(26)- Doppler Echo, Limited or F/U (PRO FEE)",3431004,CDM,483,RC,93321,HCPCS,Outpatient,,,46.64,23.32,,34.98,75,,,percent of total billed charges,75% of total billed charges,34.98,75,,,percent of total billed charges,75% of total billed charges,14.92,32,,,percent of total billed charges,32% of total billed charges,16.47,100,,,Fee Schedule,100% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.47,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.53,14,,,percent of total billed charges,14% of total billed charges,6.53,34.98,
93321-Limited or Follow Up TEE,3556733,CDM,483,RC,93321,HCPCS,Outpatient,,,46.64,23.32,,34.98,75,,,percent of total billed charges,75% of total billed charges,34.98,75,,,percent of total billed charges,75% of total billed charges,14.92,32,,,percent of total billed charges,32% of total billed charges,16.47,100,,,Fee Schedule,100% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.47,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.53,14,,,percent of total billed charges,14% of total billed charges,6.53,34.98,
Limited Spectral Doppler,3558606,CDM,483,RC,93321,HCPCS,Outpatient,,,46.64,23.32,,34.98,75,,,percent of total billed charges,75% of total billed charges,34.98,75,,,percent of total billed charges,75% of total billed charges,14.92,32,,,percent of total billed charges,32% of total billed charges,16.47,100,,,Fee Schedule,100% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.47,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.53,14,,,percent of total billed charges,14% of total billed charges,6.53,34.98,
93325 - Color Flow Mapping Pro Fee,3635416,CDM,960,RC,93325,HCPCS,Outpatient,,,6.06,3.03,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
93325 Doppler echo color flow,4061247,CDM,483,RC,93325,HCPCS,Outpatient,,,6.06,3.03,,4.55,75,,,percent of total billed charges,75% of total billed charges,4.55,75,,,percent of total billed charges,75% of total billed charges,1.94,32,,,percent of total billed charges,32% of total billed charges,6.06,100,,,Fee Schedule,100% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.06,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.94,6.06,
93325- Doppler echo color flow,3431006,CDM,483,RC,93325,HCPCS,Outpatient,,,6.06,3.03,,4.55,75,,,percent of total billed charges,75% of total billed charges,4.55,75,,,percent of total billed charges,75% of total billed charges,1.94,32,,,percent of total billed charges,32% of total billed charges,6.06,100,,,Fee Schedule,100% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.06,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.94,6.06,
Color Flow Mapping,604586,CDM,483,RC,93325,HCPCS,Outpatient,,,6.06,3.03,,4.55,75,,,percent of total billed charges,75% of total billed charges,4.55,75,,,percent of total billed charges,75% of total billed charges,1.94,32,,,percent of total billed charges,32% of total billed charges,6.06,100,,,Fee Schedule,100% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.06,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.94,6.06,
93350 (26)- Stress Echo w/ I&R (PRO FEE),3431007,CDM,483,RC,93350,HCPCS,Outpatient,,,136.49,68.25,,102.37,75,,,percent of total billed charges,75% of total billed charges,102.37,75,,,percent of total billed charges,75% of total billed charges,473.01,100,,,Fee Schedule,100% of CMS OPPS Rate,124.13,100,,,Fee Schedule,100% of WV Medicaid Rate,780.48,165,,,Fee Schedule,165% of CMS OPPS Rate,490.24,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1358.69,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1863.34,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,2334.03,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,124.13,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,473.01,100,,,Fee Schedule,100% of CMS OPPS Rate,490.24,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,19.11,14,,,percent of total billed charges,14% of total billed charges,19.11,2334.03,
93350- Stress echo/2D/M-mode/I&R,3431008,CDM,483,RC,93350,HCPCS,Outpatient,,,136.49,68.25,,102.37,75,,,percent of total billed charges,75% of total billed charges,102.37,75,,,percent of total billed charges,75% of total billed charges,473.01,100,,,Fee Schedule,100% of CMS OPPS Rate,124.13,100,,,Fee Schedule,100% of WV Medicaid Rate,780.48,165,,,Fee Schedule,165% of CMS OPPS Rate,490.24,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1358.69,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1863.34,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,2334.03,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,124.13,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,473.01,100,,,Fee Schedule,100% of CMS OPPS Rate,490.24,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,19.11,14,,,percent of total billed charges,14% of total billed charges,19.11,2334.03,
CL Exercise Stress Echocardiogram,3334934,CDM,483,RC,93350,HCPCS,Outpatient,,,136.49,68.25,,102.37,75,,,percent of total billed charges,75% of total billed charges,102.37,75,,,percent of total billed charges,75% of total billed charges,473.01,100,,,Fee Schedule,100% of CMS OPPS Rate,124.13,100,,,Fee Schedule,100% of WV Medicaid Rate,780.48,165,,,Fee Schedule,165% of CMS OPPS Rate,490.24,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1358.69,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1863.34,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,2334.03,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,124.13,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,473.01,100,,,Fee Schedule,100% of CMS OPPS Rate,490.24,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,19.11,14,,,percent of total billed charges,14% of total billed charges,19.11,2334.03,
CVS Charge Stress Echo,1157011,CDM,483,RC,93350,HCPCS,Outpatient,,,136.49,68.25,,102.37,75,,,percent of total billed charges,75% of total billed charges,102.37,75,,,percent of total billed charges,75% of total billed charges,473.01,100,,,Fee Schedule,100% of CMS OPPS Rate,124.13,100,,,Fee Schedule,100% of WV Medicaid Rate,780.48,165,,,Fee Schedule,165% of CMS OPPS Rate,490.24,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1358.69,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1863.34,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,2334.03,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,124.13,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,473.01,100,,,Fee Schedule,100% of CMS OPPS Rate,490.24,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,19.11,14,,,percent of total billed charges,14% of total billed charges,19.11,2334.03,
Stress Echocardiogram,604568,CDM,483,RC,93350,HCPCS,Outpatient,,,136.49,68.25,,102.37,75,,,percent of total billed charges,75% of total billed charges,102.37,75,,,percent of total billed charges,75% of total billed charges,473.01,100,,,Fee Schedule,100% of CMS OPPS Rate,124.13,100,,,Fee Schedule,100% of WV Medicaid Rate,780.48,165,,,Fee Schedule,165% of CMS OPPS Rate,490.24,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1358.69,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1863.34,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,2334.03,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,124.13,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,473.01,100,,,Fee Schedule,100% of CMS OPPS Rate,490.24,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,19.11,14,,,percent of total billed charges,14% of total billed charges,19.11,2334.03,
93351- TTE/rest/stress/2D/M-mode/cont ECG,3431009,CDM,483,RC,93351,HCPCS,Outpatient,,,359.72,179.86,,269.79,75,,,percent of total billed charges,75% of total billed charges,269.79,75,,,percent of total billed charges,75% of total billed charges,473.01,100,,,Fee Schedule,100% of CMS OPPS Rate,154.12,100,,,Fee Schedule,100% of WV Medicaid Rate,780.48,165,,,Fee Schedule,165% of CMS OPPS Rate,490.24,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1358.69,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1863.34,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,2334.03,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,154.12,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,473.01,100,,,Fee Schedule,100% of CMS OPPS Rate,490.24,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,50.36,14,,,percent of total billed charges,14% of total billed charges,50.36,2334.03,
CL Dobutamine Stress Echocardiogram,3334935,CDM,483,RC,93351,HCPCS,Outpatient,,,359.72,179.86,,269.79,75,,,percent of total billed charges,75% of total billed charges,269.79,75,,,percent of total billed charges,75% of total billed charges,473.01,100,,,Fee Schedule,100% of CMS OPPS Rate,154.12,100,,,Fee Schedule,100% of WV Medicaid Rate,780.48,165,,,Fee Schedule,165% of CMS OPPS Rate,490.24,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1358.69,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1863.34,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,2334.03,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,154.12,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,473.01,100,,,Fee Schedule,100% of CMS OPPS Rate,490.24,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,50.36,14,,,percent of total billed charges,14% of total billed charges,50.36,2334.03,
Dobutamine Stress Echo,3569308,CDM,483,RC,93351,HCPCS,Outpatient,,,560.85,280.43,,420.64,75,,,percent of total billed charges,75% of total billed charges,420.64,75,,,percent of total billed charges,75% of total billed charges,473.01,100,,,Fee Schedule,100% of CMS OPPS Rate,154.12,100,,,Fee Schedule,100% of WV Medicaid Rate,780.48,165,,,Fee Schedule,165% of CMS OPPS Rate,490.24,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1358.69,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1863.34,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,2334.03,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,154.12,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,473.01,100,,,Fee Schedule,100% of CMS OPPS Rate,490.24,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,78.52,14,,,percent of total billed charges,14% of total billed charges,78.52,2334.03,
"Stress Echo, Complete",1259040,CDM,483,RC,93351,HCPCS,Outpatient,,,560.85,280.43,,420.64,75,,,percent of total billed charges,75% of total billed charges,420.64,75,,,percent of total billed charges,75% of total billed charges,473.01,100,,,Fee Schedule,100% of CMS OPPS Rate,154.12,100,,,Fee Schedule,100% of WV Medicaid Rate,780.48,165,,,Fee Schedule,165% of CMS OPPS Rate,490.24,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1358.69,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1863.34,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,2334.03,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,154.12,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,473.01,100,,,Fee Schedule,100% of CMS OPPS Rate,490.24,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,78.52,14,,,percent of total billed charges,14% of total billed charges,78.52,2334.03,
93355-Structural Heart TEE,3554695,CDM,481,RC,93355,HCPCS,Outpatient,,,593.93,296.97,,445.45,75,,,percent of total billed charges,75% of total billed charges,445.45,75,,,percent of total billed charges,75% of total billed charges,190.06,32,,,percent of total billed charges,32% of total billed charges,158.79,100,,,Fee Schedule,100% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,158.79,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,83.15,14,,,percent of total billed charges,14% of total billed charges,83.15,445.45,
Structural Heart TEE,3569306,CDM,483,RC,93355,HCPCS,Outpatient,,,593.93,296.97,,445.45,75,,,percent of total billed charges,75% of total billed charges,445.45,75,,,percent of total billed charges,75% of total billed charges,190.06,32,,,percent of total billed charges,32% of total billed charges,158.79,100,,,Fee Schedule,100% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,158.79,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,83.15,14,,,percent of total billed charges,14% of total billed charges,83.15,445.45,
93356-PF Myocardial Strain Imaging,3818894,CDM,960,RC,93356,HCPCS,Outpatient,,,23.3,11.65,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
Myocardial Strain Imaging,3818893,CDM,483,RC,93356,HCPCS,Outpatient,,,23.3,11.65,,17.48,75,,,percent of total billed charges,75% of total billed charges,17.48,75,,,percent of total billed charges,75% of total billed charges,7.46,32,,,percent of total billed charges,32% of total billed charges,8.36,100,,,Fee Schedule,100% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.36,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.26,14,,,percent of total billed charges,14% of total billed charges,3.26,17.48,
Myocardial Strain Imaging,3824895,CDM,483,RC,93356,HCPCS,Outpatient,,,23.3,11.65,,17.48,75,,,percent of total billed charges,75% of total billed charges,17.48,75,,,percent of total billed charges,75% of total billed charges,7.46,32,,,percent of total billed charges,32% of total billed charges,8.36,100,,,Fee Schedule,100% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.36,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.26,14,,,percent of total billed charges,14% of total billed charges,3.26,17.48,
93451- Rt heart cath/O2 sats/CO,3430767,CDM,481,RC,93451,HCPCS,Outpatient,,,1831.56,915.78,,1373.67,75,,,percent of total billed charges,75% of total billed charges,1373.67,75,,,percent of total billed charges,75% of total billed charges,2781.44,100,,,Fee Schedule,100% of CMS OPPS Rate,581.8,100,,,Fee Schedule,100% of WV Medicaid Rate,4589.37,165,,,Fee Schedule,165% of CMS OPPS Rate,2882.73,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,7989.31,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,10956.7,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13724.38,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,581.8,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2781.44,100,,,Fee Schedule,100% of CMS OPPS Rate,2882.73,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,256.42,14,,,percent of total billed charges,14% of total billed charges,256.42,13724.38,
93451-PF RIGHT HEART CATH,3580915,CDM,960,RC,93451,HCPCS,Outpatient,,,1831.56,915.78,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
93451-RIGHT HEART CATH,3432005,CDM,481,RC,93451,HCPCS,Outpatient,,,1831.56,915.78,,1373.67,75,,,percent of total billed charges,75% of total billed charges,1373.67,75,,,percent of total billed charges,75% of total billed charges,2781.44,100,,,Fee Schedule,100% of CMS OPPS Rate,581.8,100,,,Fee Schedule,100% of WV Medicaid Rate,4589.37,165,,,Fee Schedule,165% of CMS OPPS Rate,2882.73,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,7989.31,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,10956.7,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13724.38,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,581.8,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2781.44,100,,,Fee Schedule,100% of CMS OPPS Rate,2882.73,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,256.42,14,,,percent of total billed charges,14% of total billed charges,256.42,13724.38,
93452- Lt heart cath/LV gram,3430769,CDM,510,RC,93452,HCPCS,Outpatient,,,1661.82,830.91,,1246.37,75,,,percent of total billed charges,75% of total billed charges,1246.37,75,,,percent of total billed charges,75% of total billed charges,2781.44,100,,,Fee Schedule,100% of CMS OPPS Rate,613.03,100,,,Fee Schedule,100% of WV Medicaid Rate,4589.37,165,,,Fee Schedule,165% of CMS OPPS Rate,2882.73,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,7989.31,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,10956.7,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13724.38,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,613.03,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2781.44,100,,,Fee Schedule,100% of CMS OPPS Rate,2882.73,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,232.65,14,,,percent of total billed charges,14% of total billed charges,232.65,13724.38,
"93452-LHC, LV only",3560666,CDM,481,RC,93452,HCPCS,Outpatient,,,1661.82,830.91,,1246.37,75,,,percent of total billed charges,75% of total billed charges,1246.37,75,,,percent of total billed charges,75% of total billed charges,2781.44,100,,,Fee Schedule,100% of CMS OPPS Rate,613.03,100,,,Fee Schedule,100% of WV Medicaid Rate,4589.37,165,,,Fee Schedule,165% of CMS OPPS Rate,2882.73,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,7989.31,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,10956.7,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13724.38,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,613.03,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2781.44,100,,,Fee Schedule,100% of CMS OPPS Rate,2882.73,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,232.65,14,,,percent of total billed charges,14% of total billed charges,232.65,13724.38,
"93452-PF LHC, LV only",3580916,CDM,960,RC,93452,HCPCS,Outpatient,,,1661.82,830.91,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
"93453- RHC w LHC, LV only",3560648,CDM,481,RC,93453,HCPCS,Outpatient,,,2071.94,1035.97,,1553.96,75,,,percent of total billed charges,75% of total billed charges,1553.96,75,,,percent of total billed charges,75% of total billed charges,2781.44,100,,,Fee Schedule,100% of CMS OPPS Rate,777.96,100,,,Fee Schedule,100% of WV Medicaid Rate,4589.37,165,,,Fee Schedule,165% of CMS OPPS Rate,2882.73,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,7989.31,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,10956.7,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13724.38,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,777.96,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2781.44,100,,,Fee Schedule,100% of CMS OPPS Rate,2882.73,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,290.07,14,,,percent of total billed charges,14% of total billed charges,290.07,13724.38,
93453- Rt/Lt heart cath w/LV,3430770,CDM,481,RC,93453,HCPCS,Outpatient,,,2071.94,1035.97,,1553.96,75,,,percent of total billed charges,75% of total billed charges,1553.96,75,,,percent of total billed charges,75% of total billed charges,2781.44,100,,,Fee Schedule,100% of CMS OPPS Rate,777.96,100,,,Fee Schedule,100% of WV Medicaid Rate,4589.37,165,,,Fee Schedule,165% of CMS OPPS Rate,2882.73,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,7989.31,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,10956.7,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13724.38,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,777.96,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2781.44,100,,,Fee Schedule,100% of CMS OPPS Rate,2882.73,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,290.07,14,,,percent of total billed charges,14% of total billed charges,290.07,13724.38,
"93453-PF RHC w LHC, LV only",3580917,CDM,960,RC,93453,HCPCS,Outpatient,,,2071.94,1035.97,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
"93453-RHC w LHC, LV only",3554698,CDM,481,RC,93453,HCPCS,Outpatient,,,2071.94,1035.97,,1553.96,75,,,percent of total billed charges,75% of total billed charges,1553.96,75,,,percent of total billed charges,75% of total billed charges,2781.44,100,,,Fee Schedule,100% of CMS OPPS Rate,777.96,100,,,Fee Schedule,100% of WV Medicaid Rate,4589.37,165,,,Fee Schedule,165% of CMS OPPS Rate,2882.73,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,7989.31,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,10956.7,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13724.38,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,777.96,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2781.44,100,,,Fee Schedule,100% of CMS OPPS Rate,2882.73,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,290.07,14,,,percent of total billed charges,14% of total billed charges,290.07,13724.38,
93454- Coronary angiogram,3430771,CDM,481,RC,93454,HCPCS,Outpatient,,,488.09,244.05,,366.07,75,,,percent of total billed charges,75% of total billed charges,366.07,75,,,percent of total billed charges,75% of total billed charges,2781.44,100,,,Fee Schedule,100% of CMS OPPS Rate,488.09,100,,,Fee Schedule,100% of WV Medicaid Rate,4589.37,165,,,Fee Schedule,165% of CMS OPPS Rate,2882.73,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,7989.31,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,10956.7,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13724.38,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,488.09,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2781.44,100,,,Fee Schedule,100% of CMS OPPS Rate,2882.73,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,68.33,14,,,percent of total billed charges,14% of total billed charges,68.33,13724.38,
93454-CORONARY ANGIOGRAM ONLY NO LHC,3432006,CDM,481,RC,93454,HCPCS,Outpatient,,,488.09,244.05,,366.07,75,,,percent of total billed charges,75% of total billed charges,366.07,75,,,percent of total billed charges,75% of total billed charges,2781.44,100,,,Fee Schedule,100% of CMS OPPS Rate,488.09,100,,,Fee Schedule,100% of WV Medicaid Rate,4589.37,165,,,Fee Schedule,165% of CMS OPPS Rate,2882.73,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,7989.31,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,10956.7,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13724.38,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,488.09,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2781.44,100,,,Fee Schedule,100% of CMS OPPS Rate,2882.73,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,68.33,14,,,percent of total billed charges,14% of total billed charges,68.33,13724.38,
93454-PF CORONARY ANGIOGRAM ONLY NO LHC,3580918,CDM,960,RC,93454,HCPCS,Outpatient,,,488.09,244.05,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
Coronary Angiography,604572,CDM,480,RC,93454,HCPCS,Outpatient,,,488.09,244.05,,366.07,75,,,percent of total billed charges,75% of total billed charges,366.07,75,,,percent of total billed charges,75% of total billed charges,2781.44,100,,,Fee Schedule,100% of CMS OPPS Rate,488.09,100,,,Fee Schedule,100% of WV Medicaid Rate,4589.37,165,,,Fee Schedule,165% of CMS OPPS Rate,2882.73,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,7989.31,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,10956.7,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13724.38,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,488.09,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2781.44,100,,,Fee Schedule,100% of CMS OPPS Rate,2882.73,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,68.33,14,,,percent of total billed charges,14% of total billed charges,68.33,13724.38,
93455- Coronary angiogram/w grafts,3430772,CDM,481,RC,93455,HCPCS,Outpatient,,,1818.17,909.09,,1363.63,75,,,percent of total billed charges,75% of total billed charges,1363.63,75,,,percent of total billed charges,75% of total billed charges,2781.44,100,,,Fee Schedule,100% of CMS OPPS Rate,684.31,100,,,Fee Schedule,100% of WV Medicaid Rate,4589.37,165,,,Fee Schedule,165% of CMS OPPS Rate,2882.73,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,7989.31,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,10956.7,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13724.38,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,684.31,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2781.44,100,,,Fee Schedule,100% of CMS OPPS Rate,2882.73,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,254.54,14,,,percent of total billed charges,14% of total billed charges,254.54,13724.38,
93455-CORONARY ANGIO W/GRAFTS ONLY NO LHC,3432007,CDM,481,RC,93455,HCPCS,Outpatient,,,1818.17,909.09,,1363.63,75,,,percent of total billed charges,75% of total billed charges,1363.63,75,,,percent of total billed charges,75% of total billed charges,2781.44,100,,,Fee Schedule,100% of CMS OPPS Rate,684.31,100,,,Fee Schedule,100% of WV Medicaid Rate,4589.37,165,,,Fee Schedule,165% of CMS OPPS Rate,2882.73,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,7989.31,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,10956.7,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13724.38,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,684.31,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2781.44,100,,,Fee Schedule,100% of CMS OPPS Rate,2882.73,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,254.54,14,,,percent of total billed charges,14% of total billed charges,254.54,13724.38,
93455-PF CORONARY ANGIO W/GRAFTS ONLY NO LHC,3580919,CDM,960,RC,93455,HCPCS,Outpatient,,,1818.17,909.09,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
93456- Rt Heart Cath w/cors,3430773,CDM,481,RC,93456,HCPCS,Outpatient,,,2032.92,1016.46,,1524.69,75,,,percent of total billed charges,75% of total billed charges,1524.69,75,,,percent of total billed charges,75% of total billed charges,2781.44,100,,,Fee Schedule,100% of CMS OPPS Rate,764.44,100,,,Fee Schedule,100% of WV Medicaid Rate,4589.37,165,,,Fee Schedule,165% of CMS OPPS Rate,2882.73,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,7989.31,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,10956.7,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13724.38,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,764.44,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2781.44,100,,,Fee Schedule,100% of CMS OPPS Rate,2882.73,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,284.61,14,,,percent of total billed charges,14% of total billed charges,284.61,13724.38,
93456-PF RHC w/COR only,3680917,CDM,960,RC,93456,HCPCS,Outpatient,,,2032.92,1016.46,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
93456-RHC w/COR only,3680915,CDM,481,RC,93456,HCPCS,Outpatient,,,2032.92,1016.46,,1524.69,75,,,percent of total billed charges,75% of total billed charges,1524.69,75,,,percent of total billed charges,75% of total billed charges,2781.44,100,,,Fee Schedule,100% of CMS OPPS Rate,764.44,100,,,Fee Schedule,100% of WV Medicaid Rate,4589.37,165,,,Fee Schedule,165% of CMS OPPS Rate,2882.73,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,7989.31,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,10956.7,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13724.38,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,764.44,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2781.44,100,,,Fee Schedule,100% of CMS OPPS Rate,2882.73,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,284.61,14,,,percent of total billed charges,14% of total billed charges,284.61,13724.38,
93457- Rt heart cath w/cors/grafts,3430774,CDM,510,RC,93457,HCPCS,Outpatient,,,2191.16,1095.58,,1643.37,75,,,percent of total billed charges,75% of total billed charges,1643.37,75,,,percent of total billed charges,75% of total billed charges,2781.44,100,,,Fee Schedule,100% of CMS OPPS Rate,834.98,100,,,Fee Schedule,100% of WV Medicaid Rate,4589.37,165,,,Fee Schedule,165% of CMS OPPS Rate,2882.73,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,7989.31,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,10956.7,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13724.38,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,834.98,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2781.44,100,,,Fee Schedule,100% of CMS OPPS Rate,2882.73,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,306.76,14,,,percent of total billed charges,14% of total billed charges,306.76,13724.38,
93457-PF Right Heart Cath with coronary angiography and bypass grafts- No LHC,4271190,CDM,960,RC,93457,HCPCS,Outpatient,,,2373.76,1186.88,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
93457-Right Heart Cath with coronary angiography and bypass grafts- No LHC,4271189,CDM,481,RC,93457,HCPCS,Outpatient,,,2373.76,1186.88,,1780.32,75,,,percent of total billed charges,75% of total billed charges,1780.32,75,,,percent of total billed charges,75% of total billed charges,2781.44,100,,,Fee Schedule,100% of CMS OPPS Rate,834.98,100,,,Fee Schedule,100% of WV Medicaid Rate,4589.37,165,,,Fee Schedule,165% of CMS OPPS Rate,2882.73,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,7989.31,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,10956.7,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13724.38,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,834.98,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2781.44,100,,,Fee Schedule,100% of CMS OPPS Rate,2882.73,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,332.33,14,,,percent of total billed charges,14% of total billed charges,332.33,13724.38,
93458- Lt Heart cath/LV/cors,3430775,CDM,481,RC,93458,HCPCS,Outpatient,,,1857.14,928.57,,1392.86,75,,,percent of total billed charges,75% of total billed charges,1392.86,75,,,percent of total billed charges,75% of total billed charges,2781.44,100,,,Fee Schedule,100% of CMS OPPS Rate,706.18,100,,,Fee Schedule,100% of WV Medicaid Rate,4589.37,165,,,Fee Schedule,165% of CMS OPPS Rate,2882.73,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,7989.31,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,10956.7,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13724.38,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,706.18,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2781.44,100,,,Fee Schedule,100% of CMS OPPS Rate,2882.73,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,260,14,,,percent of total billed charges,14% of total billed charges,260,13724.38,
"93458-LEFT HEART CATH, LV, COR",3432008,CDM,481,RC,93458,HCPCS,Outpatient,,,1857.14,928.57,,1392.86,75,,,percent of total billed charges,75% of total billed charges,1392.86,75,,,percent of total billed charges,75% of total billed charges,2781.44,100,,,Fee Schedule,100% of CMS OPPS Rate,706.18,100,,,Fee Schedule,100% of WV Medicaid Rate,4589.37,165,,,Fee Schedule,165% of CMS OPPS Rate,2882.73,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,7989.31,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,10956.7,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13724.38,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,706.18,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2781.44,100,,,Fee Schedule,100% of CMS OPPS Rate,2882.73,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,260,14,,,percent of total billed charges,14% of total billed charges,260,13724.38,
"93458-PF LEFT HEART CATH, LV, COR",3580920,CDM,960,RC,93458,HCPCS,Outpatient,,,1857.14,928.57,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
93458-Selective Coronary Angio (SCA) w/Left Heart Cath (LHC),3430777,CDM,481,RC,93458,HCPCS,Outpatient,,,1857.14,928.57,,1392.86,75,,,percent of total billed charges,75% of total billed charges,1392.86,75,,,percent of total billed charges,75% of total billed charges,2781.44,100,,,Fee Schedule,100% of CMS OPPS Rate,706.18,100,,,Fee Schedule,100% of WV Medicaid Rate,4589.37,165,,,Fee Schedule,165% of CMS OPPS Rate,2882.73,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,7989.31,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,10956.7,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13724.38,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,706.18,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2781.44,100,,,Fee Schedule,100% of CMS OPPS Rate,2882.73,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,260,14,,,percent of total billed charges,14% of total billed charges,260,13724.38,
93459- Lt Heart cath/LV/cors/grafts,3430778,CDM,481,RC,93459,HCPCS,Outpatient,,,1956.64,978.32,,1467.48,75,,,percent of total billed charges,75% of total billed charges,1467.48,75,,,percent of total billed charges,75% of total billed charges,2781.44,100,,,Fee Schedule,100% of CMS OPPS Rate,761.24,100,,,Fee Schedule,100% of WV Medicaid Rate,4589.37,165,,,Fee Schedule,165% of CMS OPPS Rate,2882.73,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,7989.31,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,10956.7,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13724.38,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,761.24,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2781.44,100,,,Fee Schedule,100% of CMS OPPS Rate,2882.73,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,273.93,14,,,percent of total billed charges,14% of total billed charges,273.93,13724.38,
"93459-LEFT HEART CATH, LV ,COR, SVG, IMA",3432009,CDM,481,RC,93459,HCPCS,Outpatient,,,1956.64,978.32,,1467.48,75,,,percent of total billed charges,75% of total billed charges,1467.48,75,,,percent of total billed charges,75% of total billed charges,2781.44,100,,,Fee Schedule,100% of CMS OPPS Rate,761.24,100,,,Fee Schedule,100% of WV Medicaid Rate,4589.37,165,,,Fee Schedule,165% of CMS OPPS Rate,2882.73,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,7989.31,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,10956.7,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13724.38,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,761.24,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2781.44,100,,,Fee Schedule,100% of CMS OPPS Rate,2882.73,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,273.93,14,,,percent of total billed charges,14% of total billed charges,273.93,13724.38,
"93459-PF LEFT HEART CATH, LV ,COR, SVG, IMA",3580921,CDM,960,RC,93459,HCPCS,Outpatient,,,1956.64,978.32,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
93460- Rt & Lt Heart cath/LV/cors,3430779,CDM,481,RC,93460,HCPCS,Outpatient,,,2167.46,1083.73,,1625.6,75,,,percent of total billed charges,75% of total billed charges,1625.6,75,,,percent of total billed charges,75% of total billed charges,2781.44,100,,,Fee Schedule,100% of CMS OPPS Rate,846.04,100,,,Fee Schedule,100% of WV Medicaid Rate,4589.37,165,,,Fee Schedule,165% of CMS OPPS Rate,2882.73,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,7989.31,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,10956.7,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13724.38,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,846.04,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2781.44,100,,,Fee Schedule,100% of CMS OPPS Rate,2882.73,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,303.44,14,,,percent of total billed charges,14% of total billed charges,303.44,13724.38,
"93460-R & L HEART CATH, LV,COR",3432010,CDM,481,RC,93460,HCPCS,Outpatient,,,2167.46,1083.73,,1625.6,75,,,percent of total billed charges,75% of total billed charges,1625.6,75,,,percent of total billed charges,75% of total billed charges,2781.44,100,,,Fee Schedule,100% of CMS OPPS Rate,846.04,100,,,Fee Schedule,100% of WV Medicaid Rate,4589.37,165,,,Fee Schedule,165% of CMS OPPS Rate,2882.73,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,7989.31,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,10956.7,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13724.38,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,846.04,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2781.44,100,,,Fee Schedule,100% of CMS OPPS Rate,2882.73,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,303.44,14,,,percent of total billed charges,14% of total billed charges,303.44,13724.38,
Left and Right Heart Cath,3437578,CDM,960,RC,93460,HCPCS,Outpatient,,,3012.94,1506.47,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
93461- Rt & Lt Heart cath/LV/cors/grafts,3430780,CDM,481,RC,93461,HCPCS,Outpatient,,,2387.6,1193.8,,1790.7,75,,,percent of total billed charges,75% of total billed charges,1790.7,75,,,percent of total billed charges,75% of total billed charges,2781.44,100,,,Fee Schedule,100% of CMS OPPS Rate,932.81,100,,,Fee Schedule,100% of WV Medicaid Rate,4589.37,165,,,Fee Schedule,165% of CMS OPPS Rate,2882.73,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,7989.31,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,10956.7,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13724.38,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,932.81,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2781.44,100,,,Fee Schedule,100% of CMS OPPS Rate,2882.73,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,334.26,14,,,percent of total billed charges,14% of total billed charges,334.26,13724.38,
"93461-PF R & L HEART CATH,LV,COR,SVG,IMA",3580922,CDM,960,RC,93461,HCPCS,Outpatient,,,2387.6,1193.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
"93461-R & L HEART CATH,LV,COR,SVG,IMA",3432011,CDM,481,RC,93461,HCPCS,Outpatient,,,2387.6,1193.8,,1790.7,75,,,percent of total billed charges,75% of total billed charges,1790.7,75,,,percent of total billed charges,75% of total billed charges,2781.44,100,,,Fee Schedule,100% of CMS OPPS Rate,932.81,100,,,Fee Schedule,100% of WV Medicaid Rate,4589.37,165,,,Fee Schedule,165% of CMS OPPS Rate,2882.73,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,7989.31,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,10956.7,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13724.38,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,932.81,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2781.44,100,,,Fee Schedule,100% of CMS OPPS Rate,2882.73,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,334.26,14,,,percent of total billed charges,14% of total billed charges,334.26,13724.38,
93462- Lt Heart Cath by transseptal punc,3430781,CDM,510,RC,93462,HCPCS,Outpatient,,,563.16,281.58,,422.37,75,,,percent of total billed charges,75% of total billed charges,422.37,75,,,percent of total billed charges,75% of total billed charges,180.21,32,,,percent of total billed charges,32% of total billed charges,150.43,100,,,Fee Schedule,100% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,150.43,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.84,14,,,percent of total billed charges,14% of total billed charges,78.84,422.37,
93462-Transseptal Puncture,3432012,CDM,481,RC,93462,HCPCS,Outpatient,,,563.16,281.58,,422.37,75,,,percent of total billed charges,75% of total billed charges,422.37,75,,,percent of total billed charges,75% of total billed charges,180.21,32,,,percent of total billed charges,32% of total billed charges,150.43,100,,,Fee Schedule,100% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,150.43,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.84,14,,,percent of total billed charges,14% of total billed charges,78.84,422.37,
Transseptal Puncture,3427173,CDM,960,RC,93462,HCPCS,Outpatient,,,563.16,281.58,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
93463- Pharma admin/hemo before/dur/after,3430782,CDM,481,RC,93463,HCPCS,Outpatient,,,258.85,129.43,,194.14,75,,,percent of total billed charges,75% of total billed charges,194.14,75,,,percent of total billed charges,75% of total billed charges,82.83,32,,,percent of total billed charges,32% of total billed charges,69.06,100,,,Fee Schedule,100% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,69.06,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.24,14,,,percent of total billed charges,14% of total billed charges,36.24,194.14,
93463-Pharmacological RHC,3432026,CDM,481,RC,93463,HCPCS,Outpatient,,,258.81,129.41,,194.11,75,,,percent of total billed charges,75% of total billed charges,194.11,75,,,percent of total billed charges,75% of total billed charges,82.82,32,,,percent of total billed charges,32% of total billed charges,69.06,100,,,Fee Schedule,100% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,69.06,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.23,14,,,percent of total billed charges,14% of total billed charges,36.23,194.11,
Pharmacological RHC,,,480,RC,93463,HCPCS,Outpatient,,,258.81,129.41,,194.11,75,,,percent of total billed charges,75% of total billed charges,194.11,75,,,percent of total billed charges,75% of total billed charges,82.82,32,,,percent of total billed charges,32% of total billed charges,69.06,100,,,Fee Schedule,100% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,69.06,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.23,14,,,percent of total billed charges,14% of total billed charges,36.23,194.11,
93464- Physio ex study/hemo before/after,3430783,CDM,510,RC,93464,HCPCS,Outpatient,,,322.46,161.23,,241.85,75,,,percent of total billed charges,75% of total billed charges,241.85,75,,,percent of total billed charges,75% of total billed charges,103.19,32,,,percent of total billed charges,32% of total billed charges,147.97,100,,,Fee Schedule,100% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,147.97,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.14,14,,,percent of total billed charges,14% of total billed charges,45.14,241.85,
93503- Inser/place/flo dir cath/Swan-Ganz,3431011,CDM,510,RC,93503,HCPCS,Outpatient,,,235.8,117.9,,176.85,75,,,percent of total billed charges,75% of total billed charges,176.85,75,,,percent of total billed charges,75% of total billed charges,1398.82,100,,,Fee Schedule,100% of CMS OPPS Rate,62.92,100,,,Fee Schedule,100% of WV Medicaid Rate,2308.05,165,,,Fee Schedule,165% of CMS OPPS Rate,1449.76,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4017.93,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5510.28,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6902.18,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,62.92,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1398.82,100,,,Fee Schedule,100% of CMS OPPS Rate,1449.76,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,33.01,14,,,percent of total billed charges,14% of total billed charges,33.01,6902.18,
93503-Swan Ganz Insertion only,3432013,CDM,481,RC,93503,HCPCS,Outpatient,,,235.8,117.9,,176.85,75,,,percent of total billed charges,75% of total billed charges,176.85,75,,,percent of total billed charges,75% of total billed charges,1398.82,100,,,Fee Schedule,100% of CMS OPPS Rate,62.92,100,,,Fee Schedule,100% of WV Medicaid Rate,2308.05,165,,,Fee Schedule,165% of CMS OPPS Rate,1449.76,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4017.93,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5510.28,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6902.18,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,62.92,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1398.82,100,,,Fee Schedule,100% of CMS OPPS Rate,1449.76,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,33.01,14,,,percent of total billed charges,14% of total billed charges,33.01,6902.18,
Swan Ganz Insertion only,,,480,RC,93503,HCPCS,Outpatient,,,230.95,115.48,,173.21,75,,,percent of total billed charges,75% of total billed charges,173.21,75,,,percent of total billed charges,75% of total billed charges,1398.82,100,,,Fee Schedule,100% of CMS OPPS Rate,62.92,100,,,Fee Schedule,100% of WV Medicaid Rate,2308.05,165,,,Fee Schedule,165% of CMS OPPS Rate,1449.76,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4017.93,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5510.28,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6902.18,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,62.92,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1398.82,100,,,Fee Schedule,100% of CMS OPPS Rate,1449.76,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,32.33,14,,,percent of total billed charges,14% of total billed charges,32.33,6902.18,
93505- Endomyocardial biopsy,3431012,CDM,510,RC,93505,HCPCS,Outpatient,,,1048.44,524.22,,786.33,75,,,percent of total billed charges,75% of total billed charges,786.33,75,,,percent of total billed charges,75% of total billed charges,2800.71,100,,,Fee Schedule,100% of CMS OPPS Rate,440.97,100,,,Fee Schedule,100% of WV Medicaid Rate,4621.18,165,,,Fee Schedule,165% of CMS OPPS Rate,2902.7,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8044.7,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11032.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13819.53,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,440.97,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2800.71,100,,,Fee Schedule,100% of CMS OPPS Rate,2902.7,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,146.78,14,,,percent of total billed charges,14% of total billed charges,146.78,13819.53,
93505-Myocardial Biopsy,3432014,CDM,481,RC,93505,HCPCS,Outpatient,,,1048.44,524.22,,786.33,75,,,percent of total billed charges,75% of total billed charges,786.33,75,,,percent of total billed charges,75% of total billed charges,2800.71,100,,,Fee Schedule,100% of CMS OPPS Rate,440.97,100,,,Fee Schedule,100% of WV Medicaid Rate,4621.18,165,,,Fee Schedule,165% of CMS OPPS Rate,2902.7,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8044.7,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11032.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13819.53,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,440.97,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2800.71,100,,,Fee Schedule,100% of CMS OPPS Rate,2902.7,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,146.78,14,,,percent of total billed charges,14% of total billed charges,146.78,13819.53,
Myocardial Biopsy,,,480,RC,93505,HCPCS,Outpatient,,,1572.7,786.35,,1179.53,75,,,percent of total billed charges,75% of total billed charges,1179.53,75,,,percent of total billed charges,75% of total billed charges,2800.71,100,,,Fee Schedule,100% of CMS OPPS Rate,440.97,100,,,Fee Schedule,100% of WV Medicaid Rate,4621.18,165,,,Fee Schedule,165% of CMS OPPS Rate,2902.7,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8044.7,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11032.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13819.53,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,440.97,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2800.71,100,,,Fee Schedule,100% of CMS OPPS Rate,2902.7,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,220.18,14,,,percent of total billed charges,14% of total billed charges,220.18,13819.53,
93530- Right Heart Cath (RHC) Only 93530,3430785,CDM,510,RC,93530,HCPCS,Outpatient,,,2237.5,1118.75,,1678.13,75,,,percent of total billed charges,75% of total billed charges,1678.13,75,,,percent of total billed charges,75% of total billed charges,716,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,313.25,14,,,percent of total billed charges,14% of total billed charges,313.25,1678.13,
93531- Rt ht/retrograde Lt ht/congen anom,3431015,CDM,510,RC,93531,HCPCS,Outpatient,,,5954.32,2977.16,,4465.74,75,,,percent of total billed charges,75% of total billed charges,4465.74,75,,,percent of total billed charges,75% of total billed charges,1905.38,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,833.6,14,,,percent of total billed charges,14% of total billed charges,833.6,4465.74,
93532- Rt ht/tran sep Lt ht/intact septum,3431016,CDM,510,RC,93532,HCPCS,Outpatient,,,1494.62,747.31,,1120.97,75,,,percent of total billed charges,75% of total billed charges,1120.97,75,,,percent of total billed charges,75% of total billed charges,478.28,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,209.25,14,,,percent of total billed charges,14% of total billed charges,209.25,1120.97,
93533- Rt ht/trans sep Lt ht/septal open,3431017,CDM,510,RC,93533,HCPCS,Outpatient,,,997.35,498.68,,748.01,75,,,percent of total billed charges,75% of total billed charges,748.01,75,,,percent of total billed charges,75% of total billed charges,319.15,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,139.63,14,,,percent of total billed charges,14% of total billed charges,139.63,748.01,
93561- Cath w/thermodilution/card ouput,3431023,CDM,510,RC,93561,HCPCS,Outpatient,,,177.65,88.83,,133.24,75,,,percent of total billed charges,75% of total billed charges,133.24,75,,,percent of total billed charges,75% of total billed charges,56.85,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.87,14,,,percent of total billed charges,14% of total billed charges,24.87,133.24,
93562- Subseq measure of CO w thermodilut,3431024,CDM,510,RC,93562,HCPCS,Outpatient,,,133.66,66.83,,100.25,75,,,percent of total billed charges,75% of total billed charges,100.25,75,,,percent of total billed charges,75% of total billed charges,42.77,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.71,14,,,percent of total billed charges,14% of total billed charges,18.71,100.25,
93563- Cath inj/S&I/rept congenital heart,3430787,CDM,510,RC,93563,HCPCS,Outpatient,,,154.7,77.35,,116.03,75,,,percent of total billed charges,75% of total billed charges,116.03,75,,,percent of total billed charges,75% of total billed charges,49.5,32,,,percent of total billed charges,32% of total billed charges,41.29,100,,,Fee Schedule,100% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.29,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.66,14,,,percent of total billed charges,14% of total billed charges,21.66,116.03,
93564- Cath inj/S&I/rep congen hrt grafts,3430788,CDM,510,RC,93564,HCPCS,Outpatient,,,162.35,81.18,,121.76,75,,,percent of total billed charges,75% of total billed charges,121.76,75,,,percent of total billed charges,75% of total billed charges,51.95,32,,,percent of total billed charges,32% of total billed charges,43.26,100,,,Fee Schedule,100% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.26,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.73,14,,,percent of total billed charges,14% of total billed charges,22.73,121.76,
93565- Cath inj/S&I/rept LV or LA angio,3430789,CDM,510,RC,93565,HCPCS,Outpatient,,,124.88,62.44,,93.66,75,,,percent of total billed charges,75% of total billed charges,93.66,75,,,percent of total billed charges,75% of total billed charges,39.96,32,,,percent of total billed charges,32% of total billed charges,33.43,100,,,Fee Schedule,100% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.43,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.48,14,,,percent of total billed charges,14% of total billed charges,17.48,93.66,
93566- RV or RA angio w cath,3430790,CDM,510,RC,93566,HCPCS,Outpatient,,,324.03,162.02,,243.02,75,,,percent of total billed charges,75% of total billed charges,243.02,75,,,percent of total billed charges,75% of total billed charges,103.69,32,,,percent of total billed charges,32% of total billed charges,33.18,100,,,Fee Schedule,100% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.18,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.36,14,,,percent of total billed charges,14% of total billed charges,33.18,243.02,
93566-Injection procedure during cardiac cath for selective RV or RA angiography,4271191,CDM,481,RC,93566,HCPCS,Outpatient,,,56.14,28.07,,42.11,75,,,percent of total billed charges,75% of total billed charges,42.11,75,,,percent of total billed charges,75% of total billed charges,17.96,32,,,percent of total billed charges,32% of total billed charges,33.18,100,,,Fee Schedule,100% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.18,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.86,14,,,percent of total billed charges,14% of total billed charges,7.86,42.11,
93566-PF Injection procedure during cardiac cath for selective RV or RA angiography,4271192,CDM,960,RC,93566,HCPCS,Outpatient,,,56.14,28.07,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
93567- Supra valv aortography inj/w cath,3430791,CDM,481,RC,93567,HCPCS,Outpatient,,,279.33,139.67,,209.5,75,,,percent of total billed charges,75% of total billed charges,209.5,75,,,percent of total billed charges,75% of total billed charges,89.39,32,,,percent of total billed charges,32% of total billed charges,37.36,100,,,Fee Schedule,100% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.36,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.11,14,,,percent of total billed charges,14% of total billed charges,37.36,209.5,
93567-PF SUPRAVALVULAR AORTOGRAM WITH CATH,3580923,CDM,960,RC,93567,HCPCS,Outpatient,,,279.33,139.67,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
93567-SUPRAVALVULAR AORTOGRAM WITH CATH,3432015,CDM,481,RC,93567,HCPCS,Outpatient,,,279.33,139.67,,209.5,75,,,percent of total billed charges,75% of total billed charges,209.5,75,,,percent of total billed charges,75% of total billed charges,89.39,32,,,percent of total billed charges,32% of total billed charges,37.36,100,,,Fee Schedule,100% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.36,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.11,14,,,percent of total billed charges,14% of total billed charges,37.36,209.5,
93568- Pulmonary angio w cath,3430792,CDM,510,RC,93568,HCPCS,Outpatient,,,308.35,154.18,,231.26,75,,,percent of total billed charges,75% of total billed charges,231.26,75,,,percent of total billed charges,75% of total billed charges,98.67,32,,,percent of total billed charges,32% of total billed charges,34.17,100,,,Fee Schedule,100% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.17,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.17,14,,,percent of total billed charges,14% of total billed charges,34.17,231.26,
93568-Pulmonary Angiography during Cath,3432016,CDM,481,RC,93568,HCPCS,Outpatient,,,308.35,154.18,,231.26,75,,,percent of total billed charges,75% of total billed charges,231.26,75,,,percent of total billed charges,75% of total billed charges,98.67,32,,,percent of total billed charges,32% of total billed charges,34.17,100,,,Fee Schedule,100% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.17,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.17,14,,,percent of total billed charges,14% of total billed charges,34.17,231.26,
Pulmonary Angiography (Cardiology),3316233,CDM,960,RC,93568,HCPCS,Outpatient,,,124.58,62.29,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
Pulmonary Angiography during Cath,3427257,CDM,960,RC,93568,HCPCS,Outpatient,,,124.58,62.29,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
93571- FFR w/cath/initial vessel,3431025,CDM,481,RC,93571,HCPCS,Outpatient,,,192.45,96.23,,144.34,75,,,percent of total billed charges,75% of total billed charges,144.34,75,,,percent of total billed charges,75% of total billed charges,61.58,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.94,14,,,percent of total billed charges,14% of total billed charges,26.94,144.34,
93571-FFR RAMUS,4179744,CDM,481,RC,93571,HCPCS,Outpatient,,,192.45,96.23,,144.34,75,,,percent of total billed charges,75% of total billed charges,144.34,75,,,percent of total billed charges,75% of total billed charges,61.58,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.94,14,,,percent of total billed charges,14% of total billed charges,26.94,144.34,
93571-PF FFR RAMUS,4179745,CDM,960,RC,93571,HCPCS,Outpatient,,,192.45,96.23,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
93571-PRESSURE WIRE/FFR CIRC,3432017,CDM,481,RC,93571,HCPCS,Outpatient,,,192.45,96.23,,144.34,75,,,percent of total billed charges,75% of total billed charges,144.34,75,,,percent of total billed charges,75% of total billed charges,61.58,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.94,14,,,percent of total billed charges,14% of total billed charges,26.94,144.34,
93571-PRESSURE WIRE/FFR LAD,3432018,CDM,481,RC,93571,HCPCS,Outpatient,,,192.45,96.23,,144.34,75,,,percent of total billed charges,75% of total billed charges,144.34,75,,,percent of total billed charges,75% of total billed charges,61.58,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.94,14,,,percent of total billed charges,14% of total billed charges,26.94,144.34,
93571-PRESSURE WIRE/FFR LM,3432019,CDM,481,RC,93571,HCPCS,Outpatient,,,192.45,96.23,,144.34,75,,,percent of total billed charges,75% of total billed charges,144.34,75,,,percent of total billed charges,75% of total billed charges,61.58,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.94,14,,,percent of total billed charges,14% of total billed charges,26.94,144.34,
93571-PRESSURE WIRE/FFR RCA,3432020,CDM,481,RC,93571,HCPCS,Outpatient,,,192.45,96.23,,144.34,75,,,percent of total billed charges,75% of total billed charges,144.34,75,,,percent of total billed charges,75% of total billed charges,61.58,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.94,14,,,percent of total billed charges,14% of total billed charges,26.94,144.34,
93572- FFR w/cath/each add vessel,3431026,CDM,480,RC,93572,HCPCS,Outpatient,,,141.71,70.86,,106.28,75,,,percent of total billed charges,75% of total billed charges,106.28,75,,,percent of total billed charges,75% of total billed charges,45.35,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.84,14,,,percent of total billed charges,14% of total billed charges,19.84,106.28,
93572-ADDL PRESSURE WIRE/FFR LC,3432021,CDM,480,RC,93572,HCPCS,Outpatient,,,141.71,70.86,,106.28,75,,,percent of total billed charges,75% of total billed charges,106.28,75,,,percent of total billed charges,75% of total billed charges,45.35,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.84,14,,,percent of total billed charges,14% of total billed charges,19.84,106.28,
93572-ADDL PRESSURE WIRE/FFR LD,3432022,CDM,480,RC,93572,HCPCS,Outpatient,,,141.71,70.86,,106.28,75,,,percent of total billed charges,75% of total billed charges,106.28,75,,,percent of total billed charges,75% of total billed charges,45.35,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.84,14,,,percent of total billed charges,14% of total billed charges,19.84,106.28,
93572-ADDL PRESSURE WIRE/FFR RC,3432023,CDM,481,RC,93572,HCPCS,Outpatient,,,141.71,70.86,,106.28,75,,,percent of total billed charges,75% of total billed charges,106.28,75,,,percent of total billed charges,75% of total billed charges,45.35,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.84,14,,,percent of total billed charges,14% of total billed charges,19.84,106.28,
93572-FFR RAMUS ADDITIONAL,4179746,CDM,481,RC,93572,HCPCS,Outpatient,,,253.06,126.53,,189.8,75,,,percent of total billed charges,75% of total billed charges,189.8,75,,,percent of total billed charges,75% of total billed charges,80.98,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.43,14,,,percent of total billed charges,14% of total billed charges,35.43,189.8,
93572-PF RMAUS ADDITIONAL,4179747,CDM,960,RC,93572,HCPCS,Outpatient,,,253.06,126.53,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
93572-Pressue Wire FF R Additional,3560653,CDM,481,RC,93572,HCPCS,Outpatient,,,141.71,70.86,,106.28,75,,,percent of total billed charges,75% of total billed charges,106.28,75,,,percent of total billed charges,75% of total billed charges,45.35,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.84,14,,,percent of total billed charges,14% of total billed charges,19.84,106.28,
93573-PF Pulmonary Artery (ies) injection  during heart catheterization,4271240,CDM,960,RC,93573,HCPCS,Outpatient,,,130.3,65.15,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
93573-Pulmonary Artery (ies) injection  during heart catheterization,4271239,CDM,481,RC,93573,HCPCS,Outpatient,,,130.3,65.15,,97.73,75,,,percent of total billed charges,75% of total billed charges,97.73,75,,,percent of total billed charges,75% of total billed charges,41.7,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.24,14,,,percent of total billed charges,14% of total billed charges,18.24,97.73,
93580- ASD closure/transcath/w implant,3431027,CDM,480,RC,93580,HCPCS,Outpatient,,,2612.6,1306.3,,1959.45,75,,,percent of total billed charges,75% of total billed charges,1959.45,75,,,percent of total billed charges,75% of total billed charges,16149.79,100,,,Fee Schedule,100% of CMS OPPS Rate,697.83,100,,,Fee Schedule,100% of WV Medicaid Rate,26647.16,165,,,Fee Schedule,165% of CMS OPPS Rate,16737.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,46388.09,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,63617.56,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,79687.45,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,697.83,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,16149.79,100,,,Fee Schedule,100% of CMS OPPS Rate,16737.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,365.76,14,,,percent of total billed charges,14% of total billed charges,365.76,79687.45,
93580-ASD Closure,3432024,CDM,481,RC,93580,HCPCS,Outpatient,,,2612.6,1306.3,,1959.45,75,,,percent of total billed charges,75% of total billed charges,1959.45,75,,,percent of total billed charges,75% of total billed charges,16149.79,100,,,Fee Schedule,100% of CMS OPPS Rate,697.83,100,,,Fee Schedule,100% of WV Medicaid Rate,26647.16,165,,,Fee Schedule,165% of CMS OPPS Rate,16737.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,46388.09,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,63617.56,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,79687.45,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,697.83,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,16149.79,100,,,Fee Schedule,100% of CMS OPPS Rate,16737.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,365.76,14,,,percent of total billed charges,14% of total billed charges,365.76,79687.45,
93580-PFO Closure,3432025,CDM,481,RC,93580,HCPCS,Outpatient,,,2612.6,1306.3,,1959.45,75,,,percent of total billed charges,75% of total billed charges,1959.45,75,,,percent of total billed charges,75% of total billed charges,16149.79,100,,,Fee Schedule,100% of CMS OPPS Rate,697.83,100,,,Fee Schedule,100% of WV Medicaid Rate,26647.16,165,,,Fee Schedule,165% of CMS OPPS Rate,16737.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,46388.09,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,63617.56,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,79687.45,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,697.83,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,16149.79,100,,,Fee Schedule,100% of CMS OPPS Rate,16737.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,365.76,14,,,percent of total billed charges,14% of total billed charges,365.76,79687.45,
93580-Transcatheter closure of congenital defect with implant,3560651,CDM,481,RC,93580,HCPCS,Outpatient,,,2612.6,1306.3,,1959.45,75,,,percent of total billed charges,75% of total billed charges,1959.45,75,,,percent of total billed charges,75% of total billed charges,16149.79,100,,,Fee Schedule,100% of CMS OPPS Rate,697.83,100,,,Fee Schedule,100% of WV Medicaid Rate,26647.16,165,,,Fee Schedule,165% of CMS OPPS Rate,16737.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,46388.09,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,63617.56,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,79687.45,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,697.83,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,16149.79,100,,,Fee Schedule,100% of CMS OPPS Rate,16737.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,365.76,14,,,percent of total billed charges,14% of total billed charges,365.76,79687.45,
ASD Closure,,,480,RC,93580,HCPCS,Outpatient,,,2561.42,1280.71,,1921.07,75,,,percent of total billed charges,75% of total billed charges,1921.07,75,,,percent of total billed charges,75% of total billed charges,16149.79,100,,,Fee Schedule,100% of CMS OPPS Rate,697.83,100,,,Fee Schedule,100% of WV Medicaid Rate,26647.16,165,,,Fee Schedule,165% of CMS OPPS Rate,16737.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,46388.09,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,63617.56,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,79687.45,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,697.83,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,16149.79,100,,,Fee Schedule,100% of CMS OPPS Rate,16737.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,358.6,14,,,percent of total billed charges,14% of total billed charges,358.6,79687.45,
PFO Closure,,,480,RC,93580,HCPCS,Outpatient,,,2561.42,1280.71,,1921.07,75,,,percent of total billed charges,75% of total billed charges,1921.07,75,,,percent of total billed charges,75% of total billed charges,16149.79,100,,,Fee Schedule,100% of CMS OPPS Rate,697.83,100,,,Fee Schedule,100% of WV Medicaid Rate,26647.16,165,,,Fee Schedule,165% of CMS OPPS Rate,16737.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,46388.09,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,63617.56,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,79687.45,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,697.83,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,16149.79,100,,,Fee Schedule,100% of CMS OPPS Rate,16737.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,358.6,14,,,percent of total billed charges,14% of total billed charges,358.6,79687.45,
93581- VSD closure/transcath/implant,3431028,CDM,510,RC,93581,HCPCS,Outpatient,,,3566.93,1783.47,,2675.2,75,,,percent of total billed charges,75% of total billed charges,2675.2,75,,,percent of total billed charges,75% of total billed charges,16149.79,100,,,Fee Schedule,100% of CMS OPPS Rate,952.72,100,,,Fee Schedule,100% of WV Medicaid Rate,26647.16,165,,,Fee Schedule,165% of CMS OPPS Rate,16737.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,46388.09,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,63617.56,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,79687.45,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,952.72,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,16149.79,100,,,Fee Schedule,100% of CMS OPPS Rate,16737.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,499.37,14,,,percent of total billed charges,14% of total billed charges,499.37,79687.45,
93583-Septal Ablation,3432027,CDM,481,RC,93583,HCPCS,Outpatient,,,1993.6,996.8,,1495.2,75,,,percent of total billed charges,75% of total billed charges,1495.2,75,,,percent of total billed charges,75% of total billed charges,1993.6,100,,,Fee Schedule,Pays at line item charges based on APC Setting,532.65,100,,,Fee Schedule,100% of WV Medicaid Rate,1993.6,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1993.6,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1993.6,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1993.6,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1993.6,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,532.65,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1993.6,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1993.6,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,279.1,14,,,percent of total billed charges,14% of total billed charges,279.1,1993.6,
Septal Ablation,,,480,RC,93583,HCPCS,Outpatient,,,1950.72,975.36,,1463.04,75,,,percent of total billed charges,75% of total billed charges,1463.04,75,,,percent of total billed charges,75% of total billed charges,1950.72,100,,,Fee Schedule,Pays at line item charges based on APC Setting,532.65,100,,,Fee Schedule,100% of WV Medicaid Rate,1950.72,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1950.72,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1950.72,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1950.72,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1950.72,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,532.65,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1950.72,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1950.72,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,273.1,14,,,percent of total billed charges,14% of total billed charges,273.1,1950.72,
93590-Perivalvular Plug,3432028,CDM,481,RC,93590,HCPCS,Outpatient,,,2811.26,1405.63,,2108.45,75,,,percent of total billed charges,75% of total billed charges,2108.45,75,,,percent of total billed charges,75% of total billed charges,16149.79,100,,,Fee Schedule,100% of CMS OPPS Rate,750.92,100,,,Fee Schedule,100% of WV Medicaid Rate,26647.16,165,,,Fee Schedule,165% of CMS OPPS Rate,16737.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,46388.09,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,63617.56,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,79687.45,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,750.92,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,16149.79,100,,,Fee Schedule,100% of CMS OPPS Rate,16737.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,393.58,14,,,percent of total billed charges,14% of total billed charges,393.58,79687.45,
Perivalvular Plug,,,480,RC,93590,HCPCS,Outpatient,,,2751.58,1375.79,,2063.69,75,,,percent of total billed charges,75% of total billed charges,2063.69,75,,,percent of total billed charges,75% of total billed charges,16149.79,100,,,Fee Schedule,100% of CMS OPPS Rate,750.92,100,,,Fee Schedule,100% of WV Medicaid Rate,26647.16,165,,,Fee Schedule,165% of CMS OPPS Rate,16737.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,46388.09,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,63617.56,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,79687.45,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,750.92,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,16149.79,100,,,Fee Schedule,100% of CMS OPPS Rate,16737.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,385.22,14,,,percent of total billed charges,14% of total billed charges,385.22,79687.45,
93591-Perivalvular Plug,3432029,CDM,481,RC,93591,HCPCS,Outpatient,,,2322.47,1161.24,,1741.85,75,,,percent of total billed charges,75% of total billed charges,1741.85,75,,,percent of total billed charges,75% of total billed charges,16149.79,100,,,Fee Schedule,100% of CMS OPPS Rate,620.4,100,,,Fee Schedule,100% of WV Medicaid Rate,26647.16,165,,,Fee Schedule,165% of CMS OPPS Rate,16737.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,46388.09,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,63617.56,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,79687.45,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,620.4,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,16149.79,100,,,Fee Schedule,100% of CMS OPPS Rate,16737.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,325.15,14,,,percent of total billed charges,14% of total billed charges,325.15,79687.45,
93591-PF Perivalvular Plug,3580924,CDM,960,RC,93591,HCPCS,Outpatient,,,2322.47,1161.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
93592-Perivalvular Plug,3432030,CDM,481,RC,93592,HCPCS,Outpatient,,,1026.63,513.32,,769.97,75,,,percent of total billed charges,75% of total billed charges,769.97,75,,,percent of total billed charges,75% of total billed charges,328.52,32,,,percent of total billed charges,32% of total billed charges,274.31,100,,,Fee Schedule,100% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,274.31,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,143.73,14,,,percent of total billed charges,14% of total billed charges,143.73,769.97,
93592-PF Perivalvular Plug,3580925,CDM,960,RC,93592,HCPCS,Outpatient,,,1026.63,513.32,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
93595 (26) - L Hrt Cath Chd Img Cath Trgt Zon Nml/Abnl Nt Cnj,4169604,CDM,960,RC,93595,HCPCS,Outpatient,,,626.01,313.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
"93596-PF R&L Heart Cath for Congen Hrt Dfct, Norm Natv Connect",4348481,CDM,960,RC,93596,HCPCS,Outpatient,,,601.2,300.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
"93596-R&L Heart Cath for Congen Hrt Dfct, Norm Natv Connect",4127773,CDM,481,RC,93596,HCPCS,Outpatient,,,601.2,300.6,,450.9,75,,,percent of total billed charges,75% of total billed charges,450.9,75,,,percent of total billed charges,75% of total billed charges,2781.44,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,4589.37,165,,,Fee Schedule,165% of CMS OPPS Rate,2882.73,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,7989.31,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,10956.7,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13724.38,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,2781.44,100,,,Fee Schedule,100% of CMS OPPS Rate,2882.73,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,84.17,14,,,percent of total billed charges,14% of total billed charges,84.17,13724.38,
"R&L Heart Cath for Congen Hrt Dfct, Norm Natv Connect",,,480,RC,93596,HCPCS,Outpatient,,,601.2,300.6,,450.9,75,,,percent of total billed charges,75% of total billed charges,450.9,75,,,percent of total billed charges,75% of total billed charges,2781.44,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,4589.37,165,,,Fee Schedule,165% of CMS OPPS Rate,2882.73,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,7989.31,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,10956.7,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13724.38,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,2781.44,100,,,Fee Schedule,100% of CMS OPPS Rate,2882.73,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,84.17,14,,,percent of total billed charges,14% of total billed charges,84.17,13724.38,
93600- Bundle of HIS recording,3431029,CDM,510,RC,93600,HCPCS,Outpatient,,,312.63,156.32,,234.47,75,,,percent of total billed charges,75% of total billed charges,234.47,75,,,percent of total billed charges,75% of total billed charges,6329.89,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,10444.33,165,,,Fee Schedule,165% of CMS OPPS Rate,6560.4,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,18181.77,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,24934.86,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,31233.45,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,6329.89,100,,,Fee Schedule,100% of CMS OPPS Rate,6560.4,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,43.77,14,,,percent of total billed charges,14% of total billed charges,43.77,31233.45,
93600-Bundle of His Recording,4271193,CDM,481,RC,93600,HCPCS,Outpatient,,,491.84,245.92,,368.88,75,,,percent of total billed charges,75% of total billed charges,368.88,75,,,percent of total billed charges,75% of total billed charges,6329.89,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,10444.33,165,,,Fee Schedule,165% of CMS OPPS Rate,6560.4,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,18181.77,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,24934.86,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,31233.45,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,6329.89,100,,,Fee Schedule,100% of CMS OPPS Rate,6560.4,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,68.86,14,,,percent of total billed charges,14% of total billed charges,68.86,31233.45,
93600-PF Bundle of His Recording,4271194,CDM,960,RC,93600,HCPCS,Outpatient,,,491.84,245.92,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
93602- Intra-atrial recording,3431030,CDM,510,RC,93602,HCPCS,Outpatient,,,308.69,154.35,,231.52,75,,,percent of total billed charges,75% of total billed charges,231.52,75,,,percent of total billed charges,75% of total billed charges,6329.89,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,10444.33,165,,,Fee Schedule,165% of CMS OPPS Rate,6560.4,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,18181.77,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,24934.86,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,31233.45,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,6329.89,100,,,Fee Schedule,100% of CMS OPPS Rate,6560.4,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,43.22,14,,,percent of total billed charges,14% of total billed charges,43.22,31233.45,
93602-Intra-Atrial Recording,4271195,CDM,481,RC,93602,HCPCS,Outpatient,,,360.4,180.2,,270.3,75,,,percent of total billed charges,75% of total billed charges,270.3,75,,,percent of total billed charges,75% of total billed charges,6329.89,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,10444.33,165,,,Fee Schedule,165% of CMS OPPS Rate,6560.4,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,18181.77,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,24934.86,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,31233.45,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,6329.89,100,,,Fee Schedule,100% of CMS OPPS Rate,6560.4,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,50.46,14,,,percent of total billed charges,14% of total billed charges,50.46,31233.45,
93602-PF Intra-Atrial Recording,4271196,CDM,960,RC,93602,HCPCS,Outpatient,,,360.4,180.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
93603- Right ventricular recording,3431031,CDM,510,RC,93603,HCPCS,Outpatient,,,308.69,154.35,,231.52,75,,,percent of total billed charges,75% of total billed charges,231.52,75,,,percent of total billed charges,75% of total billed charges,1050.22,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1732.85,165,,,Fee Schedule,165% of CMS OPPS Rate,1088.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,3016.61,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,4137.05,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,5182.07,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,1050.22,100,,,Fee Schedule,100% of CMS OPPS Rate,1088.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,43.22,14,,,percent of total billed charges,14% of total billed charges,43.22,5182.07,
93603-PF RV Recording,4271263,CDM,960,RC,93603,HCPCS,Outpatient,,,477,238.5,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
93603-RV Recording,4271262,CDM,481,RC,93603,HCPCS,Outpatient,,,477,238.5,,357.75,75,,,percent of total billed charges,75% of total billed charges,357.75,75,,,percent of total billed charges,75% of total billed charges,1050.22,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1732.85,165,,,Fee Schedule,165% of CMS OPPS Rate,1088.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,3016.61,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,4137.05,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,5182.07,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,1050.22,100,,,Fee Schedule,100% of CMS OPPS Rate,1088.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,66.78,14,,,percent of total billed charges,14% of total billed charges,66.78,5182.07,
93609- Intra vent and/or atrial map/tachy,3431032,CDM,480,RC,93609,HCPCS,Outpatient,,,734.83,367.42,,551.12,75,,,percent of total billed charges,75% of total billed charges,551.12,75,,,percent of total billed charges,75% of total billed charges,235.15,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,102.88,14,,,percent of total billed charges,14% of total billed charges,102.88,551.12,
93609-CARDIAC MAPPING,3432031,CDM,481,RC,93609,HCPCS,Outpatient,,,734.83,367.42,,551.12,75,,,percent of total billed charges,75% of total billed charges,551.12,75,,,percent of total billed charges,75% of total billed charges,235.15,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,102.88,14,,,percent of total billed charges,14% of total billed charges,102.88,551.12,
93610- Intra-atrial pacing,3431033,CDM,510,RC,93610,HCPCS,Outpatient,,,436.32,218.16,,327.24,75,,,percent of total billed charges,75% of total billed charges,327.24,75,,,percent of total billed charges,75% of total billed charges,6329.89,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,10444.33,165,,,Fee Schedule,165% of CMS OPPS Rate,6560.4,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,18181.77,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,24934.86,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,31233.45,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,6329.89,100,,,Fee Schedule,100% of CMS OPPS Rate,6560.4,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,61.08,14,,,percent of total billed charges,14% of total billed charges,61.08,31233.45,
93610-Intra-Atrial Pacing,4271197,CDM,481,RC,93610,HCPCS,Outpatient,,,511.98,255.99,,383.99,75,,,percent of total billed charges,75% of total billed charges,383.99,75,,,percent of total billed charges,75% of total billed charges,6329.89,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,10444.33,165,,,Fee Schedule,165% of CMS OPPS Rate,6560.4,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,18181.77,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,24934.86,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,31233.45,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,6329.89,100,,,Fee Schedule,100% of CMS OPPS Rate,6560.4,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,71.68,14,,,percent of total billed charges,14% of total billed charges,71.68,31233.45,
93610-PF Intra-Atrial Pacing,4271198,CDM,960,RC,93610,HCPCS,Outpatient,,,511.98,255.99,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
93612- Intraventricular pacing,3431034,CDM,510,RC,93612,HCPCS,Outpatient,,,432.83,216.42,,324.62,75,,,percent of total billed charges,75% of total billed charges,324.62,75,,,percent of total billed charges,75% of total billed charges,6329.89,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,10444.33,165,,,Fee Schedule,165% of CMS OPPS Rate,6560.4,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,18181.77,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,24934.86,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,31233.45,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,6329.89,100,,,Fee Schedule,100% of CMS OPPS Rate,6560.4,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,60.6,14,,,percent of total billed charges,14% of total billed charges,60.6,31233.45,
93612-IntraVentricular Pacing,4271199,CDM,481,RC,93612,HCPCS,Outpatient,,,507.74,253.87,,380.81,75,,,percent of total billed charges,75% of total billed charges,380.81,75,,,percent of total billed charges,75% of total billed charges,6329.89,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,10444.33,165,,,Fee Schedule,165% of CMS OPPS Rate,6560.4,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,18181.77,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,24934.86,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,31233.45,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,6329.89,100,,,Fee Schedule,100% of CMS OPPS Rate,6560.4,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,71.08,14,,,percent of total billed charges,14% of total billed charges,71.08,31233.45,
93612-PF IntraVentricular Pacing,4271200,CDM,960,RC,93612,HCPCS,Outpatient,,,507.74,253.87,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
3 D Mapping,,,480,RC,93613,HCPCS,Outpatient,,,771.84,385.92,,578.88,75,,,percent of total billed charges,75% of total billed charges,578.88,75,,,percent of total billed charges,75% of total billed charges,246.99,32,,,percent of total billed charges,32% of total billed charges,211.39,100,,,Fee Schedule,100% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,211.39,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,108.06,14,,,percent of total billed charges,14% of total billed charges,108.06,578.88,
93613- Electrophysiologic/3D mapping,3431035,CDM,480,RC,93613,HCPCS,Outpatient,,,791.28,395.64,,593.46,75,,,percent of total billed charges,75% of total billed charges,593.46,75,,,percent of total billed charges,75% of total billed charges,253.21,32,,,percent of total billed charges,32% of total billed charges,211.39,100,,,Fee Schedule,100% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,211.39,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,110.78,14,,,percent of total billed charges,14% of total billed charges,110.78,593.46,
93613-3 D Mapping,3432032,CDM,480,RC,93613,HCPCS,Outpatient,,,791.28,395.64,,593.46,75,,,percent of total billed charges,75% of total billed charges,593.46,75,,,percent of total billed charges,75% of total billed charges,253.21,32,,,percent of total billed charges,32% of total billed charges,211.39,100,,,Fee Schedule,100% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,211.39,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,110.78,14,,,percent of total billed charges,14% of total billed charges,110.78,593.46,
"93613-3D MAPPING, INTRACARDIAC",3432033,CDM,481,RC,93613,HCPCS,Outpatient,,,791.28,395.64,,593.46,75,,,percent of total billed charges,75% of total billed charges,593.46,75,,,percent of total billed charges,75% of total billed charges,253.21,32,,,percent of total billed charges,32% of total billed charges,211.39,100,,,Fee Schedule,100% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,211.39,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,110.78,14,,,percent of total billed charges,14% of total billed charges,110.78,593.46,
93615- Esop rec/ECG at/w w/o ven/w/o pace,3431036,CDM,510,RC,93615,HCPCS,Outpatient,,,96.38,48.19,,72.29,75,,,percent of total billed charges,75% of total billed charges,72.29,75,,,percent of total billed charges,75% of total billed charges,1050.22,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1732.85,165,,,Fee Schedule,165% of CMS OPPS Rate,1088.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,3016.61,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,4137.05,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,5182.07,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,1050.22,100,,,Fee Schedule,100% of CMS OPPS Rate,1088.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,13.49,14,,,percent of total billed charges,14% of total billed charges,13.49,5182.07,
93616- Esoph rec/ECG atr/w w/o ven/w/pace,3431037,CDM,510,RC,93616,HCPCS,Outpatient,,,152.48,76.24,,114.36,75,,,percent of total billed charges,75% of total billed charges,114.36,75,,,percent of total billed charges,75% of total billed charges,1050.22,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1732.85,165,,,Fee Schedule,165% of CMS OPPS Rate,1088.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,3016.61,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,4137.05,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,5182.07,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,1050.22,100,,,Fee Schedule,100% of CMS OPPS Rate,1088.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,21.35,14,,,percent of total billed charges,14% of total billed charges,21.35,5182.07,
93618- Induction arrhythmia/elec pacing,3431038,CDM,510,RC,93618,HCPCS,Outpatient,,,582.21,291.11,,436.66,75,,,percent of total billed charges,75% of total billed charges,436.66,75,,,percent of total billed charges,75% of total billed charges,1050.22,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1732.85,165,,,Fee Schedule,165% of CMS OPPS Rate,1088.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,3016.61,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,4137.05,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,5182.07,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,1050.22,100,,,Fee Schedule,100% of CMS OPPS Rate,1088.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,81.51,14,,,percent of total billed charges,14% of total billed charges,81.51,5182.07,
93618-Induction of Arrhythmia By Electrical Pacing,4271201,CDM,481,RC,93618,HCPCS,Outpatient,,,879.8,439.9,,659.85,75,,,percent of total billed charges,75% of total billed charges,659.85,75,,,percent of total billed charges,75% of total billed charges,1050.22,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1732.85,165,,,Fee Schedule,165% of CMS OPPS Rate,1088.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,3016.61,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,4137.05,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,5182.07,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,1050.22,100,,,Fee Schedule,100% of CMS OPPS Rate,1088.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,123.17,14,,,percent of total billed charges,14% of total billed charges,123.17,5182.07,
93618-PF Induction of Arrhythmia By Electrical Pacing,4271202,CDM,960,RC,93618,HCPCS,Outpatient,,,879.8,439.9,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
93619- Comp EP eval w/o ind of arrhythmia,3431039,CDM,481,RC,93619,HCPCS,Outpatient,,,1033.55,516.78,,775.16,75,,,percent of total billed charges,75% of total billed charges,775.16,75,,,percent of total billed charges,75% of total billed charges,6329.89,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,10444.33,165,,,Fee Schedule,165% of CMS OPPS Rate,6560.4,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,18181.77,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,24934.86,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,31233.45,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,6329.89,100,,,Fee Schedule,100% of CMS OPPS Rate,6560.4,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,144.7,14,,,percent of total billed charges,14% of total billed charges,144.7,31233.45,
93619-Atrial Fibrillation,3432034,CDM,481,RC,93619,HCPCS,Outpatient,,,1033.55,516.78,,775.16,75,,,percent of total billed charges,75% of total billed charges,775.16,75,,,percent of total billed charges,75% of total billed charges,6329.89,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,10444.33,165,,,Fee Schedule,165% of CMS OPPS Rate,6560.4,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,18181.77,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,24934.86,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,31233.45,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,6329.89,100,,,Fee Schedule,100% of CMS OPPS Rate,6560.4,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,144.7,14,,,percent of total billed charges,14% of total billed charges,144.7,31233.45,
93619-Atrial Flutter,3432035,CDM,481,RC,93619,HCPCS,Outpatient,,,1033.55,516.78,,775.16,75,,,percent of total billed charges,75% of total billed charges,775.16,75,,,percent of total billed charges,75% of total billed charges,6329.89,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,10444.33,165,,,Fee Schedule,165% of CMS OPPS Rate,6560.4,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,18181.77,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,24934.86,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,31233.45,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,6329.89,100,,,Fee Schedule,100% of CMS OPPS Rate,6560.4,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,144.7,14,,,percent of total billed charges,14% of total billed charges,144.7,31233.45,
93619-Atrial Tachycardia,3432036,CDM,481,RC,93619,HCPCS,Outpatient,,,1033.55,516.78,,775.16,75,,,percent of total billed charges,75% of total billed charges,775.16,75,,,percent of total billed charges,75% of total billed charges,6329.89,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,10444.33,165,,,Fee Schedule,165% of CMS OPPS Rate,6560.4,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,18181.77,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,24934.86,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,31233.45,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,6329.89,100,,,Fee Schedule,100% of CMS OPPS Rate,6560.4,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,144.7,14,,,percent of total billed charges,14% of total billed charges,144.7,31233.45,
93619-EPS W/O INDUCTION OR ATTEMPT,3432037,CDM,481,RC,93619,HCPCS,Outpatient,,,1033.55,516.78,,775.16,75,,,percent of total billed charges,75% of total billed charges,775.16,75,,,percent of total billed charges,75% of total billed charges,6329.89,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,10444.33,165,,,Fee Schedule,165% of CMS OPPS Rate,6560.4,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,18181.77,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,24934.86,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,31233.45,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,6329.89,100,,,Fee Schedule,100% of CMS OPPS Rate,6560.4,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,144.7,14,,,percent of total billed charges,14% of total billed charges,144.7,31233.45,
93620- Comp EP eval w/induc of arrhythmia,3431040,CDM,480,RC,93620,HCPCS,Outpatient,,,1661.92,830.96,,1246.44,75,,,percent of total billed charges,75% of total billed charges,1246.44,75,,,percent of total billed charges,75% of total billed charges,6329.89,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,10444.33,165,,,Fee Schedule,165% of CMS OPPS Rate,6560.4,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,18181.77,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,24934.86,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,31233.45,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,6329.89,100,,,Fee Schedule,100% of CMS OPPS Rate,6560.4,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,232.67,14,,,percent of total billed charges,14% of total billed charges,232.67,31233.45,
93620-Atrial Fibrillation,3432038,CDM,481,RC,93620,HCPCS,Outpatient,,,1661.92,830.96,,1246.44,75,,,percent of total billed charges,75% of total billed charges,1246.44,75,,,percent of total billed charges,75% of total billed charges,6329.89,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,10444.33,165,,,Fee Schedule,165% of CMS OPPS Rate,6560.4,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,18181.77,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,24934.86,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,31233.45,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,6329.89,100,,,Fee Schedule,100% of CMS OPPS Rate,6560.4,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,232.67,14,,,percent of total billed charges,14% of total billed charges,232.67,31233.45,
93620-Atrial Flutter,3432039,CDM,481,RC,93620,HCPCS,Outpatient,,,1661.92,830.96,,1246.44,75,,,percent of total billed charges,75% of total billed charges,1246.44,75,,,percent of total billed charges,75% of total billed charges,6329.89,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,10444.33,165,,,Fee Schedule,165% of CMS OPPS Rate,6560.4,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,18181.77,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,24934.86,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,31233.45,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,6329.89,100,,,Fee Schedule,100% of CMS OPPS Rate,6560.4,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,232.67,14,,,percent of total billed charges,14% of total billed charges,232.67,31233.45,
93620-Atrial Tachycardia,3432040,CDM,481,RC,93620,HCPCS,Outpatient,,,1661.92,830.96,,1246.44,75,,,percent of total billed charges,75% of total billed charges,1246.44,75,,,percent of total billed charges,75% of total billed charges,6329.89,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,10444.33,165,,,Fee Schedule,165% of CMS OPPS Rate,6560.4,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,18181.77,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,24934.86,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,31233.45,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,6329.89,100,,,Fee Schedule,100% of CMS OPPS Rate,6560.4,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,232.67,14,,,percent of total billed charges,14% of total billed charges,232.67,31233.45,
93620-EPS w Induction or Attempted Induction,3560652,CDM,481,RC,93620,HCPCS,Outpatient,,,1661.92,830.96,,1246.44,75,,,percent of total billed charges,75% of total billed charges,1246.44,75,,,percent of total billed charges,75% of total billed charges,6329.89,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,10444.33,165,,,Fee Schedule,165% of CMS OPPS Rate,6560.4,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,18181.77,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,24934.86,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,31233.45,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,6329.89,100,,,Fee Schedule,100% of CMS OPPS Rate,6560.4,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,232.67,14,,,percent of total billed charges,14% of total billed charges,232.67,31233.45,
93620-EPS WITH INDUCTION OR ATTEMPT,3432041,CDM,480,RC,93620,HCPCS,Outpatient,,,1661.92,830.96,,1246.44,75,,,percent of total billed charges,75% of total billed charges,1246.44,75,,,percent of total billed charges,75% of total billed charges,6329.89,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,10444.33,165,,,Fee Schedule,165% of CMS OPPS Rate,6560.4,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,18181.77,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,24934.86,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,31233.45,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,6329.89,100,,,Fee Schedule,100% of CMS OPPS Rate,6560.4,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,232.67,14,,,percent of total billed charges,14% of total billed charges,232.67,31233.45,
93621- EP eval/comp/lt atrial pace/record,3431041,CDM,480,RC,93621,HCPCS,Outpatient,,,247.08,123.54,,185.31,75,,,percent of total billed charges,75% of total billed charges,185.31,75,,,percent of total billed charges,75% of total billed charges,79.07,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.59,14,,,percent of total billed charges,14% of total billed charges,34.59,185.31,
"93621-CS, LA PACE RECORD",3432042,CDM,480,RC,93621,HCPCS,Outpatient,,,247.08,123.54,,185.31,75,,,percent of total billed charges,75% of total billed charges,185.31,75,,,percent of total billed charges,75% of total billed charges,79.07,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.59,14,,,percent of total billed charges,14% of total billed charges,34.59,185.31,
93621-Record from CS,3432043,CDM,481,RC,93621,HCPCS,Outpatient,,,247.08,123.54,,185.31,75,,,percent of total billed charges,75% of total billed charges,185.31,75,,,percent of total billed charges,75% of total billed charges,79.07,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.59,14,,,percent of total billed charges,14% of total billed charges,34.59,185.31,
93622- LV pacing/recording,3431042,CDM,510,RC,93622,HCPCS,Outpatient,,,455.67,227.84,,341.75,75,,,percent of total billed charges,75% of total billed charges,341.75,75,,,percent of total billed charges,75% of total billed charges,145.81,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,63.79,14,,,percent of total billed charges,14% of total billed charges,63.79,341.75,
"93622-Comp. EP with induction or attempted induction with RA, RV, HIS and LV pace and recording",4271203,CDM,481,RC,93622,HCPCS,Outpatient,,,710.2,355.1,,532.65,75,,,percent of total billed charges,75% of total billed charges,532.65,75,,,percent of total billed charges,75% of total billed charges,227.26,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,99.43,14,,,percent of total billed charges,14% of total billed charges,99.43,532.65,
"93622-PF Comp. EP with induction or attempted induction with RA, RV, HIS and LV pace and recording",4271204,CDM,960,RC,93622,HCPCS,Outpatient,,,710.2,355.1,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
93623- Program stim/pace/IV drug inf,3431043,CDM,480,RC,93623,HCPCS,Outpatient,,,256.73,128.37,,192.55,75,,,percent of total billed charges,75% of total billed charges,192.55,75,,,percent of total billed charges,75% of total billed charges,82.15,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.94,14,,,percent of total billed charges,14% of total billed charges,35.94,192.55,
93623-EP Study Drug Infusion,3432044,CDM,480,RC,93623,HCPCS,Outpatient,,,256.73,128.37,,192.55,75,,,percent of total billed charges,75% of total billed charges,192.55,75,,,percent of total billed charges,75% of total billed charges,82.15,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.94,14,,,percent of total billed charges,14% of total billed charges,35.94,192.55,
93623-PROGM STIM AFTER DRUG INF,3432045,CDM,480,RC,93623,HCPCS,Outpatient,,,256.73,128.37,,192.55,75,,,percent of total billed charges,75% of total billed charges,192.55,75,,,percent of total billed charges,75% of total billed charges,82.15,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.94,14,,,percent of total billed charges,14% of total billed charges,35.94,192.55,
93623-Program Stim after Drug Inf,3560654,CDM,481,RC,93623,HCPCS,Outpatient,,,256.73,128.37,,192.55,75,,,percent of total billed charges,75% of total billed charges,192.55,75,,,percent of total billed charges,75% of total billed charges,82.15,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.94,14,,,percent of total billed charges,14% of total billed charges,35.94,192.55,
93624- EP follow-up study w/induction,3431044,CDM,510,RC,93624,HCPCS,Outpatient,,,641.94,320.97,,481.46,75,,,percent of total billed charges,75% of total billed charges,481.46,75,,,percent of total billed charges,75% of total billed charges,6329.89,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,10444.33,165,,,Fee Schedule,165% of CMS OPPS Rate,6560.4,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,18181.77,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,24934.86,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,31233.45,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,6329.89,100,,,Fee Schedule,100% of CMS OPPS Rate,6560.4,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,89.87,14,,,percent of total billed charges,14% of total billed charges,89.87,31233.45,
93631- Intraop epicard/endocard/pace/map,3431045,CDM,510,RC,93631,HCPCS,Outpatient,,,1060.17,530.09,,795.13,75,,,percent of total billed charges,75% of total billed charges,795.13,75,,,percent of total billed charges,75% of total billed charges,339.25,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,148.42,14,,,percent of total billed charges,14% of total billed charges,148.42,795.13,
93640- EP eval sng/dual/ICD leads/implant,3431046,CDM,480,RC,93640,HCPCS,Outpatient,,,474.18,237.09,,355.64,75,,,percent of total billed charges,75% of total billed charges,355.64,75,,,percent of total billed charges,75% of total billed charges,151.74,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.39,14,,,percent of total billed charges,14% of total billed charges,66.39,355.64,
93640-TESTING OF ICD LEAD AT INSERT/REPL,3432046,CDM,480,RC,93640,HCPCS,Outpatient,,,474.18,237.09,,355.64,75,,,percent of total billed charges,75% of total billed charges,355.64,75,,,percent of total billed charges,75% of total billed charges,151.74,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.39,14,,,percent of total billed charges,14% of total billed charges,66.39,355.64,
93641-PF TESTING OF ICD GENER AT INSERT/REPL,3580926,CDM,960,RC,93641,HCPCS,Outpatient,,,826.76,413.38,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
93641-TESTING OF ICD GENER AT INSERT/REPL,3432047,CDM,481,RC,93641,HCPCS,Outpatient,,,826.76,413.38,,620.07,75,,,percent of total billed charges,75% of total billed charges,620.07,75,,,percent of total billed charges,75% of total billed charges,264.56,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,115.75,14,,,percent of total billed charges,14% of total billed charges,115.75,620.07,
93642- EP eval/single/dual ICD,3437842,CDM,983,RC,93642,HCPCS,Outpatient,,,192.51,96.26,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
"93642-Eval of single or dual pacing ICD. Incl. DFTs, induction of arrthymia, evaluation, programming",4271205,CDM,481,RC,93642,HCPCS,Outpatient,,,681.09,340.55,,510.82,75,,,percent of total billed charges,75% of total billed charges,510.82,75,,,percent of total billed charges,75% of total billed charges,1050.22,100,,,Fee Schedule,100% of CMS OPPS Rate,232.04,100,,,Fee Schedule,100% of WV Medicaid Rate,1732.85,165,,,Fee Schedule,165% of CMS OPPS Rate,1088.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,3016.61,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,4137.05,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,5182.07,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,232.04,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1050.22,100,,,Fee Schedule,100% of CMS OPPS Rate,1088.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,95.35,14,,,percent of total billed charges,14% of total billed charges,95.35,5182.07,
"93642-PF Eval of single or dual pacing ICD. Incl. DFTs, induction of arrthymia, evaluation, programm",4271206,CDM,960,RC,93642,HCPCS,Outpatient,,,681.09,340.55,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
93644 - Ephys Eval SubQ Implantable Defibrillator,4201243,CDM,983,RC,93644,HCPCS,Outpatient,,,297.92,148.96,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
93650- Ablation AV Node,3560647,CDM,481,RC,93650,HCPCS,Outpatient,,,1191.21,595.61,,893.41,75,,,percent of total billed charges,75% of total billed charges,893.41,75,,,percent of total billed charges,75% of total billed charges,6329.89,100,,,Fee Schedule,100% of CMS OPPS Rate,420.81,100,,,Fee Schedule,100% of WV Medicaid Rate,10444.33,165,,,Fee Schedule,165% of CMS OPPS Rate,6560.4,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,18181.77,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,24934.86,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,31233.45,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,420.81,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,6329.89,100,,,Fee Schedule,100% of CMS OPPS Rate,6560.4,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,166.77,14,,,percent of total billed charges,14% of total billed charges,166.77,31233.45,
93650- Ablation AV node/conduction,3431047,CDM,960,RC,93650,HCPCS,Outpatient,,,1191.21,595.61,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
93650-ABLATION AV NODE,3432048,CDM,480,RC,93650,HCPCS,Outpatient,,,1191.21,595.61,,893.41,75,,,percent of total billed charges,75% of total billed charges,893.41,75,,,percent of total billed charges,75% of total billed charges,6329.89,100,,,Fee Schedule,100% of CMS OPPS Rate,420.81,100,,,Fee Schedule,100% of WV Medicaid Rate,10444.33,165,,,Fee Schedule,165% of CMS OPPS Rate,6560.4,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,18181.77,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,24934.86,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,31233.45,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,420.81,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,6329.89,100,,,Fee Schedule,100% of CMS OPPS Rate,6560.4,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,166.77,14,,,percent of total billed charges,14% of total billed charges,166.77,31233.45,
93650-AV Nodal Ablation,3432049,CDM,480,RC,93650,HCPCS,Outpatient,,,1191.21,595.61,,893.41,75,,,percent of total billed charges,75% of total billed charges,893.41,75,,,percent of total billed charges,75% of total billed charges,6329.89,100,,,Fee Schedule,100% of CMS OPPS Rate,420.81,100,,,Fee Schedule,100% of WV Medicaid Rate,10444.33,165,,,Fee Schedule,165% of CMS OPPS Rate,6560.4,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,18181.77,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,24934.86,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,31233.45,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,420.81,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,6329.89,100,,,Fee Schedule,100% of CMS OPPS Rate,6560.4,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,166.77,14,,,percent of total billed charges,14% of total billed charges,166.77,31233.45,
AV Nodal Ablation,3427172,CDM,480,RC,93650,HCPCS,Outpatient,,,1191.21,595.61,,893.41,75,,,percent of total billed charges,75% of total billed charges,893.41,75,,,percent of total billed charges,75% of total billed charges,6329.89,100,,,Fee Schedule,100% of CMS OPPS Rate,420.81,100,,,Fee Schedule,100% of WV Medicaid Rate,10444.33,165,,,Fee Schedule,165% of CMS OPPS Rate,6560.4,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,18181.77,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,24934.86,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,31233.45,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,420.81,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,6329.89,100,,,Fee Schedule,100% of CMS OPPS Rate,6560.4,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,166.77,14,,,percent of total billed charges,14% of total billed charges,166.77,31233.45,
AV Node Ablation,651265,CDM,480,RC,93650,HCPCS,Outpatient,,,1191.21,595.61,,893.41,75,,,percent of total billed charges,75% of total billed charges,893.41,75,,,percent of total billed charges,75% of total billed charges,6329.89,100,,,Fee Schedule,100% of CMS OPPS Rate,420.81,100,,,Fee Schedule,100% of WV Medicaid Rate,10444.33,165,,,Fee Schedule,165% of CMS OPPS Rate,6560.4,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,18181.77,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,24934.86,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,31233.45,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,420.81,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,6329.89,100,,,Fee Schedule,100% of CMS OPPS Rate,6560.4,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,166.77,14,,,percent of total billed charges,14% of total billed charges,166.77,31233.45,
93653- Ablation SVT,3560646,CDM,481,RC,93653,HCPCS,Outpatient,,,2233.22,1116.61,,1674.92,75,,,percent of total billed charges,75% of total billed charges,1674.92,75,,,percent of total billed charges,75% of total billed charges,22076.31,100,,,Fee Schedule,100% of CMS OPPS Rate,596.55,100,,,Fee Schedule,100% of WV Medicaid Rate,36425.92,165,,,Fee Schedule,165% of CMS OPPS Rate,22880.22,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,63411.2,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,86963.4,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,108930.48,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,596.55,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,22076.31,100,,,Fee Schedule,100% of CMS OPPS Rate,22880.22,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,312.65,14,,,percent of total billed charges,14% of total billed charges,312.65,108930.48,
93653- Comp EP/SVT ablat/single atr focus,3430793,CDM,480,RC,93653,HCPCS,Outpatient,,,2233.22,1116.61,,1674.92,75,,,percent of total billed charges,75% of total billed charges,1674.92,75,,,percent of total billed charges,75% of total billed charges,22076.31,100,,,Fee Schedule,100% of CMS OPPS Rate,596.55,100,,,Fee Schedule,100% of WV Medicaid Rate,36425.92,165,,,Fee Schedule,165% of CMS OPPS Rate,22880.22,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,63411.2,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,86963.4,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,108930.48,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,596.55,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,22076.31,100,,,Fee Schedule,100% of CMS OPPS Rate,22880.22,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,312.65,14,,,percent of total billed charges,14% of total billed charges,312.65,108930.48,
"93653-ABLATION SVT,ATRIAL AV NODE PATHWAY",3432050,CDM,480,RC,93653,HCPCS,Outpatient,,,2233.22,1116.61,,1674.92,75,,,percent of total billed charges,75% of total billed charges,1674.92,75,,,percent of total billed charges,75% of total billed charges,22076.31,100,,,Fee Schedule,100% of CMS OPPS Rate,596.55,100,,,Fee Schedule,100% of WV Medicaid Rate,36425.92,165,,,Fee Schedule,165% of CMS OPPS Rate,22880.22,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,63411.2,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,86963.4,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,108930.48,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,596.55,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,22076.31,100,,,Fee Schedule,100% of CMS OPPS Rate,22880.22,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,312.65,14,,,percent of total billed charges,14% of total billed charges,312.65,108930.48,
93653-SVT Ablation,3432051,CDM,481,RC,93653,HCPCS,Outpatient,,,2233.22,1116.61,,1674.92,75,,,percent of total billed charges,75% of total billed charges,1674.92,75,,,percent of total billed charges,75% of total billed charges,22076.31,100,,,Fee Schedule,100% of CMS OPPS Rate,596.55,100,,,Fee Schedule,100% of WV Medicaid Rate,36425.92,165,,,Fee Schedule,165% of CMS OPPS Rate,22880.22,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,63411.2,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,86963.4,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,108930.48,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,596.55,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,22076.31,100,,,Fee Schedule,100% of CMS OPPS Rate,22880.22,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,312.65,14,,,percent of total billed charges,14% of total billed charges,312.65,108930.48,
SVT Ablation,,,480,RC,93653,HCPCS,Outpatient,,,2217.55,1108.78,,1663.16,75,,,percent of total billed charges,75% of total billed charges,1663.16,75,,,percent of total billed charges,75% of total billed charges,22076.31,100,,,Fee Schedule,100% of CMS OPPS Rate,596.55,100,,,Fee Schedule,100% of WV Medicaid Rate,36425.92,165,,,Fee Schedule,165% of CMS OPPS Rate,22880.22,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,63411.2,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,86963.4,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,108930.48,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,596.55,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,22076.31,100,,,Fee Schedule,100% of CMS OPPS Rate,22880.22,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,310.46,14,,,percent of total billed charges,14% of total billed charges,310.46,108930.48,
93654- Comp EP/VT tx/3Dmap/LV pace/rec,3430794,CDM,480,RC,93654,HCPCS,Outpatient,,,2987.86,1493.93,,2240.9,75,,,percent of total billed charges,75% of total billed charges,2240.9,75,,,percent of total billed charges,75% of total billed charges,22076.31,100,,,Fee Schedule,100% of CMS OPPS Rate,797.87,100,,,Fee Schedule,100% of WV Medicaid Rate,36425.92,165,,,Fee Schedule,165% of CMS OPPS Rate,22880.22,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,63411.2,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,86963.4,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,108930.48,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,797.87,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,22076.31,100,,,Fee Schedule,100% of CMS OPPS Rate,22880.22,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,418.3,14,,,percent of total billed charges,14% of total billed charges,418.3,108930.48,
93654-ABLATION VT,3432052,CDM,480,RC,93654,HCPCS,Outpatient,,,2987.86,1493.93,,2240.9,75,,,percent of total billed charges,75% of total billed charges,2240.9,75,,,percent of total billed charges,75% of total billed charges,22076.31,100,,,Fee Schedule,100% of CMS OPPS Rate,797.87,100,,,Fee Schedule,100% of WV Medicaid Rate,36425.92,165,,,Fee Schedule,165% of CMS OPPS Rate,22880.22,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,63411.2,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,86963.4,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,108930.48,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,797.87,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,22076.31,100,,,Fee Schedule,100% of CMS OPPS Rate,22880.22,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,418.3,14,,,percent of total billed charges,14% of total billed charges,418.3,108930.48,
93654-Vtach Ablation,3432053,CDM,481,RC,93654,HCPCS,Outpatient,,,2987.86,1493.93,,2240.9,75,,,percent of total billed charges,75% of total billed charges,2240.9,75,,,percent of total billed charges,75% of total billed charges,22076.31,100,,,Fee Schedule,100% of CMS OPPS Rate,797.87,100,,,Fee Schedule,100% of WV Medicaid Rate,36425.92,165,,,Fee Schedule,165% of CMS OPPS Rate,22880.22,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,63411.2,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,86963.4,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,108930.48,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,797.87,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,22076.31,100,,,Fee Schedule,100% of CMS OPPS Rate,22880.22,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,418.3,14,,,percent of total billed charges,14% of total billed charges,418.3,108930.48,
Vtach Ablation,,,480,RC,93654,HCPCS,Outpatient,,,2673.25,1336.63,,2004.94,75,,,percent of total billed charges,75% of total billed charges,2004.94,75,,,percent of total billed charges,75% of total billed charges,22076.31,100,,,Fee Schedule,100% of CMS OPPS Rate,797.87,100,,,Fee Schedule,100% of WV Medicaid Rate,36425.92,165,,,Fee Schedule,165% of CMS OPPS Rate,22880.22,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,63411.2,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,86963.4,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,108930.48,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,797.87,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,22076.31,100,,,Fee Schedule,100% of CMS OPPS Rate,22880.22,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,374.26,14,,,percent of total billed charges,14% of total billed charges,374.26,108930.48,
93655-Additional Tachycardia Mechanism,3554699,CDM,481,RC,93655,HCPCS,Outpatient,,,834.41,417.21,,625.81,75,,,percent of total billed charges,75% of total billed charges,625.81,75,,,percent of total billed charges,75% of total billed charges,267.01,32,,,percent of total billed charges,32% of total billed charges,222.69,100,,,Fee Schedule,100% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,222.69,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,116.82,14,,,percent of total billed charges,14% of total billed charges,116.82,625.81,
93655-PF Additional Tachycardia Mechanism,3580927,CDM,960,RC,93655,HCPCS,Outpatient,,,834.41,417.21,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
93656 - AFIB ABLATION,3432054,CDM,481,RC,93656,HCPCS,Outpatient,,,2996.31,1498.16,,2247.23,75,,,percent of total billed charges,75% of total billed charges,2247.23,75,,,percent of total billed charges,75% of total billed charges,22076.31,100,,,Fee Schedule,100% of CMS OPPS Rate,800.32,100,,,Fee Schedule,100% of WV Medicaid Rate,36425.92,165,,,Fee Schedule,165% of CMS OPPS Rate,22880.22,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,63411.2,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,86963.4,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,108930.48,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,800.32,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,22076.31,100,,,Fee Schedule,100% of CMS OPPS Rate,22880.22,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,419.48,14,,,percent of total billed charges,14% of total billed charges,419.48,108930.48,
93656- Comp EP/ Afib ablat/pul vein iso,3430795,CDM,481,RC,93656,HCPCS,Outpatient,,,2996.31,1498.16,,2247.23,75,,,percent of total billed charges,75% of total billed charges,2247.23,75,,,percent of total billed charges,75% of total billed charges,22076.31,100,,,Fee Schedule,100% of CMS OPPS Rate,800.32,100,,,Fee Schedule,100% of WV Medicaid Rate,36425.92,165,,,Fee Schedule,165% of CMS OPPS Rate,22880.22,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,63411.2,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,86963.4,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,108930.48,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,800.32,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,22076.31,100,,,Fee Schedule,100% of CMS OPPS Rate,22880.22,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,419.48,14,,,percent of total billed charges,14% of total billed charges,419.48,108930.48,
Atrial Fibrillation,3427167,CDM,960,RC,93656,HCPCS,Outpatient,,,2514.72,1257.36,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
93657- Addl linear or focal intracard cath ablatn L or R atrium,3569421,CDM,510,RC,93657,HCPCS,Outpatient,,,833.62,416.81,,625.22,75,,,percent of total billed charges,75% of total billed charges,625.22,75,,,percent of total billed charges,75% of total billed charges,266.76,32,,,percent of total billed charges,32% of total billed charges,222.45,100,,,Fee Schedule,100% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,222.45,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,116.71,14,,,percent of total billed charges,14% of total billed charges,116.71,625.22,
93657-Additional linear or focal catheter ablation of LA or RA for TX of Afib after PVI,4271207,CDM,481,RC,93657,HCPCS,Outpatient,,,650.37,325.19,,487.78,75,,,percent of total billed charges,75% of total billed charges,487.78,75,,,percent of total billed charges,75% of total billed charges,208.12,32,,,percent of total billed charges,32% of total billed charges,222.45,100,,,Fee Schedule,100% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,222.45,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,91.05,14,,,percent of total billed charges,14% of total billed charges,91.05,487.78,
93657-PF Additional linear or focal catheter ablation of LA or RA for TX of Afib after PVI,4271208,CDM,960,RC,93657,HCPCS,Outpatient,,,650.37,325.19,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
93660- Tilt table/cont ECG/BP mon,3431049,CDM,480,RC,93660,HCPCS,Outpatient,,,159.19,79.6,,119.39,75,,,percent of total billed charges,75% of total billed charges,119.39,75,,,percent of total billed charges,75% of total billed charges,454.5,100,,,Fee Schedule,100% of CMS OPPS Rate,106.43,100,,,Fee Schedule,100% of WV Medicaid Rate,749.91,165,,,Fee Schedule,165% of CMS OPPS Rate,471.04,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1305.49,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1790.39,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,2242.64,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,106.43,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,454.5,100,,,Fee Schedule,100% of CMS OPPS Rate,471.04,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,22.29,14,,,percent of total billed charges,14% of total billed charges,22.29,2242.64,
93660-TILT TABLE TESTING,3432055,CDM,481,RC,93660,HCPCS,Outpatient,,,159.19,79.6,,119.39,75,,,percent of total billed charges,75% of total billed charges,119.39,75,,,percent of total billed charges,75% of total billed charges,454.5,100,,,Fee Schedule,100% of CMS OPPS Rate,106.43,100,,,Fee Schedule,100% of WV Medicaid Rate,749.91,165,,,Fee Schedule,165% of CMS OPPS Rate,471.04,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1305.49,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1790.39,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,2242.64,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,106.43,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,454.5,100,,,Fee Schedule,100% of CMS OPPS Rate,471.04,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,22.29,14,,,percent of total billed charges,14% of total billed charges,22.29,2242.64,
Tilt Table Test,604553,CDM,480,RC,93660,HCPCS,Outpatient,,,396.58,198.29,,297.44,75,,,percent of total billed charges,75% of total billed charges,297.44,75,,,percent of total billed charges,75% of total billed charges,454.5,100,,,Fee Schedule,100% of CMS OPPS Rate,106.43,100,,,Fee Schedule,100% of WV Medicaid Rate,749.91,165,,,Fee Schedule,165% of CMS OPPS Rate,471.04,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1305.49,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1790.39,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,2242.64,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,106.43,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,454.5,100,,,Fee Schedule,100% of CMS OPPS Rate,471.04,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,55.52,14,,,percent of total billed charges,14% of total billed charges,55.52,2242.64,
93662- IC echo/w therap/diag interven,3431050,CDM,480,RC,93662,HCPCS,Outpatient,,,231.21,115.61,,173.41,75,,,percent of total billed charges,75% of total billed charges,173.41,75,,,percent of total billed charges,75% of total billed charges,73.99,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.37,14,,,percent of total billed charges,14% of total billed charges,32.37,173.41,
93662-ICE-INTRACARDIAC ECHOCARDIOGRAPHY,3432056,CDM,481,RC,93662,HCPCS,Outpatient,,,231.21,115.61,,173.41,75,,,percent of total billed charges,75% of total billed charges,173.41,75,,,percent of total billed charges,75% of total billed charges,73.99,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.37,14,,,percent of total billed charges,14% of total billed charges,32.37,173.41,
93662-Intracardiac Echocardiography,3432057,CDM,480,RC,93662,HCPCS,Outpatient,,,231.21,115.61,,173.41,75,,,percent of total billed charges,75% of total billed charges,173.41,75,,,percent of total billed charges,75% of total billed charges,73.99,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.37,14,,,percent of total billed charges,14% of total billed charges,32.37,173.41,
93662-PF ICE-INTRACARDIAC ECHOCARDIOGRAPHY,3611084,CDM,960,RC,93662,HCPCS,Outpatient,,,231.21,115.61,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
93668- PAD rehab/per session,3431051,CDM,480,RC,93668,HCPCS,Outpatient,,,32.68,16.34,,24.51,75,,,percent of total billed charges,75% of total billed charges,24.51,75,,,percent of total billed charges,75% of total billed charges,54.03,100,,,Fee Schedule,100% of CMS OPPS Rate,8.6,100,,,Fee Schedule,100% of WV Medicaid Rate,89.16,165,,,Fee Schedule,165% of CMS OPPS Rate,56,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,155.22,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,212.87,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,266.64,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,8.6,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,54.03,100,,,Fee Schedule,100% of CMS OPPS Rate,56,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4.58,14,,,percent of total billed charges,14% of total billed charges,4.58,266.64,
93724- PPM antitac eval/reprog/interp/rec,3431053,CDM,510,RC,93724,HCPCS,Outpatient,,,109.26,54.63,,81.95,75,,,percent of total billed charges,75% of total billed charges,81.95,75,,,percent of total billed charges,75% of total billed charges,260.08,100,,,Fee Schedule,100% of CMS OPPS Rate,109.26,100,,,Fee Schedule,100% of WV Medicaid Rate,429.14,165,,,Fee Schedule,165% of CMS OPPS Rate,269.56,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,747.08,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1024.57,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1283.38,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,109.26,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,260.08,100,,,Fee Schedule,100% of CMS OPPS Rate,269.56,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,15.3,14,,,percent of total billed charges,14% of total billed charges,15.3,1283.38,
93724-NIPS Procedure,3644934,CDM,481,RC,93724,HCPCS,Outpatient,,,109.26,54.63,,81.95,75,,,percent of total billed charges,75% of total billed charges,81.95,75,,,percent of total billed charges,75% of total billed charges,260.08,100,,,Fee Schedule,100% of CMS OPPS Rate,109.26,100,,,Fee Schedule,100% of WV Medicaid Rate,429.14,165,,,Fee Schedule,165% of CMS OPPS Rate,269.56,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,747.08,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1024.57,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1283.38,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,109.26,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,260.08,100,,,Fee Schedule,100% of CMS OPPS Rate,269.56,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,15.3,14,,,percent of total billed charges,14% of total billed charges,15.3,1283.38,
93724-PF NIPS Procedure,3644935,CDM,960,RC,93724,HCPCS,Outpatient,,,109.26,54.63,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
NIPS Procedure,,,480,RC,93724,HCPCS,Outpatient,,,715.11,357.56,,536.33,75,,,percent of total billed charges,75% of total billed charges,536.33,75,,,percent of total billed charges,75% of total billed charges,260.08,100,,,Fee Schedule,100% of CMS OPPS Rate,195.66,100,,,Fee Schedule,100% of WV Medicaid Rate,429.14,165,,,Fee Schedule,165% of CMS OPPS Rate,269.56,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,747.08,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1024.57,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1283.38,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,195.66,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,260.08,100,,,Fee Schedule,100% of CMS OPPS Rate,269.56,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,100.12,14,,,percent of total billed charges,14% of total billed charges,100.12,1283.38,
93745- Init set up/prog/inst/wearable ICD,3431056,CDM,510,RC,93745,HCPCS,Outpatient,,,193.87,96.94,,145.4,75,,,percent of total billed charges,75% of total billed charges,145.4,75,,,percent of total billed charges,75% of total billed charges,260.08,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,429.14,165,,,Fee Schedule,165% of CMS OPPS Rate,269.56,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,747.08,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1024.57,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1283.38,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,260.08,100,,,Fee Schedule,100% of CMS OPPS Rate,269.56,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,27.14,14,,,percent of total billed charges,14% of total billed charges,27.14,1283.38,
93750- VAD interr/in person/program/rept,3431057,CDM,510,RC,93750,HCPCS,Outpatient,,,130.09,65.05,,97.57,75,,,percent of total billed charges,75% of total billed charges,97.57,75,,,percent of total billed charges,75% of total billed charges,93.83,100,,,Fee Schedule,100% of CMS OPPS Rate,28.27,100,,,Fee Schedule,100% of WV Medicaid Rate,154.82,165,,,Fee Schedule,165% of CMS OPPS Rate,97.24,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,269.52,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,369.64,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,463.01,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,28.27,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,93.83,100,,,Fee Schedule,100% of CMS OPPS Rate,97.24,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,18.21,14,,,percent of total billed charges,14% of total billed charges,18.21,463.01,
93784- Amb BP mon/rec 24 hr>/interp/rept,3431059,CDM,510,RC,93784,HCPCS,Outpatient,,,112.51,56.26,,84.38,75,,,percent of total billed charges,75% of total billed charges,84.38,75,,,percent of total billed charges,75% of total billed charges,36,32,,,percent of total billed charges,32% of total billed charges,30.23,100,,,Fee Schedule,100% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.23,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.75,14,,,percent of total billed charges,14% of total billed charges,15.75,84.38,
93786- Amb BP mon/24 hrs> record only,3431060,CDM,510,RC,93786,HCPCS,Outpatient,,,53.21,26.61,,39.91,75,,,percent of total billed charges,75% of total billed charges,39.91,75,,,percent of total billed charges,75% of total billed charges,109.16,100,,,Fee Schedule,100% of CMS OPPS Rate,14.26,100,,,Fee Schedule,100% of WV Medicaid Rate,180.11,165,,,Fee Schedule,165% of CMS OPPS Rate,113.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,313.55,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,430.01,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,538.63,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,14.26,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,109.16,100,,,Fee Schedule,100% of CMS OPPS Rate,113.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,7.45,14,,,percent of total billed charges,14% of total billed charges,7.45,538.63,
93788- AMB BP mon/24 hrs> scan/rept only,3431061,CDM,510,RC,93788,HCPCS,Outpatient,,,12.16,6.08,,9.12,75,,,percent of total billed charges,75% of total billed charges,9.12,75,,,percent of total billed charges,75% of total billed charges,109.16,100,,,Fee Schedule,100% of CMS OPPS Rate,3.2,100,,,Fee Schedule,100% of WV Medicaid Rate,180.11,165,,,Fee Schedule,165% of CMS OPPS Rate,113.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,313.55,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,430.01,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,538.63,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,3.2,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,109.16,100,,,Fee Schedule,100% of CMS OPPS Rate,113.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1.7,14,,,percent of total billed charges,14% of total billed charges,1.7,538.63,
93790- Amb BP mon/24 hrs/interp/rept only,3431062,CDM,510,RC,93790,HCPCS,Outpatient,,,47.12,23.56,,35.34,75,,,percent of total billed charges,75% of total billed charges,35.34,75,,,percent of total billed charges,75% of total billed charges,15.08,32,,,percent of total billed charges,32% of total billed charges,12.54,100,,,Fee Schedule,100% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.54,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.6,14,,,percent of total billed charges,14% of total billed charges,6.6,35.34,
INR Monitoring- Home,3561523,CDM,960,RC,93793,HCPCS,Outpatient,,,28.72,14.36,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
INR POC,3444194,CDM,300,RC,93793,HCPCS,Outpatient,,,28.72,14.36,,21.54,75,,,percent of total billed charges,75% of total billed charges,21.54,75,,,percent of total billed charges,75% of total billed charges,9.19,32,,,percent of total billed charges,32% of total billed charges,7.62,100,,,Fee Schedule,100% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.62,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.02,14,,,percent of total billed charges,14% of total billed charges,4.02,21.54,
Prothrombin and INR POC,3444204,CDM,300,RC,93793,HCPCS,Outpatient,,,28.72,14.36,,21.54,75,,,percent of total billed charges,75% of total billed charges,21.54,75,,,percent of total billed charges,75% of total billed charges,9.19,32,,,percent of total billed charges,32% of total billed charges,7.62,100,,,Fee Schedule,100% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.62,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.02,14,,,percent of total billed charges,14% of total billed charges,4.02,21.54,
93797- OP card rehab w/o cont ECG monitor,3431063,CDM,943,RC,93797,HCPCS,Outpatient,,,41.67,20.84,,31.25,75,,,percent of total billed charges,75% of total billed charges,31.25,75,,,percent of total billed charges,75% of total billed charges,112.88,100,,,Fee Schedule,100% of CMS OPPS Rate,6.39,100,,,Fee Schedule,100% of WV Medicaid Rate,186.25,165,,,Fee Schedule,165% of CMS OPPS Rate,116.99,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,324.24,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,444.67,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,557,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,6.39,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,112.88,100,,,Fee Schedule,100% of CMS OPPS Rate,116.99,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,5.83,14,,,percent of total billed charges,14% of total billed charges,5.83,557,
93798- OP card rehab w/ECG mon/q session,3431064,CDM,943,RC,93798,HCPCS,Outpatient,,,64.3,32.15,,48.23,75,,,percent of total billed charges,75% of total billed charges,48.23,75,,,percent of total billed charges,75% of total billed charges,112.88,100,,,Fee Schedule,100% of CMS OPPS Rate,9.59,100,,,Fee Schedule,100% of WV Medicaid Rate,186.25,165,,,Fee Schedule,165% of CMS OPPS Rate,116.99,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,324.24,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,444.67,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,557,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,9.59,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,112.88,100,,,Fee Schedule,100% of CMS OPPS Rate,116.99,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,9,14,,,percent of total billed charges,14% of total billed charges,9,557,
93799-iFR,4305231,CDM,481,RC,93799,HCPCS,Outpatient,,,151.54,75.77,,113.66,75,,,percent of total billed charges,75% of total billed charges,113.66,75,,,percent of total billed charges,75% of total billed charges,136.72,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,225.58,165,,,Fee Schedule,165% of CMS OPPS Rate,141.69,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,392.72,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,538.59,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,674.64,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,136.72,100,,,Fee Schedule,100% of CMS OPPS Rate,141.69,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,21.22,14,,,percent of total billed charges,14% of total billed charges,21.22,674.64,
93880 - (26) Duplex scan of extracranial arteries; complete,3898953,CDM,983,RC,93880,HCPCS,Outpatient,,,76.98,38.49,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
93880 - Duplex scan of extracranial arteries; complete bilat,3898967,CDM,510,RC,93880,HCPCS,Outpatient,,,76.98,38.49,,57.74,75,,,percent of total billed charges,75% of total billed charges,57.74,75,,,percent of total billed charges,75% of total billed charges,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,76.98,100,,,Fee Schedule,100% of WV Medicaid Rate,362.24,165,,,Fee Schedule,165% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,630.61,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,864.84,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1083.29,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,76.98,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,10.78,14,,,percent of total billed charges,14% of total billed charges,10.78,1083.29,
93880-CL Carotid Duplex Complete BILAT,3432058,CDM,960,RC,93880,HCPCS,Outpatient,,,76.98,38.49,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
93880-CL Carotid Duplex Complete LT,3432059,CDM,960,RC,93880,HCPCS,Outpatient,,,76.98,38.49,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
93880-CL Carotid Duplex Complete RT,3432060,CDM,960,RC,93880,HCPCS,Outpatient,,,76.98,38.49,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
CL Carotid Duplex Complete BILAT,3427518,CDM,921,RC,93880,HCPCS,Outpatient,,,76.98,38.49,,57.74,75,,,percent of total billed charges,75% of total billed charges,57.74,75,,,percent of total billed charges,75% of total billed charges,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,76.98,100,,,Fee Schedule,100% of WV Medicaid Rate,362.24,165,,,Fee Schedule,165% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,630.61,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,864.84,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1083.29,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,76.98,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,10.78,14,,,percent of total billed charges,14% of total billed charges,10.78,1083.29,
CL Carotid Duplex Complete LT,3427513,CDM,921,RC,93880,HCPCS,Outpatient,,,76.98,38.49,,57.74,75,,,percent of total billed charges,75% of total billed charges,57.74,75,,,percent of total billed charges,75% of total billed charges,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,76.98,100,,,Fee Schedule,100% of WV Medicaid Rate,362.24,165,,,Fee Schedule,165% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,630.61,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,864.84,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1083.29,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,76.98,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,10.78,14,,,percent of total billed charges,14% of total billed charges,10.78,1083.29,
CL Carotid Duplex Complete RT,3427515,CDM,921,RC,93880,HCPCS,Outpatient,,,76.98,38.49,,57.74,75,,,percent of total billed charges,75% of total billed charges,57.74,75,,,percent of total billed charges,75% of total billed charges,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,76.98,100,,,Fee Schedule,100% of WV Medicaid Rate,362.24,165,,,Fee Schedule,165% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,630.61,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,864.84,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1083.29,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,76.98,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,10.78,14,,,percent of total billed charges,14% of total billed charges,10.78,1083.29,
Read,3575287,CDM,972,RC,93880,HCPCS,Outpatient,,,76.98,38.49,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
US Carotids Bilat:Read,596599,CDM,972,RC,93880,HCPCS,Outpatient,,,76.98,38.49,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
93882- Dup scan/extracran art/unilat/ltd,3435543,CDM,921,RC,93882,HCPCS,Outpatient,,,48.63,24.32,,36.47,75,,,percent of total billed charges,75% of total billed charges,36.47,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,48.63,100,,,Fee Schedule,100% of WV Medicaid Rate,165.79,165,,,Fee Schedule,165% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.82,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,48.63,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,6.81,14,,,percent of total billed charges,14% of total billed charges,6.81,495.81,
93882-CL Carotid Duplex Limited BILAT,3432061,CDM,960,RC,93882,HCPCS,Outpatient,,,48.63,24.32,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
93882-CL Carotid Duplex Limited LT,3432062,CDM,960,RC,93882,HCPCS,Outpatient,,,48.63,24.32,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
93882-CL Carotid Duplex Limited RT,3432063,CDM,960,RC,93882,HCPCS,Outpatient,,,48.63,24.32,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
93882-CL Limited Carotid Post Proc LT,3432064,CDM,960,RC,93882,HCPCS,Outpatient,,,48.63,24.32,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
93882-CL Limited Carotid Post Proc RT,3432065,CDM,960,RC,93882,HCPCS,Outpatient,,,48.63,24.32,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
93882-CL Limited Carotid Post Procedure BILAT,3432066,CDM,960,RC,93882,HCPCS,Outpatient,,,48.63,24.32,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
93882-CL Limited Carotid Post Procedure LT,3432067,CDM,960,RC,93882,HCPCS,Outpatient,,,48.63,24.32,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
93882-CL Limited Carotid Post Procedure RT,3432068,CDM,960,RC,93882,HCPCS,Outpatient,,,48.63,24.32,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
CL Carotid Duplex Limited BILAT,3427517,CDM,921,RC,93882,HCPCS,Outpatient,,,48.63,24.32,,36.47,75,,,percent of total billed charges,75% of total billed charges,36.47,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,48.63,100,,,Fee Schedule,100% of WV Medicaid Rate,165.79,165,,,Fee Schedule,165% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.82,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,48.63,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,6.81,14,,,percent of total billed charges,14% of total billed charges,6.81,495.81,
CL Carotid Duplex Limited LT,3427514,CDM,921,RC,93882,HCPCS,Outpatient,,,48.63,24.32,,36.47,75,,,percent of total billed charges,75% of total billed charges,36.47,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,48.63,100,,,Fee Schedule,100% of WV Medicaid Rate,165.79,165,,,Fee Schedule,165% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.82,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,48.63,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,6.81,14,,,percent of total billed charges,14% of total billed charges,6.81,495.81,
CL Carotid Duplex Limited RT,3427516,CDM,921,RC,93882,HCPCS,Outpatient,,,48.63,24.32,,36.47,75,,,percent of total billed charges,75% of total billed charges,36.47,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,48.63,100,,,Fee Schedule,100% of WV Medicaid Rate,165.79,165,,,Fee Schedule,165% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.82,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,48.63,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,6.81,14,,,percent of total billed charges,14% of total billed charges,6.81,495.81,
CL Limited Carotid Post Procedure BILAT,3427524,CDM,921,RC,93882,HCPCS,Outpatient,,,48.63,24.32,,36.47,75,,,percent of total billed charges,75% of total billed charges,36.47,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,48.63,100,,,Fee Schedule,100% of WV Medicaid Rate,165.79,165,,,Fee Schedule,165% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.82,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,48.63,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,6.81,14,,,percent of total billed charges,14% of total billed charges,6.81,495.81,
CL Limited Carotid Post Procedure LT,3427522,CDM,921,RC,93882,HCPCS,Outpatient,,,48.63,24.32,,36.47,75,,,percent of total billed charges,75% of total billed charges,36.47,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,48.63,100,,,Fee Schedule,100% of WV Medicaid Rate,165.79,165,,,Fee Schedule,165% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.82,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,48.63,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,6.81,14,,,percent of total billed charges,14% of total billed charges,6.81,495.81,
CL Limited Carotid Post Procedure RT,3427523,CDM,921,RC,93882,HCPCS,Outpatient,,,48.63,24.32,,36.47,75,,,percent of total billed charges,75% of total billed charges,36.47,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,48.63,100,,,Fee Schedule,100% of WV Medicaid Rate,165.79,165,,,Fee Schedule,165% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.82,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,48.63,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,6.81,14,,,percent of total billed charges,14% of total billed charges,6.81,495.81,
SCMP US Carotid:Read,3575233,CDM,972,RC,93882,HCPCS,Outpatient,,,48.63,24.32,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
US Carotid Unilat Lt:Read,596605,CDM,972,RC,93882,HCPCS,Outpatient,,,48.63,24.32,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
US Carotid Unilat Rt:Read,596602,CDM,972,RC,93882,HCPCS,Outpatient,,,48.63,24.32,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
93922-CL US Lower Extrem Art Limited BILAT,3432069,CDM,921,RC,93922,HCPCS,Outpatient,,,24.32,12.16,,18.24,75,,,percent of total billed charges,75% of total billed charges,18.24,75,,,percent of total billed charges,75% of total billed charges,109.16,100,,,Fee Schedule,100% of CMS OPPS Rate,24.32,100,,,Fee Schedule,100% of WV Medicaid Rate,180.11,165,,,Fee Schedule,165% of CMS OPPS Rate,113.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,313.55,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,430.01,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,538.63,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,24.32,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,109.16,100,,,Fee Schedule,100% of CMS OPPS Rate,113.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,3.4,14,,,percent of total billed charges,14% of total billed charges,3.4,538.63,
93922-CL US Lower Extrem Art Limited RT,3432070,CDM,921,RC,93922,HCPCS,Outpatient,,,24.32,12.16,,18.24,75,,,percent of total billed charges,75% of total billed charges,18.24,75,,,percent of total billed charges,75% of total billed charges,109.16,100,,,Fee Schedule,100% of CMS OPPS Rate,24.32,100,,,Fee Schedule,100% of WV Medicaid Rate,180.11,165,,,Fee Schedule,165% of CMS OPPS Rate,113.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,313.55,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,430.01,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,538.63,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,24.32,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,109.16,100,,,Fee Schedule,100% of CMS OPPS Rate,113.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,3.4,14,,,percent of total billed charges,14% of total billed charges,3.4,538.63,
93922-CL US Lower Extrem Arterial Limited LT,3432071,CDM,921,RC,93922,HCPCS,Outpatient,,,24.32,12.16,,18.24,75,,,percent of total billed charges,75% of total billed charges,18.24,75,,,percent of total billed charges,75% of total billed charges,109.16,100,,,Fee Schedule,100% of CMS OPPS Rate,24.32,100,,,Fee Schedule,100% of WV Medicaid Rate,180.11,165,,,Fee Schedule,165% of CMS OPPS Rate,113.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,313.55,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,430.01,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,538.63,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,24.32,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,109.16,100,,,Fee Schedule,100% of CMS OPPS Rate,113.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,3.4,14,,,percent of total billed charges,14% of total billed charges,3.4,538.63,
CL US Lower Extrem Art Limited BILAT,3427502,CDM,921,RC,93922,HCPCS,Outpatient,,,24.32,12.16,,18.24,75,,,percent of total billed charges,75% of total billed charges,18.24,75,,,percent of total billed charges,75% of total billed charges,109.16,100,,,Fee Schedule,100% of CMS OPPS Rate,24.32,100,,,Fee Schedule,100% of WV Medicaid Rate,180.11,165,,,Fee Schedule,165% of CMS OPPS Rate,113.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,313.55,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,430.01,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,538.63,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,24.32,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,109.16,100,,,Fee Schedule,100% of CMS OPPS Rate,113.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,3.4,14,,,percent of total billed charges,14% of total billed charges,3.4,538.63,
CL US Lower Extrem Art Limited RT,3427506,CDM,921,RC,93922,HCPCS,Outpatient,,,24.32,12.16,,18.24,75,,,percent of total billed charges,75% of total billed charges,18.24,75,,,percent of total billed charges,75% of total billed charges,109.16,100,,,Fee Schedule,100% of CMS OPPS Rate,24.32,100,,,Fee Schedule,100% of WV Medicaid Rate,180.11,165,,,Fee Schedule,165% of CMS OPPS Rate,113.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,313.55,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,430.01,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,538.63,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,24.32,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,109.16,100,,,Fee Schedule,100% of CMS OPPS Rate,113.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,3.4,14,,,percent of total billed charges,14% of total billed charges,3.4,538.63,
CL US Lower Extrem Arterial Limited LT,3427504,CDM,921,RC,93922,HCPCS,Outpatient,,,24.32,12.16,,18.24,75,,,percent of total billed charges,75% of total billed charges,18.24,75,,,percent of total billed charges,75% of total billed charges,109.16,100,,,Fee Schedule,100% of CMS OPPS Rate,24.32,100,,,Fee Schedule,100% of WV Medicaid Rate,180.11,165,,,Fee Schedule,165% of CMS OPPS Rate,113.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,313.55,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,430.01,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,538.63,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,24.32,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,109.16,100,,,Fee Schedule,100% of CMS OPPS Rate,113.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,3.4,14,,,percent of total billed charges,14% of total billed charges,3.4,538.63,
Read,3575289,CDM,972,RC,93922,HCPCS,Outpatient,,,24.32,12.16,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
93923 - (26) Non-Invasive Physiologic Study Extremity 3 Lvls,3897032,CDM,983,RC,93923,HCPCS,Outpatient,,,44.56,22.28,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
93923 - Non-Invasive Physiologic Study Extremity 3 Lvls,3897046,CDM,510,RC,93923,HCPCS,Outpatient,,,44.56,22.28,,33.42,75,,,percent of total billed charges,75% of total billed charges,33.42,75,,,percent of total billed charges,75% of total billed charges,136.72,100,,,Fee Schedule,100% of CMS OPPS Rate,44.56,100,,,Fee Schedule,100% of WV Medicaid Rate,225.58,165,,,Fee Schedule,165% of CMS OPPS Rate,141.69,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,392.72,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,538.59,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,674.64,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,44.56,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,136.72,100,,,Fee Schedule,100% of CMS OPPS Rate,141.69,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,6.24,14,,,percent of total billed charges,14% of total billed charges,6.24,674.64,
93923- Upr/lxtr art stdy 3+ lvls,3430796,CDM,920,RC,93923,HCPCS,Outpatient,,,44.56,22.28,,33.42,75,,,percent of total billed charges,75% of total billed charges,33.42,75,,,percent of total billed charges,75% of total billed charges,136.72,100,,,Fee Schedule,100% of CMS OPPS Rate,44.56,100,,,Fee Schedule,100% of WV Medicaid Rate,225.58,165,,,Fee Schedule,165% of CMS OPPS Rate,141.69,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,392.72,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,538.59,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,674.64,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,44.56,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,136.72,100,,,Fee Schedule,100% of CMS OPPS Rate,141.69,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,6.24,14,,,percent of total billed charges,14% of total billed charges,6.24,674.64,
93923-CL Lower Extrem Art Physiologic BILAT,3432072,CDM,960,RC,93923,HCPCS,Outpatient,,,44.56,22.28,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
93923-CL Lower Extrem Art Physiologic LT,3432073,CDM,960,RC,93923,HCPCS,Outpatient,,,44.56,22.28,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
93923-CL Lower Extrem Art Physiologic RT,3432074,CDM,960,RC,93923,HCPCS,Outpatient,,,44.56,22.28,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
93923-CL Lower Periph Art Duplex wo Exer BILAT,3432075,CDM,960,RC,93923,HCPCS,Outpatient,,,44.56,22.28,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
93923-CL Lower Periph Art Duplex wo Exer LT,3432076,CDM,960,RC,93923,HCPCS,Outpatient,,,44.56,22.28,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
93923-CL Lower Periph Art Duplex wo Exer RT,3432077,CDM,960,RC,93923,HCPCS,Outpatient,,,44.56,22.28,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
93923-CL US Lower Extrem Art Comp w ABI BILAT,3432078,CDM,960,RC,93923,HCPCS,Outpatient,,,44.56,22.28,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
93923-CL US Lower Extrem Art Complete LT,3432079,CDM,960,RC,93923,HCPCS,Outpatient,,,44.56,22.28,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
93923-CL US Lower Extrem Art Complete RT,3432080,CDM,960,RC,93923,HCPCS,Outpatient,,,44.56,22.28,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
CL Lower Extrem Art Physiologic BILAT,3427525,CDM,921,RC,93923,HCPCS,Outpatient,,,44.56,22.28,,33.42,75,,,percent of total billed charges,75% of total billed charges,33.42,75,,,percent of total billed charges,75% of total billed charges,136.72,100,,,Fee Schedule,100% of CMS OPPS Rate,44.56,100,,,Fee Schedule,100% of WV Medicaid Rate,225.58,165,,,Fee Schedule,165% of CMS OPPS Rate,141.69,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,392.72,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,538.59,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,674.64,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,44.56,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,136.72,100,,,Fee Schedule,100% of CMS OPPS Rate,141.69,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,6.24,14,,,percent of total billed charges,14% of total billed charges,6.24,674.64,
CL Lower Extrem Art Physiologic LT,3427526,CDM,921,RC,93923,HCPCS,Outpatient,,,44.56,22.28,,33.42,75,,,percent of total billed charges,75% of total billed charges,33.42,75,,,percent of total billed charges,75% of total billed charges,136.72,100,,,Fee Schedule,100% of CMS OPPS Rate,44.56,100,,,Fee Schedule,100% of WV Medicaid Rate,225.58,165,,,Fee Schedule,165% of CMS OPPS Rate,141.69,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,392.72,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,538.59,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,674.64,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,44.56,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,136.72,100,,,Fee Schedule,100% of CMS OPPS Rate,141.69,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,6.24,14,,,percent of total billed charges,14% of total billed charges,6.24,674.64,
CL Lower Extrem Art Physiologic RT,3427527,CDM,921,RC,93923,HCPCS,Outpatient,,,44.56,22.28,,33.42,75,,,percent of total billed charges,75% of total billed charges,33.42,75,,,percent of total billed charges,75% of total billed charges,136.72,100,,,Fee Schedule,100% of CMS OPPS Rate,44.56,100,,,Fee Schedule,100% of WV Medicaid Rate,225.58,165,,,Fee Schedule,165% of CMS OPPS Rate,141.69,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,392.72,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,538.59,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,674.64,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,44.56,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,136.72,100,,,Fee Schedule,100% of CMS OPPS Rate,141.69,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,6.24,14,,,percent of total billed charges,14% of total billed charges,6.24,674.64,
CL Lower Periph Art Duplex wo Exer BILAT,3427532,CDM,921,RC,93923,HCPCS,Outpatient,,,44.56,22.28,,33.42,75,,,percent of total billed charges,75% of total billed charges,33.42,75,,,percent of total billed charges,75% of total billed charges,136.72,100,,,Fee Schedule,100% of CMS OPPS Rate,44.56,100,,,Fee Schedule,100% of WV Medicaid Rate,225.58,165,,,Fee Schedule,165% of CMS OPPS Rate,141.69,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,392.72,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,538.59,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,674.64,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,44.56,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,136.72,100,,,Fee Schedule,100% of CMS OPPS Rate,141.69,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,6.24,14,,,percent of total billed charges,14% of total billed charges,6.24,674.64,
CL Lower Periph Art Duplex wo Exer LT,3427528,CDM,921,RC,93923,HCPCS,Outpatient,,,44.56,22.28,,33.42,75,,,percent of total billed charges,75% of total billed charges,33.42,75,,,percent of total billed charges,75% of total billed charges,136.72,100,,,Fee Schedule,100% of CMS OPPS Rate,44.56,100,,,Fee Schedule,100% of WV Medicaid Rate,225.58,165,,,Fee Schedule,165% of CMS OPPS Rate,141.69,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,392.72,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,538.59,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,674.64,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,44.56,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,136.72,100,,,Fee Schedule,100% of CMS OPPS Rate,141.69,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,6.24,14,,,percent of total billed charges,14% of total billed charges,6.24,674.64,
CL Lower Periph Art Duplex wo Exer RT,3427530,CDM,921,RC,93923,HCPCS,Outpatient,,,44.56,22.28,,33.42,75,,,percent of total billed charges,75% of total billed charges,33.42,75,,,percent of total billed charges,75% of total billed charges,136.72,100,,,Fee Schedule,100% of CMS OPPS Rate,44.56,100,,,Fee Schedule,100% of WV Medicaid Rate,225.58,165,,,Fee Schedule,165% of CMS OPPS Rate,141.69,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,392.72,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,538.59,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,674.64,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,44.56,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,136.72,100,,,Fee Schedule,100% of CMS OPPS Rate,141.69,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,6.24,14,,,percent of total billed charges,14% of total billed charges,6.24,674.64,
CL US Lower Extrem Art Comp w ABI BILAT,3427501,CDM,921,RC,93923,HCPCS,Outpatient,,,44.56,22.28,,33.42,75,,,percent of total billed charges,75% of total billed charges,33.42,75,,,percent of total billed charges,75% of total billed charges,136.72,100,,,Fee Schedule,100% of CMS OPPS Rate,44.56,100,,,Fee Schedule,100% of WV Medicaid Rate,225.58,165,,,Fee Schedule,165% of CMS OPPS Rate,141.69,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,392.72,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,538.59,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,674.64,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,44.56,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,136.72,100,,,Fee Schedule,100% of CMS OPPS Rate,141.69,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,6.24,14,,,percent of total billed charges,14% of total billed charges,6.24,674.64,
CL US Lower Extrem Art Complete LT,3427503,CDM,921,RC,93923,HCPCS,Outpatient,,,44.56,22.28,,33.42,75,,,percent of total billed charges,75% of total billed charges,33.42,75,,,percent of total billed charges,75% of total billed charges,136.72,100,,,Fee Schedule,100% of CMS OPPS Rate,44.56,100,,,Fee Schedule,100% of WV Medicaid Rate,225.58,165,,,Fee Schedule,165% of CMS OPPS Rate,141.69,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,392.72,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,538.59,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,674.64,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,44.56,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,136.72,100,,,Fee Schedule,100% of CMS OPPS Rate,141.69,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,6.24,14,,,percent of total billed charges,14% of total billed charges,6.24,674.64,
CL US Lower Extrem Art Complete RT,3427505,CDM,921,RC,93923,HCPCS,Outpatient,,,44.56,22.28,,33.42,75,,,percent of total billed charges,75% of total billed charges,33.42,75,,,percent of total billed charges,75% of total billed charges,136.72,100,,,Fee Schedule,100% of CMS OPPS Rate,44.56,100,,,Fee Schedule,100% of WV Medicaid Rate,225.58,165,,,Fee Schedule,165% of CMS OPPS Rate,141.69,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,392.72,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,538.59,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,674.64,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,44.56,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,136.72,100,,,Fee Schedule,100% of CMS OPPS Rate,141.69,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,6.24,14,,,percent of total billed charges,14% of total billed charges,6.24,674.64,
Read,3569752,CDM,972,RC,93923,HCPCS,Outpatient,,,44.56,22.28,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
SCSN US Arterial w Seg Pressures BILAT,3575259,CDM,972,RC,93923,HCPCS,Outpatient,,,44.56,22.28,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
US ABI Complete,3345454,CDM,921,RC,93923,HCPCS,Outpatient,,,44.56,22.28,,33.42,75,,,percent of total billed charges,75% of total billed charges,33.42,75,,,percent of total billed charges,75% of total billed charges,136.72,100,,,Fee Schedule,100% of CMS OPPS Rate,44.56,100,,,Fee Schedule,100% of WV Medicaid Rate,225.58,165,,,Fee Schedule,165% of CMS OPPS Rate,141.69,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,392.72,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,538.59,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,674.64,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,44.56,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,136.72,100,,,Fee Schedule,100% of CMS OPPS Rate,141.69,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,6.24,14,,,percent of total billed charges,14% of total billed charges,6.24,674.64,
93924 - Lwr xtr vasc stdy bilat,3435544,CDM,921,RC,93924,HCPCS,Outpatient,,,48.63,24.32,,36.47,75,,,percent of total billed charges,75% of total billed charges,36.47,75,,,percent of total billed charges,75% of total billed charges,263.29,100,,,Fee Schedule,100% of CMS OPPS Rate,48.63,100,,,Fee Schedule,100% of WV Medicaid Rate,434.44,165,,,Fee Schedule,165% of CMS OPPS Rate,272.88,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,756.29,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1037.2,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1299.2,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,48.63,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,263.29,100,,,Fee Schedule,100% of CMS OPPS Rate,272.88,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,6.81,14,,,percent of total billed charges,14% of total billed charges,6.81,1299.2,
93924-CL Lower Periph Art Duplex w Exer BILAT,3432081,CDM,960,RC,93924,HCPCS,Outpatient,,,48.63,24.32,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
93924-CL Lower Periph Art Duplex w Exer LT,3432082,CDM,960,RC,93924,HCPCS,Outpatient,,,48.63,24.32,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
93924-CL Lower Periph Art Duplex w Exer RT,3432083,CDM,960,RC,93924,HCPCS,Outpatient,,,48.63,24.32,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
CL Lower Ext Art Physio w Exer BILAT,3569307,CDM,921,RC,93924,HCPCS,Outpatient,,,48.63,24.32,,36.47,75,,,percent of total billed charges,75% of total billed charges,36.47,75,,,percent of total billed charges,75% of total billed charges,263.29,100,,,Fee Schedule,100% of CMS OPPS Rate,48.63,100,,,Fee Schedule,100% of WV Medicaid Rate,434.44,165,,,Fee Schedule,165% of CMS OPPS Rate,272.88,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,756.29,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1037.2,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1299.2,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,48.63,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,263.29,100,,,Fee Schedule,100% of CMS OPPS Rate,272.88,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,6.81,14,,,percent of total billed charges,14% of total billed charges,6.81,1299.2,
CL Lower Periph Art Duplex w Exer BILAT,3427533,CDM,921,RC,93924,HCPCS,Outpatient,,,48.63,24.32,,36.47,75,,,percent of total billed charges,75% of total billed charges,36.47,75,,,percent of total billed charges,75% of total billed charges,263.29,100,,,Fee Schedule,100% of CMS OPPS Rate,48.63,100,,,Fee Schedule,100% of WV Medicaid Rate,434.44,165,,,Fee Schedule,165% of CMS OPPS Rate,272.88,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,756.29,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1037.2,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1299.2,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,48.63,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,263.29,100,,,Fee Schedule,100% of CMS OPPS Rate,272.88,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,6.81,14,,,percent of total billed charges,14% of total billed charges,6.81,1299.2,
CL Lower Periph Art Duplex w Exer LT,3427529,CDM,921,RC,93924,HCPCS,Outpatient,,,48.63,24.32,,36.47,75,,,percent of total billed charges,75% of total billed charges,36.47,75,,,percent of total billed charges,75% of total billed charges,263.29,100,,,Fee Schedule,100% of CMS OPPS Rate,48.63,100,,,Fee Schedule,100% of WV Medicaid Rate,434.44,165,,,Fee Schedule,165% of CMS OPPS Rate,272.88,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,756.29,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1037.2,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1299.2,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,48.63,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,263.29,100,,,Fee Schedule,100% of CMS OPPS Rate,272.88,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,6.81,14,,,percent of total billed charges,14% of total billed charges,6.81,1299.2,
CL Lower Periph Art Duplex w Exer RT,3427531,CDM,921,RC,93924,HCPCS,Outpatient,,,48.63,24.32,,36.47,75,,,percent of total billed charges,75% of total billed charges,36.47,75,,,percent of total billed charges,75% of total billed charges,263.29,100,,,Fee Schedule,100% of CMS OPPS Rate,48.63,100,,,Fee Schedule,100% of WV Medicaid Rate,434.44,165,,,Fee Schedule,165% of CMS OPPS Rate,272.88,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,756.29,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1037.2,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1299.2,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,48.63,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,263.29,100,,,Fee Schedule,100% of CMS OPPS Rate,272.88,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,6.81,14,,,percent of total billed charges,14% of total billed charges,6.81,1299.2,
SCSN US Arterial w Exercise RT Interp,3575269,CDM,972,RC,93924,HCPCS,Outpatient,,,48.63,24.32,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
SCSN US Arterials w Exercise Bilat Interp,3575265,CDM,972,RC,93924,HCPCS,Outpatient,,,48.63,24.32,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
SCSN US Arterials w Exercise LT Interp,3575267,CDM,972,RC,93924,HCPCS,Outpatient,,,48.63,24.32,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
US Lower Ext Arterial Bilat Limited:Read,3374595,CDM,972,RC,93925,HCPCS,Outpatient,,,488.44,244.22,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
93926 - Duplex scan of lower extremity arteries or arterial bypass grafts; unilateral or limited,3620984,CDM,510,RC,93926,HCPCS,Outpatient,,,47.11,23.56,,35.33,75,,,percent of total billed charges,75% of total billed charges,35.33,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,47.11,100,,,Fee Schedule,100% of WV Medicaid Rate,165.79,165,,,Fee Schedule,165% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.82,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,47.11,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,6.6,14,,,percent of total billed charges,14% of total billed charges,6.6,495.81,
93926 (26) Duplex scan of lower extremity arteries or arterial bypass grafts; unilateral or limited,3620983,CDM,510,RC,93926,HCPCS,Outpatient,,,47.11,23.56,,35.33,75,,,percent of total billed charges,75% of total billed charges,35.33,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,47.11,100,,,Fee Schedule,100% of WV Medicaid Rate,165.79,165,,,Fee Schedule,165% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.82,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,47.11,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,6.6,14,,,percent of total billed charges,14% of total billed charges,6.6,495.81,
93926- Dup scan/LE art/graft/unilat/ltd,3435546,CDM,921,RC,93926,HCPCS,Outpatient,,,47.11,23.56,,35.33,75,,,percent of total billed charges,75% of total billed charges,35.33,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,47.11,100,,,Fee Schedule,100% of WV Medicaid Rate,165.79,165,,,Fee Schedule,165% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.82,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,47.11,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,6.6,14,,,percent of total billed charges,14% of total billed charges,6.6,495.81,
93926-CL Femoral Groin Artery BILAT,3432084,CDM,960,RC,93926,HCPCS,Outpatient,,,47.11,23.56,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
93926-CL Femoral Groin Artery LT,3432085,CDM,960,RC,93926,HCPCS,Outpatient,,,47.11,23.56,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
93926-CL Femoral Groin Artery RT,3432086,CDM,960,RC,93926,HCPCS,Outpatient,,,47.11,23.56,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
CL Femoral Groin Artery BILAT,3427521,CDM,921,RC,93926,HCPCS,Outpatient,,,47.11,23.56,,35.33,75,,,percent of total billed charges,75% of total billed charges,35.33,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,47.11,100,,,Fee Schedule,100% of WV Medicaid Rate,165.79,165,,,Fee Schedule,165% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.82,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,47.11,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,6.6,14,,,percent of total billed charges,14% of total billed charges,6.6,495.81,
CL Femoral Groin Artery LT,3427519,CDM,921,RC,93926,HCPCS,Outpatient,,,47.11,23.56,,35.33,75,,,percent of total billed charges,75% of total billed charges,35.33,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,47.11,100,,,Fee Schedule,100% of WV Medicaid Rate,165.79,165,,,Fee Schedule,165% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.82,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,47.11,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,6.6,14,,,percent of total billed charges,14% of total billed charges,6.6,495.81,
CL Femoral Groin Artery RT,3427520,CDM,921,RC,93926,HCPCS,Outpatient,,,47.11,23.56,,35.33,75,,,percent of total billed charges,75% of total billed charges,35.33,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,47.11,100,,,Fee Schedule,100% of WV Medicaid Rate,165.79,165,,,Fee Schedule,165% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.82,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,47.11,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,6.6,14,,,percent of total billed charges,14% of total billed charges,6.6,495.81,
Read,3374599,CDM,972,RC,93926,HCPCS,Outpatient,,,47.11,23.56,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
Read,3374603,CDM,972,RC,93926,HCPCS,Outpatient,,,47.11,23.56,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
Read,3575243,CDM,972,RC,93926,HCPCS,Outpatient,,,47.11,23.56,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
SCSN US Arterial w Seg Pressures LT,3575263,CDM,972,RC,93926,HCPCS,Outpatient,,,47.11,23.56,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
US Duplex Limited Lower,3345452,CDM,921,RC,93926,HCPCS,Outpatient,,,47.11,23.56,,35.33,75,,,percent of total billed charges,75% of total billed charges,35.33,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,47.11,100,,,Fee Schedule,100% of WV Medicaid Rate,165.79,165,,,Fee Schedule,165% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.82,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,47.11,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,6.6,14,,,percent of total billed charges,14% of total billed charges,6.6,495.81,
US Lower Ext Arterial Lt Complete:Read,3374597,CDM,972,RC,93926,HCPCS,Outpatient,,,47.11,23.56,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
US Lower Ext Arterial Rt Complete:Read,3374601,CDM,510,RC,93926,HCPCS,Outpatient,,,47.11,23.56,,35.33,75,,,percent of total billed charges,75% of total billed charges,35.33,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,47.11,100,,,Fee Schedule,100% of WV Medicaid Rate,165.79,165,,,Fee Schedule,165% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.82,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,47.11,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,6.6,14,,,percent of total billed charges,14% of total billed charges,6.6,495.81,
US Lower Ext Arterial Rt Limited:Read,630811,CDM,972,RC,93926,HCPCS,Outpatient,,,47.11,23.56,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
US Upper Ext Arterial Bilat Complete-Read,3351993,CDM,972,RC,93930,HCPCS,Outpatient,,,378.7,189.35,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
Read,3351997,CDM,972,RC,93931,HCPCS,Outpatient,,,240.67,120.34,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
Read,3352001,CDM,972,RC,93931,HCPCS,Outpatient,,,240.67,120.34,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
Read,3352003,CDM,972,RC,93931,HCPCS,Outpatient,,,240.67,120.34,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
93970 26 Duplex scan of extremity veins including response,3621410,CDM,960,RC,93970,HCPCS,Outpatient,,,66.72,33.36,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
93970- Dup scan/extremity vein/bilat/comp,3435549,CDM,921,RC,93970,HCPCS,Outpatient,,,66.72,33.36,,50.04,75,,,percent of total billed charges,75% of total billed charges,50.04,75,,,percent of total billed charges,75% of total billed charges,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,66.72,100,,,Fee Schedule,100% of WV Medicaid Rate,362.24,165,,,Fee Schedule,165% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,630.61,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,864.84,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1083.29,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,66.72,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,9.34,14,,,percent of total billed charges,14% of total billed charges,9.34,1083.29,
93970-CL Periph Venous US Lower BILAT,3432087,CDM,481,RC,93970,HCPCS,Outpatient,,,66.72,33.36,,50.04,75,,,percent of total billed charges,75% of total billed charges,50.04,75,,,percent of total billed charges,75% of total billed charges,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,66.72,100,,,Fee Schedule,100% of WV Medicaid Rate,362.24,165,,,Fee Schedule,165% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,630.61,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,864.84,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1083.29,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,66.72,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,9.34,14,,,percent of total billed charges,14% of total billed charges,9.34,1083.29,
93970-CL Periph Venous US Upper BILAT,3432088,CDM,481,RC,93970,HCPCS,Outpatient,,,66.72,33.36,,50.04,75,,,percent of total billed charges,75% of total billed charges,50.04,75,,,percent of total billed charges,75% of total billed charges,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,66.72,100,,,Fee Schedule,100% of WV Medicaid Rate,362.24,165,,,Fee Schedule,165% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,630.61,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,864.84,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1083.29,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,66.72,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,9.34,14,,,percent of total billed charges,14% of total billed charges,9.34,1083.29,
93970-CL Upper Periph Arterial Duplex BILAT,3432089,CDM,481,RC,93970,HCPCS,Outpatient,,,66.72,33.36,,50.04,75,,,percent of total billed charges,75% of total billed charges,50.04,75,,,percent of total billed charges,75% of total billed charges,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,66.72,100,,,Fee Schedule,100% of WV Medicaid Rate,362.24,165,,,Fee Schedule,165% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,630.61,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,864.84,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1083.29,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,66.72,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,9.34,14,,,percent of total billed charges,14% of total billed charges,9.34,1083.29,
93970-CL US Vein Map Mark Lower Extrem BILAT,3432090,CDM,481,RC,93970,HCPCS,Outpatient,,,66.72,33.36,,50.04,75,,,percent of total billed charges,75% of total billed charges,50.04,75,,,percent of total billed charges,75% of total billed charges,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,66.72,100,,,Fee Schedule,100% of WV Medicaid Rate,362.24,165,,,Fee Schedule,165% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,630.61,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,864.84,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1083.29,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,66.72,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,9.34,14,,,percent of total billed charges,14% of total billed charges,9.34,1083.29,
93970-CL US Vein Map Mark Upper Extrem BILAT,3432091,CDM,481,RC,93970,HCPCS,Outpatient,,,66.72,33.36,,50.04,75,,,percent of total billed charges,75% of total billed charges,50.04,75,,,percent of total billed charges,75% of total billed charges,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,66.72,100,,,Fee Schedule,100% of WV Medicaid Rate,362.24,165,,,Fee Schedule,165% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,630.61,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,864.84,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1083.29,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,66.72,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,9.34,14,,,percent of total billed charges,14% of total billed charges,9.34,1083.29,
93970-CL US Venous Insuff Lower Extrem BILAT,3432092,CDM,481,RC,93970,HCPCS,Outpatient,,,66.72,33.36,,50.04,75,,,percent of total billed charges,75% of total billed charges,50.04,75,,,percent of total billed charges,75% of total billed charges,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,66.72,100,,,Fee Schedule,100% of WV Medicaid Rate,362.24,165,,,Fee Schedule,165% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,630.61,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,864.84,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1083.29,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,66.72,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,9.34,14,,,percent of total billed charges,14% of total billed charges,9.34,1083.29,
93970-CL US Venous Insuff Upper Extrem BILAT,3432093,CDM,481,RC,93970,HCPCS,Outpatient,,,66.72,33.36,,50.04,75,,,percent of total billed charges,75% of total billed charges,50.04,75,,,percent of total billed charges,75% of total billed charges,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,66.72,100,,,Fee Schedule,100% of WV Medicaid Rate,362.24,165,,,Fee Schedule,165% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,630.61,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,864.84,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1083.29,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,66.72,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,9.34,14,,,percent of total billed charges,14% of total billed charges,9.34,1083.29,
CL Periph Venous US Lower BILAT,3427536,CDM,921,RC,93970,HCPCS,Outpatient,,,66.72,33.36,,50.04,75,,,percent of total billed charges,75% of total billed charges,50.04,75,,,percent of total billed charges,75% of total billed charges,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,66.72,100,,,Fee Schedule,100% of WV Medicaid Rate,362.24,165,,,Fee Schedule,165% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,630.61,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,864.84,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1083.29,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,66.72,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,9.34,14,,,percent of total billed charges,14% of total billed charges,9.34,1083.29,
CL Periph Venous US Upper BILAT,3427537,CDM,921,RC,93970,HCPCS,Outpatient,,,66.72,33.36,,50.04,75,,,percent of total billed charges,75% of total billed charges,50.04,75,,,percent of total billed charges,75% of total billed charges,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,66.72,100,,,Fee Schedule,100% of WV Medicaid Rate,362.24,165,,,Fee Schedule,165% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,630.61,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,864.84,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1083.29,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,66.72,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,9.34,14,,,percent of total billed charges,14% of total billed charges,9.34,1083.29,
CL Upper Periph Arterial Duplex BILAT,3427571,CDM,921,RC,93970,HCPCS,Outpatient,,,66.72,33.36,,50.04,75,,,percent of total billed charges,75% of total billed charges,50.04,75,,,percent of total billed charges,75% of total billed charges,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,66.72,100,,,Fee Schedule,100% of WV Medicaid Rate,362.24,165,,,Fee Schedule,165% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,630.61,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,864.84,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1083.29,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,66.72,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,9.34,14,,,percent of total billed charges,14% of total billed charges,9.34,1083.29,
CL US Vein Map Mark Lower Extrem BILAT,3427463,CDM,921,RC,93970,HCPCS,Outpatient,,,66.72,33.36,,50.04,75,,,percent of total billed charges,75% of total billed charges,50.04,75,,,percent of total billed charges,75% of total billed charges,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,66.72,100,,,Fee Schedule,100% of WV Medicaid Rate,362.24,165,,,Fee Schedule,165% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,630.61,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,864.84,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1083.29,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,66.72,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,9.34,14,,,percent of total billed charges,14% of total billed charges,9.34,1083.29,
CL US Vein Map Mark Upper Extrem BILAT,3427498,CDM,921,RC,93970,HCPCS,Outpatient,,,66.72,33.36,,50.04,75,,,percent of total billed charges,75% of total billed charges,50.04,75,,,percent of total billed charges,75% of total billed charges,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,66.72,100,,,Fee Schedule,100% of WV Medicaid Rate,362.24,165,,,Fee Schedule,165% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,630.61,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,864.84,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1083.29,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,66.72,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,9.34,14,,,percent of total billed charges,14% of total billed charges,9.34,1083.29,
CL US Venous Insuff Lower Extrem BILAT,3427507,CDM,921,RC,93970,HCPCS,Outpatient,,,66.72,33.36,,50.04,75,,,percent of total billed charges,75% of total billed charges,50.04,75,,,percent of total billed charges,75% of total billed charges,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,66.72,100,,,Fee Schedule,100% of WV Medicaid Rate,362.24,165,,,Fee Schedule,165% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,630.61,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,864.84,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1083.29,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,66.72,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,9.34,14,,,percent of total billed charges,14% of total billed charges,9.34,1083.29,
CL US Venous Insuff Upper Extrem BILAT,3427510,CDM,921,RC,93970,HCPCS,Outpatient,,,66.72,33.36,,50.04,75,,,percent of total billed charges,75% of total billed charges,50.04,75,,,percent of total billed charges,75% of total billed charges,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,66.72,100,,,Fee Schedule,100% of WV Medicaid Rate,362.24,165,,,Fee Schedule,165% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,630.61,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,864.84,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1083.29,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,66.72,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,9.34,14,,,percent of total billed charges,14% of total billed charges,9.34,1083.29,
Read,596573,CDM,972,RC,93970,HCPCS,Outpatient,,,66.72,33.36,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
Read,1257041,CDM,972,RC,93970,HCPCS,Outpatient,,,66.72,33.36,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
Read,3352011,CDM,972,RC,93970,HCPCS,Outpatient,,,66.72,33.36,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
Read,3370918,CDM,972,RC,93970,HCPCS,Outpatient,,,66.72,33.36,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
Read,3370921,CDM,972,RC,93970,HCPCS,Outpatient,,,66.72,33.36,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
Read,3569776,CDM,972,RC,93970,HCPCS,Outpatient,,,66.72,33.36,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
Read,3569782,CDM,972,RC,93970,HCPCS,Outpatient,,,66.72,33.36,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
Read,3569788,CDM,972,RC,93970,HCPCS,Outpatient,,,66.72,33.36,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
US Extremity Complete Bilat Lower for DVT:Read,3347590,CDM,972,RC,93970,HCPCS,Outpatient,,,66.72,33.36,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
US Extremity Complete Bilat Upper for DVT:Read,3347592,CDM,972,RC,93970,HCPCS,Outpatient,,,66.72,33.36,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
US Lower Ext Arterial Bilat Complete-Read,3374593,CDM,972,RC,93970,HCPCS,Outpatient,,,66.72,33.36,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
93971 - PF Duplex scan of extremity veins including responses to compression and other maneuvers; un,3641198,CDM,960,RC,93971,HCPCS,Outpatient,,,42.4,21.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
93971 (26) Duplex scan of extremity veins including responses to compression and other maneuvers; un,3620981,CDM,960,RC,93971,HCPCS,Outpatient,,,42.4,21.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
93971- Dup scan/extremity vein/unilat/ltd,3435550,CDM,921,RC,93971,HCPCS,Outpatient,,,42.4,21.2,,31.8,75,,,percent of total billed charges,75% of total billed charges,31.8,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,42.4,100,,,Fee Schedule,100% of WV Medicaid Rate,165.79,165,,,Fee Schedule,165% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.82,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,42.4,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,5.94,14,,,percent of total billed charges,14% of total billed charges,5.94,495.81,
93971 -Duplex scan of extremity veins including responses to compression and other maneuvers; unilat,3641196,CDM,510,RC,93971,HCPCS,Outpatient,,,42.4,21.2,,31.8,75,,,percent of total billed charges,75% of total billed charges,31.8,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,42.4,100,,,Fee Schedule,100% of WV Medicaid Rate,165.79,165,,,Fee Schedule,165% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.82,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,42.4,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,5.94,14,,,percent of total billed charges,14% of total billed charges,5.94,495.81,
93971-CL Periph Venous US Lower LT,3432094,CDM,921,RC,93971,HCPCS,Outpatient,,,42.4,21.2,,31.8,75,,,percent of total billed charges,75% of total billed charges,31.8,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,42.4,100,,,Fee Schedule,100% of WV Medicaid Rate,165.79,165,,,Fee Schedule,165% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.82,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,42.4,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,5.94,14,,,percent of total billed charges,14% of total billed charges,5.94,495.81,
93971-CL Periph Venous US Lower RT,3432095,CDM,921,RC,93971,HCPCS,Outpatient,,,42.4,21.2,,31.8,75,,,percent of total billed charges,75% of total billed charges,31.8,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,42.4,100,,,Fee Schedule,100% of WV Medicaid Rate,165.79,165,,,Fee Schedule,165% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.82,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,42.4,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,5.94,14,,,percent of total billed charges,14% of total billed charges,5.94,495.81,
93971-CL Periph Venous US Upper LT,3432096,CDM,921,RC,93971,HCPCS,Outpatient,,,42.4,21.2,,31.8,75,,,percent of total billed charges,75% of total billed charges,31.8,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,42.4,100,,,Fee Schedule,100% of WV Medicaid Rate,165.79,165,,,Fee Schedule,165% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.82,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,42.4,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,5.94,14,,,percent of total billed charges,14% of total billed charges,5.94,495.81,
93971-CL Periph Venous US Upper RT,3432097,CDM,921,RC,93971,HCPCS,Outpatient,,,42.4,21.2,,31.8,75,,,percent of total billed charges,75% of total billed charges,31.8,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,42.4,100,,,Fee Schedule,100% of WV Medicaid Rate,165.79,165,,,Fee Schedule,165% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.82,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,42.4,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,5.94,14,,,percent of total billed charges,14% of total billed charges,5.94,495.81,
93971-CL Upper Periph Arterial Duplex LT,3432098,CDM,921,RC,93971,HCPCS,Outpatient,,,42.4,21.2,,31.8,75,,,percent of total billed charges,75% of total billed charges,31.8,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,42.4,100,,,Fee Schedule,100% of WV Medicaid Rate,165.79,165,,,Fee Schedule,165% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.82,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,42.4,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,5.94,14,,,percent of total billed charges,14% of total billed charges,5.94,495.81,
93971-CL Upper Periph Arterial Duplex RT,3432099,CDM,921,RC,93971,HCPCS,Outpatient,,,42.4,21.2,,31.8,75,,,percent of total billed charges,75% of total billed charges,31.8,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,42.4,100,,,Fee Schedule,100% of WV Medicaid Rate,165.79,165,,,Fee Schedule,165% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.82,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,42.4,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,5.94,14,,,percent of total billed charges,14% of total billed charges,5.94,495.81,
93971-CL US Vein Map Mark Lower Extrem LT,3432100,CDM,921,RC,93971,HCPCS,Outpatient,,,42.4,21.2,,31.8,75,,,percent of total billed charges,75% of total billed charges,31.8,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,42.4,100,,,Fee Schedule,100% of WV Medicaid Rate,165.79,165,,,Fee Schedule,165% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.82,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,42.4,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,5.94,14,,,percent of total billed charges,14% of total billed charges,5.94,495.81,
93971-CL US Vein Map Mark Lower Extrem RT,3432101,CDM,921,RC,93971,HCPCS,Outpatient,,,42.4,21.2,,31.8,75,,,percent of total billed charges,75% of total billed charges,31.8,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,42.4,100,,,Fee Schedule,100% of WV Medicaid Rate,165.79,165,,,Fee Schedule,165% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.82,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,42.4,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,5.94,14,,,percent of total billed charges,14% of total billed charges,5.94,495.81,
93971-CL US Vein Map Mark Upper Extrem LT,3432102,CDM,921,RC,93971,HCPCS,Outpatient,,,42.4,21.2,,31.8,75,,,percent of total billed charges,75% of total billed charges,31.8,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,42.4,100,,,Fee Schedule,100% of WV Medicaid Rate,165.79,165,,,Fee Schedule,165% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.82,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,42.4,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,5.94,14,,,percent of total billed charges,14% of total billed charges,5.94,495.81,
93971-CL US Vein Map Mark Upper Extrem RT,3432103,CDM,921,RC,93971,HCPCS,Outpatient,,,42.4,21.2,,31.8,75,,,percent of total billed charges,75% of total billed charges,31.8,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,42.4,100,,,Fee Schedule,100% of WV Medicaid Rate,165.79,165,,,Fee Schedule,165% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.82,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,42.4,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,5.94,14,,,percent of total billed charges,14% of total billed charges,5.94,495.81,
93971-CL US Venous Insuff Lower Extrem LT,3432104,CDM,921,RC,93971,HCPCS,Outpatient,,,42.4,21.2,,31.8,75,,,percent of total billed charges,75% of total billed charges,31.8,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,42.4,100,,,Fee Schedule,100% of WV Medicaid Rate,165.79,165,,,Fee Schedule,165% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.82,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,42.4,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,5.94,14,,,percent of total billed charges,14% of total billed charges,5.94,495.81,
93971-CL US Venous Insuff Lower Extrem RT,3432105,CDM,921,RC,93971,HCPCS,Outpatient,,,42.4,21.2,,31.8,75,,,percent of total billed charges,75% of total billed charges,31.8,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,42.4,100,,,Fee Schedule,100% of WV Medicaid Rate,165.79,165,,,Fee Schedule,165% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.82,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,42.4,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,5.94,14,,,percent of total billed charges,14% of total billed charges,5.94,495.81,
93971-CL US Venous Insuff Upper Extrem LT,3432106,CDM,921,RC,93971,HCPCS,Outpatient,,,42.4,21.2,,31.8,75,,,percent of total billed charges,75% of total billed charges,31.8,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,42.4,100,,,Fee Schedule,100% of WV Medicaid Rate,165.79,165,,,Fee Schedule,165% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.82,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,42.4,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,5.94,14,,,percent of total billed charges,14% of total billed charges,5.94,495.81,
93971-CL US Venous Insuff Upper Extrem RT,3432107,CDM,921,RC,93971,HCPCS,Outpatient,,,42.4,21.2,,31.8,75,,,percent of total billed charges,75% of total billed charges,31.8,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,42.4,100,,,Fee Schedule,100% of WV Medicaid Rate,165.79,165,,,Fee Schedule,165% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.82,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,42.4,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,5.94,14,,,percent of total billed charges,14% of total billed charges,5.94,495.81,
93971-PF DUP-SCAN XTR VEINS UNILATERAL/LIMITED STUDY,4321510,CDM,981,RC,93971,HCPCS,Outpatient,,,42.4,21.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
CL Periph Venous US Lower LT,3427534,CDM,921,RC,93971,HCPCS,Outpatient,,,42.4,21.2,,31.8,75,,,percent of total billed charges,75% of total billed charges,31.8,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,42.4,100,,,Fee Schedule,100% of WV Medicaid Rate,165.79,165,,,Fee Schedule,165% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.82,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,42.4,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,5.94,14,,,percent of total billed charges,14% of total billed charges,5.94,495.81,
CL Periph Venous US Lower RT,3427535,CDM,921,RC,93971,HCPCS,Outpatient,,,42.4,21.2,,31.8,75,,,percent of total billed charges,75% of total billed charges,31.8,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,42.4,100,,,Fee Schedule,100% of WV Medicaid Rate,165.79,165,,,Fee Schedule,165% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.82,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,42.4,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,5.94,14,,,percent of total billed charges,14% of total billed charges,5.94,495.81,
CL Periph Venous US Upper LT,3427538,CDM,921,RC,93971,HCPCS,Outpatient,,,42.4,21.2,,31.8,75,,,percent of total billed charges,75% of total billed charges,31.8,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,42.4,100,,,Fee Schedule,100% of WV Medicaid Rate,165.79,165,,,Fee Schedule,165% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.82,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,42.4,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,5.94,14,,,percent of total billed charges,14% of total billed charges,5.94,495.81,
CL Periph Venous US Upper RT,3427569,CDM,921,RC,93971,HCPCS,Outpatient,,,42.4,21.2,,31.8,75,,,percent of total billed charges,75% of total billed charges,31.8,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,42.4,100,,,Fee Schedule,100% of WV Medicaid Rate,165.79,165,,,Fee Schedule,165% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.82,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,42.4,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,5.94,14,,,percent of total billed charges,14% of total billed charges,5.94,495.81,
CL Upper Periph Arterial Duplex LT,3427572,CDM,921,RC,93971,HCPCS,Outpatient,,,42.4,21.2,,31.8,75,,,percent of total billed charges,75% of total billed charges,31.8,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,42.4,100,,,Fee Schedule,100% of WV Medicaid Rate,165.79,165,,,Fee Schedule,165% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.82,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,42.4,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,5.94,14,,,percent of total billed charges,14% of total billed charges,5.94,495.81,
CL Upper Periph Arterial Duplex RT,3427570,CDM,921,RC,93971,HCPCS,Outpatient,,,42.4,21.2,,31.8,75,,,percent of total billed charges,75% of total billed charges,31.8,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,42.4,100,,,Fee Schedule,100% of WV Medicaid Rate,165.79,165,,,Fee Schedule,165% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.82,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,42.4,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,5.94,14,,,percent of total billed charges,14% of total billed charges,5.94,495.81,
CL US Vein Map Mark Lower Extrem LT,3427464,CDM,921,RC,93971,HCPCS,Outpatient,,,42.4,21.2,,31.8,75,,,percent of total billed charges,75% of total billed charges,31.8,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,42.4,100,,,Fee Schedule,100% of WV Medicaid Rate,165.79,165,,,Fee Schedule,165% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.82,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,42.4,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,5.94,14,,,percent of total billed charges,14% of total billed charges,5.94,495.81,
CL US Vein Map Mark Lower Extrem RT,3427497,CDM,921,RC,93971,HCPCS,Outpatient,,,42.4,21.2,,31.8,75,,,percent of total billed charges,75% of total billed charges,31.8,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,42.4,100,,,Fee Schedule,100% of WV Medicaid Rate,165.79,165,,,Fee Schedule,165% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.82,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,42.4,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,5.94,14,,,percent of total billed charges,14% of total billed charges,5.94,495.81,
CL US Vein Map Mark Upper Extrem LT,3427499,CDM,921,RC,93971,HCPCS,Outpatient,,,42.4,21.2,,31.8,75,,,percent of total billed charges,75% of total billed charges,31.8,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,42.4,100,,,Fee Schedule,100% of WV Medicaid Rate,165.79,165,,,Fee Schedule,165% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.82,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,42.4,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,5.94,14,,,percent of total billed charges,14% of total billed charges,5.94,495.81,
CL US Vein Map Mark Upper Extrem RT,3427500,CDM,921,RC,93971,HCPCS,Outpatient,,,42.4,21.2,,31.8,75,,,percent of total billed charges,75% of total billed charges,31.8,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,42.4,100,,,Fee Schedule,100% of WV Medicaid Rate,165.79,165,,,Fee Schedule,165% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.82,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,42.4,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,5.94,14,,,percent of total billed charges,14% of total billed charges,5.94,495.81,
CL US Venous Insuff Lower Extrem LT,3427508,CDM,921,RC,93971,HCPCS,Outpatient,,,42.4,21.2,,31.8,75,,,percent of total billed charges,75% of total billed charges,31.8,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,42.4,100,,,Fee Schedule,100% of WV Medicaid Rate,165.79,165,,,Fee Schedule,165% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.82,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,42.4,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,5.94,14,,,percent of total billed charges,14% of total billed charges,5.94,495.81,
CL US Venous Insuff Lower Extrem RT,3427509,CDM,921,RC,93971,HCPCS,Outpatient,,,42.4,21.2,,31.8,75,,,percent of total billed charges,75% of total billed charges,31.8,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,42.4,100,,,Fee Schedule,100% of WV Medicaid Rate,165.79,165,,,Fee Schedule,165% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.82,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,42.4,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,5.94,14,,,percent of total billed charges,14% of total billed charges,5.94,495.81,
CL US Venous Insuff Upper Extrem LT,3427511,CDM,921,RC,93971,HCPCS,Outpatient,,,42.4,21.2,,31.8,75,,,percent of total billed charges,75% of total billed charges,31.8,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,42.4,100,,,Fee Schedule,100% of WV Medicaid Rate,165.79,165,,,Fee Schedule,165% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.82,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,42.4,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,5.94,14,,,percent of total billed charges,14% of total billed charges,5.94,495.81,
CL US Venous Insuff Upper Extrem RT,3427512,CDM,921,RC,93971,HCPCS,Outpatient,,,42.4,21.2,,31.8,75,,,percent of total billed charges,75% of total billed charges,31.8,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,42.4,100,,,Fee Schedule,100% of WV Medicaid Rate,165.79,165,,,Fee Schedule,165% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.82,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,42.4,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,5.94,14,,,percent of total billed charges,14% of total billed charges,5.94,495.81,
Read,596567,CDM,972,RC,93971,HCPCS,Outpatient,,,42.4,21.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
Read,1257043,CDM,972,RC,93971,HCPCS,Outpatient,,,42.4,21.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
Read,1257045,CDM,972,RC,93971,HCPCS,Outpatient,,,42.4,21.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
Read,3352009,CDM,972,RC,93971,HCPCS,Outpatient,,,42.4,21.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
Read,3352013,CDM,972,RC,93971,HCPCS,Outpatient,,,42.4,21.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
Read,3352015,CDM,972,RC,93971,HCPCS,Outpatient,,,66.72,33.36,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
Read,3352017,CDM,972,RC,93971,HCPCS,Outpatient,,,42.4,21.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
Read,3352019,CDM,972,RC,93971,HCPCS,Outpatient,,,42.4,21.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
Read,3352021,CDM,972,RC,93971,HCPCS,Outpatient,,,42.4,21.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
Read,,,972,RC,93971,HCPCS,Outpatient,,,42.4,21.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
Read,3370951,CDM,972,RC,93971,HCPCS,Outpatient,,,42.4,21.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
Read,3370953,CDM,972,RC,93971,HCPCS,Outpatient,,,42.4,21.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
Read,3575295,CDM,972,RC,93971,HCPCS,Outpatient,,,42.4,21.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
Read,3575297,CDM,972,RC,93971,HCPCS,Outpatient,,,42.4,21.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
US Extremity Vein Unilat Lt Lower for DVT:Read,3347594,CDM,972,RC,93971,HCPCS,Outpatient,,,42.4,21.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
US Extremity Vein Unilat Lt Upper for DVT:Read,3347596,CDM,972,RC,93971,HCPCS,Outpatient,,,42.4,21.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
US Extremity Vein Unilat Rt Lower for DVT:Read,3347598,CDM,972,RC,93971,HCPCS,Outpatient,,,42.4,21.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
US Extremity Vein Unilat Rt Upper for DVT:Read,3347600,CDM,972,RC,93971,HCPCS,Outpatient,,,42.4,21.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
WHC US Extremity Vein Lt:Read,2198106,CDM,972,RC,93971,HCPCS,Outpatient,,,42.4,21.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
US Duplex Abd Pelvic Retro Complete:Read,596592,CDM,972,RC,93975,HCPCS,Outpatient,,,111,55.5,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
US Renal Artery:Read,1225049,CDM,972,RC,93975,HCPCS,Outpatient,,,111,55.5,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
US Duplex Aorta IVC Complete:Read,596586,CDM,972,RC,93978,HCPCS,Outpatient,,,77.95,38.98,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
93985-CL US Ext AVF Comp Bilat Upper Pre-Op Wavelinq,3432108,CDM,960,RC,93985,HCPCS,Outpatient,,,508.97,254.49,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
93986-CL US Ext AVF Comp Upper Pre-Op Wavelinq LT,3432109,CDM,960,RC,93986,HCPCS,Outpatient,,,299.09,149.55,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
93986-CL US Ext AVF Comp Upper Pre-Op Wavelinq RT,3432110,CDM,960,RC,93986,HCPCS,Outpatient,,,299.09,149.55,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
93990-CL US Ext AVF Comp Upper for AVF Wavelinq LT,3432111,CDM,960,RC,93990,HCPCS,Outpatient,,,295.93,147.97,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
93990-CL US Ext AVF Comp Upper for AVF Wavelinq RT,3432112,CDM,960,RC,93990,HCPCS,Outpatient,,,295.93,147.97,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
94002-PF-VENT MGMT INPAT INIT DAY,4321572,CDM,981,RC,94002,HCPCS,Outpatient,,,180.94,90.47,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
94004-PF VENT MGMT NF PER DAY,4321571,CDM,981,RC,94004,HCPCS,Outpatient,,,93.3,46.65,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
Clinic Spirometry without,3435735,CDM,460,RC,94010,HCPCS,Outpatient,,,43.75,21.88,,32.81,75,,,percent of total billed charges,75% of total billed charges,32.81,75,,,percent of total billed charges,75% of total billed charges,136.72,100,,,Fee Schedule,100% of CMS OPPS Rate,17.21,100,,,Fee Schedule,100% of WV Medicaid Rate,225.6,165,,,Fee Schedule,165% of CMS OPPS Rate,141.7,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,392.73,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,538.6,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,674.65,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,17.21,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,136.72,100,,,Fee Schedule,100% of CMS OPPS Rate,141.7,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,6.13,14,,,percent of total billed charges,14% of total billed charges,6.13,674.65,
Peak Expiratory Flow,617712,CDM,460,RC,94010,HCPCS,Outpatient,,,43.75,21.88,,32.81,75,,,percent of total billed charges,75% of total billed charges,32.81,75,,,percent of total billed charges,75% of total billed charges,136.72,100,,,Fee Schedule,100% of CMS OPPS Rate,17.21,100,,,Fee Schedule,100% of WV Medicaid Rate,225.6,165,,,Fee Schedule,165% of CMS OPPS Rate,141.7,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,392.73,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,538.6,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,674.65,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,17.21,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,136.72,100,,,Fee Schedule,100% of CMS OPPS Rate,141.7,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,6.13,14,,,percent of total billed charges,14% of total billed charges,6.13,674.65,
Peak Flow POC,3444203,CDM,460,RC,94010,HCPCS,Outpatient,,,43.75,21.88,,32.81,75,,,percent of total billed charges,75% of total billed charges,32.81,75,,,percent of total billed charges,75% of total billed charges,136.72,100,,,Fee Schedule,100% of CMS OPPS Rate,17.21,100,,,Fee Schedule,100% of WV Medicaid Rate,225.6,165,,,Fee Schedule,165% of CMS OPPS Rate,141.7,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,392.73,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,538.6,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,674.65,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,17.21,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,136.72,100,,,Fee Schedule,100% of CMS OPPS Rate,141.7,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,6.13,14,,,percent of total billed charges,14% of total billed charges,6.13,674.65,
Spirometry POC,3444207,CDM,460,RC,94010,HCPCS,Outpatient,,,43.75,21.88,,32.81,75,,,percent of total billed charges,75% of total billed charges,32.81,75,,,percent of total billed charges,75% of total billed charges,136.72,100,,,Fee Schedule,100% of CMS OPPS Rate,17.21,100,,,Fee Schedule,100% of WV Medicaid Rate,225.6,165,,,Fee Schedule,165% of CMS OPPS Rate,141.7,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,392.73,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,538.6,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,674.65,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,17.21,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,136.72,100,,,Fee Schedule,100% of CMS OPPS Rate,141.7,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,6.13,14,,,percent of total billed charges,14% of total billed charges,6.13,674.65,
94013- Measure lung vol/inf/child thro 2y,3435679,CDM,510,RC,94013,HCPCS,Outpatient,,,51.62,25.81,,38.72,75,,,percent of total billed charges,75% of total billed charges,38.72,75,,,percent of total billed charges,75% of total billed charges,454.5,100,,,Fee Schedule,100% of CMS OPPS Rate,13.76,100,,,Fee Schedule,100% of WV Medicaid Rate,749.91,165,,,Fee Schedule,165% of CMS OPPS Rate,471.04,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1305.49,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1790.39,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,2242.64,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,13.76,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,454.5,100,,,Fee Schedule,100% of CMS OPPS Rate,471.04,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,7.23,14,,,percent of total billed charges,14% of total billed charges,7.23,2242.64,
94014- Pt init/spiromet rec/30 day,3435680,CDM,960,RC,94014,HCPCS,Outpatient,,,135.65,67.83,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
94016- Pt init/spiromet rec/review/interp,3435682,CDM,960,RC,94016,HCPCS,Outpatient,,,64.28,32.14,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
94060 - (PF) Spirometry/pre/post bronchodilator,4237109,CDM,960,RC,94060,HCPCS,Outpatient,,,20.39,10.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
94060- Spirometry/pre/post bronchodilator,3435316,CDM,460,RC,94060,HCPCS,Outpatient,,,20.39,10.2,,15.29,75,,,percent of total billed charges,75% of total billed charges,15.29,75,,,percent of total billed charges,75% of total billed charges,263.29,100,,,Fee Schedule,100% of CMS OPPS Rate,20.39,100,,,Fee Schedule,100% of WV Medicaid Rate,434.44,165,,,Fee Schedule,165% of CMS OPPS Rate,272.88,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,756.29,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1037.2,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1299.2,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,20.39,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,263.29,100,,,Fee Schedule,100% of CMS OPPS Rate,272.88,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,2.85,14,,,percent of total billed charges,14% of total billed charges,2.85,1299.2,
Clinic Spirometry w/ Diffusion Capacity,3435733,CDM,460,RC,94060,HCPCS,Outpatient,,,20.39,10.2,,15.29,75,,,percent of total billed charges,75% of total billed charges,15.29,75,,,percent of total billed charges,75% of total billed charges,263.29,100,,,Fee Schedule,100% of CMS OPPS Rate,20.39,100,,,Fee Schedule,100% of WV Medicaid Rate,434.44,165,,,Fee Schedule,165% of CMS OPPS Rate,272.88,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,756.29,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1037.2,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1299.2,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,20.39,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,263.29,100,,,Fee Schedule,100% of CMS OPPS Rate,272.88,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,2.85,14,,,percent of total billed charges,14% of total billed charges,2.85,1299.2,
Clinic Spirometry with and without,3435734,CDM,460,RC,94060,HCPCS,Outpatient,,,20.39,10.2,,15.29,75,,,percent of total billed charges,75% of total billed charges,15.29,75,,,percent of total billed charges,75% of total billed charges,263.29,100,,,Fee Schedule,100% of CMS OPPS Rate,20.39,100,,,Fee Schedule,100% of WV Medicaid Rate,434.44,165,,,Fee Schedule,165% of CMS OPPS Rate,272.88,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,756.29,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1037.2,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1299.2,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,20.39,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,263.29,100,,,Fee Schedule,100% of CMS OPPS Rate,272.88,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,2.85,14,,,percent of total billed charges,14% of total billed charges,2.85,1299.2,
PFT,617666,CDM,460,RC,94060,HCPCS,Outpatient,,,20.39,10.2,,15.29,75,,,percent of total billed charges,75% of total billed charges,15.29,75,,,percent of total billed charges,75% of total billed charges,263.29,100,,,Fee Schedule,100% of CMS OPPS Rate,20.39,100,,,Fee Schedule,100% of WV Medicaid Rate,434.44,165,,,Fee Schedule,165% of CMS OPPS Rate,272.88,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,756.29,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1037.2,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1299.2,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,20.39,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,263.29,100,,,Fee Schedule,100% of CMS OPPS Rate,272.88,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,2.85,14,,,percent of total billed charges,14% of total billed charges,2.85,1299.2,
94070- Bronchospasm provocation eval,3435683,CDM,510,RC,94070,HCPCS,Outpatient,,,79.27,39.64,,59.45,75,,,percent of total billed charges,75% of total billed charges,59.45,75,,,percent of total billed charges,75% of total billed charges,263.29,100,,,Fee Schedule,100% of CMS OPPS Rate,40.79,100,,,Fee Schedule,100% of WV Medicaid Rate,434.44,165,,,Fee Schedule,165% of CMS OPPS Rate,272.88,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,756.29,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1037.2,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1299.2,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,40.79,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,263.29,100,,,Fee Schedule,100% of CMS OPPS Rate,272.88,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,11.1,14,,,percent of total billed charges,14% of total billed charges,11.1,1299.2,
94200- Max breathing cap/max volunt vent,3435685,CDM,460,RC,94200,HCPCS,Outpatient,,,32.86,16.43,,24.65,75,,,percent of total billed charges,75% of total billed charges,24.65,75,,,percent of total billed charges,75% of total billed charges,54.04,100,,,Fee Schedule,100% of CMS OPPS Rate,9.83,100,,,Fee Schedule,100% of WV Medicaid Rate,89.16,165,,,Fee Schedule,165% of CMS OPPS Rate,56,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,155.22,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,212.87,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,266.65,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,9.83,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,54.04,100,,,Fee Schedule,100% of CMS OPPS Rate,56,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4.6,14,,,percent of total billed charges,14% of total billed charges,4.6,266.65,
"Clinic Full PFT with spirometry, MVV,Lung Volumes and diffusion capacity",3435731,CDM,460,RC,94200,HCPCS,Outpatient,,,32.86,16.43,,24.65,75,,,percent of total billed charges,75% of total billed charges,24.65,75,,,percent of total billed charges,75% of total billed charges,54.04,100,,,Fee Schedule,100% of CMS OPPS Rate,9.83,100,,,Fee Schedule,100% of WV Medicaid Rate,89.16,165,,,Fee Schedule,165% of CMS OPPS Rate,56,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,155.22,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,212.87,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,266.65,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,9.83,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,54.04,100,,,Fee Schedule,100% of CMS OPPS Rate,56,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4.6,14,,,percent of total billed charges,14% of total billed charges,4.6,266.65,
Clinic MVV,3979027,CDM,460,RC,94200,HCPCS,Outpatient,,,32.86,16.43,,24.65,75,,,percent of total billed charges,75% of total billed charges,24.65,75,,,percent of total billed charges,75% of total billed charges,54.04,100,,,Fee Schedule,100% of CMS OPPS Rate,9.83,100,,,Fee Schedule,100% of WV Medicaid Rate,89.16,165,,,Fee Schedule,165% of CMS OPPS Rate,56,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,155.22,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,212.87,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,266.65,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,9.83,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,54.04,100,,,Fee Schedule,100% of CMS OPPS Rate,56,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4.6,14,,,percent of total billed charges,14% of total billed charges,4.6,266.65,
94375- Respiratory flow volume loop,3435689,CDM,460,RC,94375,HCPCS,Outpatient,,,56.38,28.19,,42.29,75,,,percent of total billed charges,75% of total billed charges,42.29,75,,,percent of total billed charges,75% of total billed charges,263.3,100,,,Fee Schedule,100% of CMS OPPS Rate,25.07,100,,,Fee Schedule,100% of WV Medicaid Rate,434.45,165,,,Fee Schedule,165% of CMS OPPS Rate,272.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,756.3,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1037.2,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1299.2,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,25.07,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,263.3,100,,,Fee Schedule,100% of CMS OPPS Rate,272.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,7.89,14,,,percent of total billed charges,14% of total billed charges,7.89,1299.2,
94450- Breathing response to hypoxia,3435691,CDM,510,RC,94450,HCPCS,Outpatient,,,108.8,54.4,,81.6,75,,,percent of total billed charges,75% of total billed charges,81.6,75,,,percent of total billed charges,75% of total billed charges,263.3,100,,,Fee Schedule,100% of CMS OPPS Rate,41.54,100,,,Fee Schedule,100% of WV Medicaid Rate,434.45,165,,,Fee Schedule,165% of CMS OPPS Rate,272.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,756.3,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1037.2,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1299.2,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,41.54,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,263.3,100,,,Fee Schedule,100% of CMS OPPS Rate,272.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,15.23,14,,,percent of total billed charges,14% of total billed charges,15.23,1299.2,
94452- High altitude sim test/int/rpt,3435692,CDM,510,RC,94452,HCPCS,Outpatient,,,81.64,40.82,,61.23,75,,,percent of total billed charges,75% of total billed charges,61.23,75,,,percent of total billed charges,75% of total billed charges,109.16,100,,,Fee Schedule,100% of CMS OPPS Rate,31.71,100,,,Fee Schedule,100% of WV Medicaid Rate,180.11,165,,,Fee Schedule,165% of CMS OPPS Rate,113.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,313.55,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,430.01,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,538.63,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,31.71,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,109.16,100,,,Fee Schedule,100% of CMS OPPS Rate,113.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,11.43,14,,,percent of total billed charges,14% of total billed charges,11.43,538.63,
94453- High altitude sim test/int/rpt/O2,3435693,CDM,510,RC,94453,HCPCS,Outpatient,,,112.44,56.22,,84.33,75,,,percent of total billed charges,75% of total billed charges,84.33,75,,,percent of total billed charges,75% of total billed charges,109.16,100,,,Fee Schedule,100% of CMS OPPS Rate,43.26,100,,,Fee Schedule,100% of WV Medicaid Rate,180.11,165,,,Fee Schedule,165% of CMS OPPS Rate,113.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,313.55,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,430.01,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,538.63,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,43.26,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,109.16,100,,,Fee Schedule,100% of CMS OPPS Rate,113.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,15.74,14,,,percent of total billed charges,14% of total billed charges,15.74,538.63,
94610- Intrapul surfactant admin/ET tube,3435694,CDM,510,RC,94610,HCPCS,Outpatient,,,145.9,72.95,,109.43,75,,,percent of total billed charges,75% of total billed charges,109.43,75,,,percent of total billed charges,75% of total billed charges,180.04,100,,,Fee Schedule,100% of CMS OPPS Rate,39.08,100,,,Fee Schedule,100% of WV Medicaid Rate,297.06,165,,,Fee Schedule,165% of CMS OPPS Rate,186.59,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,517.14,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,709.22,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,888.37,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,39.08,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,180.04,100,,,Fee Schedule,100% of CMS OPPS Rate,186.59,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,20.43,14,,,percent of total billed charges,14% of total billed charges,20.43,888.37,
6 Minute Walk,658839,CDM,460,RC,94618,HCPCS,Outpatient,,,44.14,22.07,,33.11,75,,,percent of total billed charges,75% of total billed charges,33.11,75,,,percent of total billed charges,75% of total billed charges,109.16,100,,,Fee Schedule,100% of CMS OPPS Rate,22.61,100,,,Fee Schedule,100% of WV Medicaid Rate,180.11,165,,,Fee Schedule,165% of CMS OPPS Rate,113.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,313.55,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,430.01,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,538.63,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,22.61,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,109.16,100,,,Fee Schedule,100% of CMS OPPS Rate,113.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,6.18,14,,,percent of total billed charges,14% of total billed charges,6.18,538.63,
94618 - (PF) Pulmonary Stress Test - 6 min Walk,4237108,CDM,960,RC,94618,HCPCS,Outpatient,,,44.14,22.07,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
Clinic 6 min walk,3435728,CDM,460,RC,94618,HCPCS,Outpatient,,,44.14,22.07,,33.11,75,,,percent of total billed charges,75% of total billed charges,33.11,75,,,percent of total billed charges,75% of total billed charges,109.16,100,,,Fee Schedule,100% of CMS OPPS Rate,22.61,100,,,Fee Schedule,100% of WV Medicaid Rate,180.11,165,,,Fee Schedule,165% of CMS OPPS Rate,113.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,313.55,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,430.01,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,538.63,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,22.61,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,109.16,100,,,Fee Schedule,100% of CMS OPPS Rate,113.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,6.18,14,,,percent of total billed charges,14% of total billed charges,6.18,538.63,
Clinic 6 min walk with Oxygen titration,3435729,CDM,460,RC,94618,HCPCS,Outpatient,,,44.14,22.07,,33.11,75,,,percent of total billed charges,75% of total billed charges,33.11,75,,,percent of total billed charges,75% of total billed charges,109.16,100,,,Fee Schedule,100% of CMS OPPS Rate,22.61,100,,,Fee Schedule,100% of WV Medicaid Rate,180.11,165,,,Fee Schedule,165% of CMS OPPS Rate,113.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,313.55,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,430.01,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,538.63,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,22.61,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,109.16,100,,,Fee Schedule,100% of CMS OPPS Rate,113.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,6.18,14,,,percent of total billed charges,14% of total billed charges,6.18,538.63,
Six Minute Walk Test,634111,CDM,460,RC,94618,HCPCS,Outpatient,,,44.14,22.07,,33.11,75,,,percent of total billed charges,75% of total billed charges,33.11,75,,,percent of total billed charges,75% of total billed charges,109.16,100,,,Fee Schedule,100% of CMS OPPS Rate,22.61,100,,,Fee Schedule,100% of WV Medicaid Rate,180.11,165,,,Fee Schedule,165% of CMS OPPS Rate,113.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,313.55,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,430.01,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,538.63,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,22.61,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,109.16,100,,,Fee Schedule,100% of CMS OPPS Rate,113.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,6.18,14,,,percent of total billed charges,14% of total billed charges,6.18,538.63,
94621- Pulmonary stress testing/complex,3435696,CDM,460,RC,94621,HCPCS,Outpatient,,,203.39,101.7,,152.54,75,,,percent of total billed charges,75% of total billed charges,152.54,75,,,percent of total billed charges,75% of total billed charges,263.29,100,,,Fee Schedule,100% of CMS OPPS Rate,102.74,100,,,Fee Schedule,100% of WV Medicaid Rate,434.44,165,,,Fee Schedule,165% of CMS OPPS Rate,272.88,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,756.29,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1037.2,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1299.2,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,102.74,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,263.29,100,,,Fee Schedule,100% of CMS OPPS Rate,272.88,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,28.47,14,,,percent of total billed charges,14% of total billed charges,28.47,1299.2,
PFT for PAT,617693,CDM,460,RC,94621,HCPCS,Outpatient,,,203.39,101.7,,152.54,75,,,percent of total billed charges,75% of total billed charges,152.54,75,,,percent of total billed charges,75% of total billed charges,263.29,100,,,Fee Schedule,100% of CMS OPPS Rate,102.74,100,,,Fee Schedule,100% of WV Medicaid Rate,434.44,165,,,Fee Schedule,165% of CMS OPPS Rate,272.88,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,756.29,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1037.2,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1299.2,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,102.74,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,263.29,100,,,Fee Schedule,100% of CMS OPPS Rate,272.88,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,28.47,14,,,percent of total billed charges,14% of total billed charges,28.47,1299.2,
Pulmonary Stress Test Study II,617696,CDM,460,RC,94621,HCPCS,Outpatient,,,374.39,187.2,,280.79,75,,,percent of total billed charges,75% of total billed charges,280.79,75,,,percent of total billed charges,75% of total billed charges,263.29,100,,,Fee Schedule,100% of CMS OPPS Rate,102.74,100,,,Fee Schedule,100% of WV Medicaid Rate,434.44,165,,,Fee Schedule,165% of CMS OPPS Rate,272.88,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,756.29,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1037.2,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1299.2,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,102.74,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,263.29,100,,,Fee Schedule,100% of CMS OPPS Rate,272.88,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,52.41,14,,,percent of total billed charges,14% of total billed charges,52.41,1299.2,
AMB Admin INH Charge -> INH Treatment 94640,3574936,CDM,410,RC,94640,HCPCS,Outpatient,,,26.38,13.19,,19.79,75,,,percent of total billed charges,75% of total billed charges,19.79,75,,,percent of total billed charges,75% of total billed charges,180.04,100,,,Fee Schedule,100% of CMS OPPS Rate,6.88,100,,,Fee Schedule,100% of WV Medicaid Rate,297.06,165,,,Fee Schedule,165% of CMS OPPS Rate,186.59,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,517.14,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,709.22,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,888.37,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,6.88,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,180.04,100,,,Fee Schedule,100% of CMS OPPS Rate,186.59,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,3.69,14,,,percent of total billed charges,14% of total billed charges,3.69,888.37,
INHELATION TX-AERO/NEB/ MDI/IPPB,3428470,CDM,981,RC,94640,HCPCS,Outpatient,,,26.38,13.19,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
RT CHARGE Aerosol Therapy -> Initial,3438247,CDM,940,RC,94640,HCPCS,Outpatient,,,21.23,10.62,,15.92,75,,,percent of total billed charges,75% of total billed charges,15.92,75,,,percent of total billed charges,75% of total billed charges,180.04,100,,,Fee Schedule,100% of CMS OPPS Rate,6.88,100,,,Fee Schedule,100% of WV Medicaid Rate,297.06,165,,,Fee Schedule,165% of CMS OPPS Rate,186.59,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,517.14,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,709.22,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,888.37,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,6.88,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,180.04,100,,,Fee Schedule,100% of CMS OPPS Rate,186.59,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,2.97,14,,,percent of total billed charges,14% of total billed charges,2.97,888.37,
RT CHARGE Aerosol Therapy -> Subsequent,3438246,CDM,940,RC,94640,HCPCS,Outpatient,,,21.23,10.62,,15.92,75,,,percent of total billed charges,75% of total billed charges,15.92,75,,,percent of total billed charges,75% of total billed charges,180.04,100,,,Fee Schedule,100% of CMS OPPS Rate,6.88,100,,,Fee Schedule,100% of WV Medicaid Rate,297.06,165,,,Fee Schedule,165% of CMS OPPS Rate,186.59,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,517.14,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,709.22,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,888.37,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,6.88,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,180.04,100,,,Fee Schedule,100% of CMS OPPS Rate,186.59,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,2.97,14,,,percent of total billed charges,14% of total billed charges,2.97,888.37,
94662- CNP ventilation/initiation/mngt,3431740,CDM,410,RC,94662,HCPCS,Outpatient,,,95.05,47.53,,71.29,75,,,percent of total billed charges,75% of total billed charges,71.29,75,,,percent of total billed charges,75% of total billed charges,523.4,100,,,Fee Schedule,100% of CMS OPPS Rate,25.32,100,,,Fee Schedule,100% of WV Medicaid Rate,863.61,165,,,Fee Schedule,165% of CMS OPPS Rate,542.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1503.41,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2061.81,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,2582.64,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,25.32,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,523.4,100,,,Fee Schedule,100% of CMS OPPS Rate,542.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,13.31,14,,,percent of total billed charges,14% of total billed charges,13.31,2582.64,
94680- O2 uptake/exp gas analy/simple,3435705,CDM,510,RC,94680,HCPCS,Outpatient,,,93.48,46.74,,70.11,75,,,percent of total billed charges,75% of total billed charges,70.11,75,,,percent of total billed charges,75% of total billed charges,136.72,100,,,Fee Schedule,100% of CMS OPPS Rate,34.17,100,,,Fee Schedule,100% of WV Medicaid Rate,225.6,165,,,Fee Schedule,165% of CMS OPPS Rate,141.7,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,392.73,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,538.6,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,674.65,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,34.17,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,136.72,100,,,Fee Schedule,100% of CMS OPPS Rate,141.7,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,13.09,14,,,percent of total billed charges,14% of total billed charges,13.09,674.65,
94681- O2 uptake/CO2 output/% O2 extrated,3435706,CDM,510,RC,94681,HCPCS,Outpatient,,,90.33,45.17,,67.75,75,,,percent of total billed charges,75% of total billed charges,67.75,75,,,percent of total billed charges,75% of total billed charges,263.3,100,,,Fee Schedule,100% of CMS OPPS Rate,30.97,100,,,Fee Schedule,100% of WV Medicaid Rate,434.45,165,,,Fee Schedule,165% of CMS OPPS Rate,272.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,756.3,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1037.2,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1299.2,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,30.97,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,263.3,100,,,Fee Schedule,100% of CMS OPPS Rate,272.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,12.65,14,,,percent of total billed charges,14% of total billed charges,12.65,1299.2,
94690- O2 uptake/rest/indirect,3435707,CDM,510,RC,94690,HCPCS,Outpatient,,,92.71,46.36,,69.53,75,,,percent of total billed charges,75% of total billed charges,69.53,75,,,percent of total billed charges,75% of total billed charges,54.04,100,,,Fee Schedule,100% of CMS OPPS Rate,27.28,100,,,Fee Schedule,100% of WV Medicaid Rate,89.16,165,,,Fee Schedule,165% of CMS OPPS Rate,56,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,155.22,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,212.87,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,266.65,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,27.28,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,54.04,100,,,Fee Schedule,100% of CMS OPPS Rate,56,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,12.98,14,,,percent of total billed charges,14% of total billed charges,12.98,266.65,
94726 - (26) Plethysmography Lung Volumes w/wo airway resist,3896956,CDM,983,RC,94726,HCPCS,Outpatient,,,23.77,11.89,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
94726 - (TC) Plethysmography Lung Volumes w/wo airway resist,3896962,CDM,460,RC,94726,HCPCS,Outpatient,,,23.77,11.89,,17.83,75,,,percent of total billed charges,75% of total billed charges,17.83,75,,,percent of total billed charges,75% of total billed charges,263.3,100,,,Fee Schedule,100% of CMS OPPS Rate,23.77,100,,,Fee Schedule,100% of WV Medicaid Rate,434.45,165,,,Fee Schedule,165% of CMS OPPS Rate,272.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,756.3,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1037.2,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1299.2,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,23.77,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,263.3,100,,,Fee Schedule,100% of CMS OPPS Rate,272.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,3.33,14,,,percent of total billed charges,14% of total billed charges,3.33,1299.2,
94726 - PF Plethysmography/lung volume,3715330,CDM,510,RC,94726,HCPCS,Outpatient,,,23.77,11.89,,17.83,75,,,percent of total billed charges,75% of total billed charges,17.83,75,,,percent of total billed charges,75% of total billed charges,263.3,100,,,Fee Schedule,100% of CMS OPPS Rate,23.77,100,,,Fee Schedule,100% of WV Medicaid Rate,434.45,165,,,Fee Schedule,165% of CMS OPPS Rate,272.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,756.3,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1037.2,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1299.2,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,23.77,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,263.3,100,,,Fee Schedule,100% of CMS OPPS Rate,272.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,3.33,14,,,percent of total billed charges,14% of total billed charges,3.33,1299.2,
94726 - Plethysmography Lung Volumes w/wo airway resist,3896968,CDM,510,RC,94726,HCPCS,Outpatient,,,23.77,11.89,,17.83,75,,,percent of total billed charges,75% of total billed charges,17.83,75,,,percent of total billed charges,75% of total billed charges,263.3,100,,,Fee Schedule,100% of CMS OPPS Rate,23.77,100,,,Fee Schedule,100% of WV Medicaid Rate,434.45,165,,,Fee Schedule,165% of CMS OPPS Rate,272.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,756.3,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1037.2,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1299.2,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,23.77,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,263.3,100,,,Fee Schedule,100% of CMS OPPS Rate,272.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,3.33,14,,,percent of total billed charges,14% of total billed charges,3.33,1299.2,
94726- Plethysmography/lung volume,3435709,CDM,460,RC,94726,HCPCS,Outpatient,,,23.77,11.89,,17.83,75,,,percent of total billed charges,75% of total billed charges,17.83,75,,,percent of total billed charges,75% of total billed charges,263.3,100,,,Fee Schedule,100% of CMS OPPS Rate,23.77,100,,,Fee Schedule,100% of WV Medicaid Rate,434.45,165,,,Fee Schedule,165% of CMS OPPS Rate,272.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,756.3,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1037.2,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1299.2,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,23.77,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,263.3,100,,,Fee Schedule,100% of CMS OPPS Rate,272.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,3.33,14,,,percent of total billed charges,14% of total billed charges,3.33,1299.2,
Clinic Lung Volumes,3435732,CDM,460,RC,94726,HCPCS,Outpatient,,,23.77,11.89,,17.83,75,,,percent of total billed charges,75% of total billed charges,17.83,75,,,percent of total billed charges,75% of total billed charges,263.3,100,,,Fee Schedule,100% of CMS OPPS Rate,23.77,100,,,Fee Schedule,100% of WV Medicaid Rate,434.45,165,,,Fee Schedule,165% of CMS OPPS Rate,272.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,756.3,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1037.2,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1299.2,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,23.77,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,263.3,100,,,Fee Schedule,100% of CMS OPPS Rate,272.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,3.33,14,,,percent of total billed charges,14% of total billed charges,3.33,1299.2,
Lung Vol & Capacity,617686,CDM,460,RC,94726,HCPCS,Outpatient,,,23.77,11.89,,17.83,75,,,percent of total billed charges,75% of total billed charges,17.83,75,,,percent of total billed charges,75% of total billed charges,263.3,100,,,Fee Schedule,100% of CMS OPPS Rate,23.77,100,,,Fee Schedule,100% of WV Medicaid Rate,434.45,165,,,Fee Schedule,165% of CMS OPPS Rate,272.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,756.3,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1037.2,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1299.2,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,23.77,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,263.3,100,,,Fee Schedule,100% of CMS OPPS Rate,272.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,3.33,14,,,percent of total billed charges,14% of total billed charges,3.33,1299.2,
94727- Gas Dilution Washout for determin Lung Volume,3435710,CDM,460,RC,94727,HCPCS,Outpatient,,,74.54,37.27,,55.91,75,,,percent of total billed charges,75% of total billed charges,55.91,75,,,percent of total billed charges,75% of total billed charges,136.72,100,,,Fee Schedule,100% of CMS OPPS Rate,28.27,100,,,Fee Schedule,100% of WV Medicaid Rate,225.6,165,,,Fee Schedule,165% of CMS OPPS Rate,141.7,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,392.73,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,538.6,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,674.65,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,28.27,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,136.72,100,,,Fee Schedule,100% of CMS OPPS Rate,141.7,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,10.44,14,,,percent of total billed charges,14% of total billed charges,10.44,674.65,
94728- Airway resist/impulse oscillometry,3435711,CDM,510,RC,94728,HCPCS,Outpatient,,,64.28,32.14,,48.21,75,,,percent of total billed charges,75% of total billed charges,48.21,75,,,percent of total billed charges,75% of total billed charges,263.3,100,,,Fee Schedule,100% of CMS OPPS Rate,25.56,100,,,Fee Schedule,100% of WV Medicaid Rate,434.45,165,,,Fee Schedule,165% of CMS OPPS Rate,272.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,756.3,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1037.2,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1299.2,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,25.56,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,263.3,100,,,Fee Schedule,100% of CMS OPPS Rate,272.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,9,14,,,percent of total billed charges,14% of total billed charges,9,1299.2,
94729 - (PF) Diffusing capacity/CO2/add on,4237110,CDM,960,RC,94729,HCPCS,Outpatient,,,17.7,8.85,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
94729- Diffusing capacity/CO2/add on,3435712,CDM,460,RC,94729,HCPCS,Outpatient,,,17.7,8.85,,13.28,75,,,percent of total billed charges,75% of total billed charges,13.28,75,,,percent of total billed charges,75% of total billed charges,5.66,32,,,percent of total billed charges,32% of total billed charges,17.7,100,,,Fee Schedule,100% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.7,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.48,14,,,percent of total billed charges,14% of total billed charges,2.48,17.7,
Carbon Monoxide Diffusing Capacity,625084,CDM,460,RC,94729,HCPCS,Outpatient,,,17.7,8.85,,13.28,75,,,percent of total billed charges,75% of total billed charges,13.28,75,,,percent of total billed charges,75% of total billed charges,5.66,32,,,percent of total billed charges,32% of total billed charges,17.7,100,,,Fee Schedule,100% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.7,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.48,14,,,percent of total billed charges,14% of total billed charges,2.48,17.7,
Clinic Diffusion Capacity,3435730,CDM,460,RC,94729,HCPCS,Outpatient,,,17.7,8.85,,13.28,75,,,percent of total billed charges,75% of total billed charges,13.28,75,,,percent of total billed charges,75% of total billed charges,5.66,32,,,percent of total billed charges,32% of total billed charges,17.7,100,,,Fee Schedule,100% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.7,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.48,14,,,percent of total billed charges,14% of total billed charges,2.48,17.7,
DLCO,617682,CDM,460,RC,94729,HCPCS,Outpatient,,,17.7,8.85,,13.28,75,,,percent of total billed charges,75% of total billed charges,13.28,75,,,percent of total billed charges,75% of total billed charges,5.66,32,,,percent of total billed charges,32% of total billed charges,17.7,100,,,Fee Schedule,100% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.7,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.48,14,,,percent of total billed charges,14% of total billed charges,2.48,17.7,
94762- Noninv ear/pulse ox/cont/overnight,3435716,CDM,460,RC,94762,HCPCS,Outpatient,,,45.81,22.91,,34.36,75,,,percent of total billed charges,75% of total billed charges,34.36,75,,,percent of total billed charges,75% of total billed charges,136.72,100,,,Fee Schedule,100% of CMS OPPS Rate,16.47,100,,,Fee Schedule,100% of WV Medicaid Rate,225.58,165,,,Fee Schedule,165% of CMS OPPS Rate,141.69,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,392.72,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,538.59,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,674.64,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,16.47,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,136.72,100,,,Fee Schedule,100% of CMS OPPS Rate,141.69,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,6.41,14,,,percent of total billed charges,14% of total billed charges,6.41,674.64,
94780- Car seat/bed test/airway/neonate,3437843,CDM,983,RC,94780,HCPCS,Outpatient,,,127.54,63.77,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
94781- Car seat/bed test/airway integ/neonate/nrsg obs/rec/interp/ad 30 min,3435723,CDM,510,RC,94781,HCPCS,Outpatient,,,49.9,24.95,,37.43,75,,,percent of total billed charges,75% of total billed charges,37.43,75,,,percent of total billed charges,75% of total billed charges,15.97,32,,,percent of total billed charges,32% of total billed charges,5.65,100,,,Fee Schedule,100% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.65,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.99,14,,,percent of total billed charges,14% of total billed charges,5.65,37.43,
Clinic MEP,3979029,CDM,960,RC,94799,HCPCS,Outpatient,,,688.77,344.39,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
Clinic MIP,3979028,CDM,960,RC,94799,HCPCS,Outpatient,,,688.77,344.39,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
"95044- Allg patch or app, # of tests",3428645,CDM,920,RC,95044,HCPCS,Outpatient,,,9.31,4.66,,6.98,75,,,percent of total billed charges,75% of total billed charges,6.98,75,,,percent of total billed charges,75% of total billed charges,878.47,100,,,Fee Schedule,100% of CMS OPPS Rate,3.2,100,,,Fee Schedule,100% of WV Medicaid Rate,1449.48,165,,,Fee Schedule,165% of CMS OPPS Rate,910.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,2523.29,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,3460.49,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,4334.61,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,3.2,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,878.47,100,,,Fee Schedule,100% of CMS OPPS Rate,910.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1.3,14,,,percent of total billed charges,14% of total billed charges,1.3,4334.61,
95115 - PF Immunotherapy One Injection,4311915,CDM,960,RC,95115,HCPCS,Outpatient,,,21.08,10.54,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
95115- Professional services for allergen immunotherapy not including provision of allergenic extrac,3715131,CDM,510,RC,95115,HCPCS,Outpatient,,,22.42,11.21,,16.82,75,,,percent of total billed charges,75% of total billed charges,16.82,75,,,percent of total billed charges,75% of total billed charges,39.83,100,,,Fee Schedule,100% of CMS OPPS Rate,5.9,100,,,Fee Schedule,100% of WV Medicaid Rate,65.72,165,,,Fee Schedule,165% of CMS OPPS Rate,41.28,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,114.42,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,156.91,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,196.55,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,5.9,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,39.83,100,,,Fee Schedule,100% of CMS OPPS Rate,41.28,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,3.14,14,,,percent of total billed charges,14% of total billed charges,3.14,196.55,
"95117 - PF Immunotherapy Injections, 2 or more",4311916,CDM,960,RC,95117,HCPCS,Outpatient,,,24.55,12.28,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
95117- Professional services for allergen immunotherapy not including provision of allergenic extrac,3715132,CDM,510,RC,95117,HCPCS,Outpatient,,,27.15,13.58,,20.36,75,,,percent of total billed charges,75% of total billed charges,20.36,75,,,percent of total billed charges,75% of total billed charges,39.83,100,,,Fee Schedule,100% of CMS OPPS Rate,7.13,100,,,Fee Schedule,100% of WV Medicaid Rate,65.72,165,,,Fee Schedule,165% of CMS OPPS Rate,41.28,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,114.42,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,156.91,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,196.55,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,7.13,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,39.83,100,,,Fee Schedule,100% of CMS OPPS Rate,41.28,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,3.8,14,,,percent of total billed charges,14% of total billed charges,3.8,196.55,
95249 ? Ambulatory CGM >72 hours; Pt Prov EQP,4279406,CDM,983,RC,95249,HCPCS,Outpatient,,,113.61,56.81,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
95249 ? CGM Patient Provided Equipment,4279414,CDM,983,RC,95249,HCPCS,Outpatient,,,113.61,56.81,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
95250 - Ambulatory CGM >72 hours; Phys/QHP EQP,4241825,CDM,983,RC,95250,HCPCS,Outpatient,,,269.3,134.65,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
95250 ? CGM Physician Provided Equipment,4279415,CDM,983,RC,95250,HCPCS,Outpatient,,,269.3,134.65,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
"95251 - Ambulatory CGM >72 hours; Analysis, Interpretation &",4241826,CDM,983,RC,95251,HCPCS,Outpatient,,,71.23,35.62,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
95251 ? CGM Analysis and Report,4279416,CDM,983,RC,95251,HCPCS,Outpatient,,,71.23,35.62,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
95717- PF EEG PHYS/QHP 2-12 HR WITHOUT VIDEO,4348528,CDM,986,RC,95717,HCPCS,Outpatient,,,199.7,99.85,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
95718- PF EEG PHYS/QHP 2-12 HR WITH VEEG,4348529,CDM,986,RC,95718,HCPCS,Outpatient,,,253.18,126.59,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
95719- PF EEG PHYS/QHP EA INCR>12HR<26HR AFTER 24HR WO VID,4348530,CDM,986,RC,95719,HCPCS,Outpatient,,,302.1,151.05,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
95720- PF EEG PHYS/QHP EA INCR>12HR<26HR AFTER 24HR W/VEEG,4348531,CDM,986,RC,95720,HCPCS,Outpatient,,,389.68,194.84,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
95721- PF EEG COMPLETE STD PHYS/QHP>36 HR<60 HR W/O VIDEO,4348532,CDM,986,RC,95721,HCPCS,Outpatient,,,388.8,194.4,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
95722- PF EEG COMPLETE STD PHYS/QHP>36 HR<60 HR W/VEEG,4348533,CDM,986,RC,95722,HCPCS,Outpatient,,,472.24,236.12,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
95723- PF EEG COMPLETE STD PHYS/QHP>60 HR<84 HR W/O VIDEO,4348534,CDM,986,RC,95723,HCPCS,Outpatient,,,471.78,235.89,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
95724- PF EEG COMPLETE STD PHYS/QHP>60 HR<84 HR W/VEEG,4348535,CDM,986,RC,95724,HCPCS,Outpatient,,,593.66,296.83,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
95725- PF EEG COMPLETE STD PHYS/QHP>84 HR W/O VID,4348538,CDM,986,RC,95725,HCPCS,Outpatient,,,544.16,272.08,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
95726- PF EEG COMPLETE STD PHYS/QHP>84 HR W/VEEG,4348539,CDM,986,RC,95726,HCPCS,Outpatient,,,760.48,380.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
95800- Sleep study/unattended/w recording,3435907,CDM,921,RC,95800,HCPCS,Outpatient,,,78.55,39.28,,58.91,75,,,percent of total billed charges,75% of total billed charges,58.91,75,,,percent of total billed charges,75% of total billed charges,136.72,100,,,Fee Schedule,100% of CMS OPPS Rate,78.55,100,,,Fee Schedule,100% of WV Medicaid Rate,225.58,165,,,Fee Schedule,165% of CMS OPPS Rate,141.69,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,392.72,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,538.59,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,674.64,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,78.55,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,136.72,100,,,Fee Schedule,100% of CMS OPPS Rate,141.69,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,11,14,,,percent of total billed charges,14% of total billed charges,11,674.64,
95800- Stdy Unatnd w/Hrt Rt/O2 Sat/Resp/Slp Time,4347083,CDM,510,RC,95800,HCPCS,Outpatient,,,78.55,39.28,,58.91,75,,,percent of total billed charges,75% of total billed charges,58.91,75,,,percent of total billed charges,75% of total billed charges,136.72,100,,,Fee Schedule,100% of CMS OPPS Rate,78.55,100,,,Fee Schedule,100% of WV Medicaid Rate,225.58,165,,,Fee Schedule,165% of CMS OPPS Rate,141.69,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,392.72,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,538.59,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,674.64,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,78.55,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,136.72,100,,,Fee Schedule,100% of CMS OPPS Rate,141.69,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,11,14,,,percent of total billed charges,14% of total billed charges,11,674.64,
Nocturnal Study,604506,CDM,920,RC,95800,HCPCS,Outpatient,,,78.55,39.28,,58.91,75,,,percent of total billed charges,75% of total billed charges,58.91,75,,,percent of total billed charges,75% of total billed charges,136.72,100,,,Fee Schedule,100% of CMS OPPS Rate,78.55,100,,,Fee Schedule,100% of WV Medicaid Rate,225.58,165,,,Fee Schedule,165% of CMS OPPS Rate,141.69,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,392.72,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,538.59,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,674.64,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,78.55,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,136.72,100,,,Fee Schedule,100% of CMS OPPS Rate,141.69,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,11,14,,,percent of total billed charges,14% of total billed charges,11,674.64,
95801- Sleep study/unattend/rec HR/sat/RR,3435908,CDM,510,RC,95801,HCPCS,Outpatient,,,80.92,40.46,,60.69,75,,,percent of total billed charges,75% of total billed charges,60.69,75,,,percent of total billed charges,75% of total billed charges,109.16,100,,,Fee Schedule,100% of CMS OPPS Rate,59.98,100,,,Fee Schedule,100% of WV Medicaid Rate,180.11,165,,,Fee Schedule,165% of CMS OPPS Rate,113.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,313.55,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,430.01,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,538.63,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,59.98,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,109.16,100,,,Fee Schedule,100% of CMS OPPS Rate,113.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,11.33,14,,,percent of total billed charges,14% of total billed charges,11.33,538.63,
95801- Slp Stdy Unatnd w/Min Hrt Rt/O2 Sat/Resp Analys,4347084,CDM,510,RC,95801,HCPCS,Outpatient,,,80.92,40.46,,60.69,75,,,percent of total billed charges,75% of total billed charges,60.69,75,,,percent of total billed charges,75% of total billed charges,109.16,100,,,Fee Schedule,100% of CMS OPPS Rate,59.98,100,,,Fee Schedule,100% of WV Medicaid Rate,180.11,165,,,Fee Schedule,165% of CMS OPPS Rate,113.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,313.55,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,430.01,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,538.63,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,59.98,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,109.16,100,,,Fee Schedule,100% of CMS OPPS Rate,113.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,11.33,14,,,percent of total billed charges,14% of total billed charges,11.33,538.63,
Sleep Study - In Lab MSLT 95805,3575514,CDM,920,RC,95805,HCPCS,Outpatient,,,113.34,56.67,,85.01,75,,,percent of total billed charges,75% of total billed charges,85.01,75,,,percent of total billed charges,75% of total billed charges,454.5,100,,,Fee Schedule,100% of CMS OPPS Rate,113.34,100,,,Fee Schedule,100% of WV Medicaid Rate,749.91,165,,,Fee Schedule,165% of CMS OPPS Rate,471.04,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1305.49,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1790.39,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,2242.64,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,113.34,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,454.5,100,,,Fee Schedule,100% of CMS OPPS Rate,471.04,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,15.87,14,,,percent of total billed charges,14% of total billed charges,15.87,2242.64,
Sleep Study - Home Study 95806,3575513,CDM,920,RC,95806,HCPCS,Outpatient,,,87.09,43.55,,65.32,75,,,percent of total billed charges,75% of total billed charges,65.32,75,,,percent of total billed charges,75% of total billed charges,136.72,100,,,Fee Schedule,100% of CMS OPPS Rate,60.71,100,,,Fee Schedule,100% of WV Medicaid Rate,225.58,165,,,Fee Schedule,165% of CMS OPPS Rate,141.69,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,392.72,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,538.59,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,674.64,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,60.71,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,136.72,100,,,Fee Schedule,100% of CMS OPPS Rate,141.69,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,12.19,14,,,percent of total billed charges,14% of total billed charges,12.19,674.64,
95807 - Sleep Study - Attended,4347085,CDM,510,RC,95807,HCPCS,Outpatient,,,753.51,376.76,,565.13,75,,,percent of total billed charges,75% of total billed charges,565.13,75,,,percent of total billed charges,75% of total billed charges,454.5,100,,,Fee Schedule,100% of CMS OPPS Rate,242.11,100,,,Fee Schedule,100% of WV Medicaid Rate,749.91,165,,,Fee Schedule,165% of CMS OPPS Rate,471.04,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1305.49,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1790.39,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,2242.64,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,242.11,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,454.5,100,,,Fee Schedule,100% of CMS OPPS Rate,471.04,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,105.49,14,,,percent of total billed charges,14% of total billed charges,105.49,2242.64,
95808- Polysomnography/any age/tech,3430545,CDM,510,RC,95808,HCPCS,Outpatient,,,164.64,82.32,,123.48,75,,,percent of total billed charges,75% of total billed charges,123.48,75,,,percent of total billed charges,75% of total billed charges,878.46,100,,,Fee Schedule,100% of CMS OPPS Rate,164.64,100,,,Fee Schedule,100% of WV Medicaid Rate,1449.46,165,,,Fee Schedule,165% of CMS OPPS Rate,910.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,2523.29,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,3460.48,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,4334.6,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,164.64,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,878.46,100,,,Fee Schedule,100% of CMS OPPS Rate,910.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,23.05,14,,,percent of total billed charges,14% of total billed charges,23.05,4334.6,
Sleep Study - In Lab PSG 95810,3575515,CDM,740,RC,95810,HCPCS,Outpatient,,,234.54,117.27,,175.91,75,,,percent of total billed charges,75% of total billed charges,175.91,75,,,percent of total billed charges,75% of total billed charges,878.46,100,,,Fee Schedule,100% of CMS OPPS Rate,234.54,100,,,Fee Schedule,100% of WV Medicaid Rate,1449.46,165,,,Fee Schedule,165% of CMS OPPS Rate,910.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,2523.29,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,3460.48,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,4334.6,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,234.54,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,878.46,100,,,Fee Schedule,100% of CMS OPPS Rate,910.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,32.84,14,,,percent of total billed charges,14% of total billed charges,32.84,4334.6,
Sleep Study - In Lab Titration 95811,3575516,CDM,740,RC,95811,HCPCS,Outpatient,,,244.18,122.09,,183.14,75,,,percent of total billed charges,75% of total billed charges,183.14,75,,,percent of total billed charges,75% of total billed charges,878.46,100,,,Fee Schedule,100% of CMS OPPS Rate,244.18,100,,,Fee Schedule,100% of WV Medicaid Rate,1449.46,165,,,Fee Schedule,165% of CMS OPPS Rate,910.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,2523.29,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,3460.48,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,4334.6,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,244.18,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,878.46,100,,,Fee Schedule,100% of CMS OPPS Rate,910.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,34.19,14,,,percent of total billed charges,14% of total billed charges,34.19,4334.6,
95812 PF EEG Extended Monitoring 41-60mins,4315920,CDM,960,RC,95812,HCPCS,Outpatient,,,613.96,306.98,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
Clinic EEG,3435538,CDM,740,RC,95812,HCPCS,Outpatient,,,613.96,306.98,,460.47,75,,,percent of total billed charges,75% of total billed charges,460.47,75,,,percent of total billed charges,75% of total billed charges,263.29,100,,,Fee Schedule,100% of CMS OPPS Rate,221.47,100,,,Fee Schedule,100% of WV Medicaid Rate,434.44,165,,,Fee Schedule,165% of CMS OPPS Rate,272.88,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,756.29,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1037.2,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1299.2,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,221.47,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,263.29,100,,,Fee Schedule,100% of CMS OPPS Rate,272.88,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,85.95,14,,,percent of total billed charges,14% of total billed charges,85.95,1299.2,
"EEG, ROUTINE 41-60 MINS",3435541,CDM,740,RC,95812,HCPCS,Outpatient,,,681.91,340.96,,511.43,75,,,percent of total billed charges,75% of total billed charges,511.43,75,,,percent of total billed charges,75% of total billed charges,263.29,100,,,Fee Schedule,100% of CMS OPPS Rate,221.47,100,,,Fee Schedule,100% of WV Medicaid Rate,434.44,165,,,Fee Schedule,165% of CMS OPPS Rate,272.88,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,756.29,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1037.2,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1299.2,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,221.47,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,263.29,100,,,Fee Schedule,100% of CMS OPPS Rate,272.88,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,95.47,14,,,percent of total billed charges,14% of total billed charges,95.47,1299.2,
95813- EEG Routine 61 - 199 Minutes,3435464,CDM,740,RC,95813,HCPCS,Outpatient,,,805.85,402.93,,604.39,75,,,percent of total billed charges,75% of total billed charges,604.39,75,,,percent of total billed charges,75% of total billed charges,263.29,100,,,Fee Schedule,100% of CMS OPPS Rate,275.05,100,,,Fee Schedule,100% of WV Medicaid Rate,434.44,165,,,Fee Schedule,165% of CMS OPPS Rate,272.88,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,756.29,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1037.2,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1299.2,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,275.05,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,263.29,100,,,Fee Schedule,100% of CMS OPPS Rate,272.88,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,112.82,14,,,percent of total billed charges,14% of total billed charges,112.82,1299.2,
95813 PF EEG Extended Monitoring 61-119mins,4315855,CDM,960,RC,95813,HCPCS,Outpatient,,,765.72,382.86,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
CL EEG Routine 61- 199 Minutes 95813,4339185,CDM,740,RC,95813,HCPCS,Outpatient,,,765.72,382.86,,574.29,75,,,percent of total billed charges,75% of total billed charges,574.29,75,,,percent of total billed charges,75% of total billed charges,263.29,100,,,Fee Schedule,100% of CMS OPPS Rate,275.05,100,,,Fee Schedule,100% of WV Medicaid Rate,434.44,165,,,Fee Schedule,165% of CMS OPPS Rate,272.88,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,756.29,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1037.2,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1299.2,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,275.05,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,263.29,100,,,Fee Schedule,100% of CMS OPPS Rate,272.88,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,107.2,14,,,percent of total billed charges,14% of total billed charges,107.2,1299.2,
95816 - PF EEG Includes Recording Awake and Drowsy,4315856,CDM,960,RC,95816,HCPCS,Outpatient,,,113.76,56.88,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
95816- EEG w/recording/awake/drowsy,3435465,CDM,740,RC,95816,HCPCS,Outpatient,,,113.76,56.88,,85.32,75,,,percent of total billed charges,75% of total billed charges,85.32,75,,,percent of total billed charges,75% of total billed charges,263.29,100,,,Fee Schedule,100% of CMS OPPS Rate,113.76,100,,,Fee Schedule,100% of WV Medicaid Rate,434.44,165,,,Fee Schedule,165% of CMS OPPS Rate,272.88,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,756.29,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1037.2,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1299.2,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,113.76,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,263.29,100,,,Fee Schedule,100% of CMS OPPS Rate,272.88,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,15.93,14,,,percent of total billed charges,14% of total billed charges,15.93,1299.2,
95819 - PF EEG Includes Recording Awake and Asleep,4315921,CDM,960,RC,95819,HCPCS,Outpatient,,,785.9,392.95,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
95822 - (26) Electroencephalogram (EEG); recording in coma or sleep only,3899091,CDM,983,RC,95822,HCPCS,Outpatient,,,111.91,55.96,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
95822 - Electroencephalogram (EEG); recording in coma or sleep only,3800934,CDM,983,RC,95822,HCPCS,Outpatient,,,111.91,55.96,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
95824 - (26) Electroencephalogram (EEG); cerebral death evaluation only,3899093,CDM,983,RC,95824,HCPCS,Outpatient,,,100.94,50.47,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
95824 - Electroencephalogram (EEG); cerebral death evaluation only,3800935,CDM,983,RC,95824,HCPCS,Outpatient,,,100.94,50.47,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
95860 - Needle electromyography; 1 extremity with or without related paraspinal areas,3715346,CDM,510,RC,95860,HCPCS,Outpatient,,,150.34,75.17,,112.76,75,,,percent of total billed charges,75% of total billed charges,112.76,75,,,percent of total billed charges,75% of total billed charges,109.16,100,,,Fee Schedule,100% of CMS OPPS Rate,75.2,100,,,Fee Schedule,100% of WV Medicaid Rate,180.11,165,,,Fee Schedule,165% of CMS OPPS Rate,113.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,313.55,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,430.01,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,538.63,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,75.2,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,109.16,100,,,Fee Schedule,100% of CMS OPPS Rate,113.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,21.05,14,,,percent of total billed charges,14% of total billed charges,21.05,538.63,
95861 - Needle electromyography; 2 extremities with or without related paraspinal areas,3715353,CDM,510,RC,95861,HCPCS,Outpatient,,,198.53,99.27,,148.9,75,,,percent of total billed charges,75% of total billed charges,148.9,75,,,percent of total billed charges,75% of total billed charges,109.16,100,,,Fee Schedule,100% of CMS OPPS Rate,109.63,100,,,Fee Schedule,100% of WV Medicaid Rate,180.11,165,,,Fee Schedule,165% of CMS OPPS Rate,113.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,313.55,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,430.01,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,538.63,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,109.63,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,109.16,100,,,Fee Schedule,100% of CMS OPPS Rate,113.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,27.79,14,,,percent of total billed charges,14% of total billed charges,27.79,538.63,
95863 - Needle electromyography; 3 extremities with or without related paraspinal areas,3715354,CDM,510,RC,95863,HCPCS,Outpatient,,,276.68,138.34,,207.51,75,,,percent of total billed charges,75% of total billed charges,207.51,75,,,percent of total billed charges,75% of total billed charges,136.72,100,,,Fee Schedule,100% of CMS OPPS Rate,142.32,100,,,Fee Schedule,100% of WV Medicaid Rate,225.58,165,,,Fee Schedule,165% of CMS OPPS Rate,141.69,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,392.72,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,538.59,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,674.64,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,142.32,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,136.72,100,,,Fee Schedule,100% of CMS OPPS Rate,141.69,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,38.74,14,,,percent of total billed charges,14% of total billed charges,38.74,674.64,
95864 - Needle electromyography; 4 extremities with or without related paraspinal areas,3715360,CDM,510,RC,95864,HCPCS,Outpatient,,,320.11,160.06,,240.08,75,,,percent of total billed charges,75% of total billed charges,240.08,75,,,percent of total billed charges,75% of total billed charges,136.72,100,,,Fee Schedule,100% of CMS OPPS Rate,158.54,100,,,Fee Schedule,100% of WV Medicaid Rate,225.58,165,,,Fee Schedule,165% of CMS OPPS Rate,141.69,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,392.72,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,538.59,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,674.64,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,158.54,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,136.72,100,,,Fee Schedule,100% of CMS OPPS Rate,141.69,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,44.82,14,,,percent of total billed charges,14% of total billed charges,44.82,674.64,
95869- Needle electromyograp/thor/paraspi,3435479,CDM,510,RC,95869,HCPCS,Outpatient,,,189.03,94.52,,141.77,75,,,percent of total billed charges,75% of total billed charges,141.77,75,,,percent of total billed charges,75% of total billed charges,136.72,100,,,Fee Schedule,100% of CMS OPPS Rate,64.4,100,,,Fee Schedule,100% of WV Medicaid Rate,225.6,165,,,Fee Schedule,165% of CMS OPPS Rate,141.7,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,392.73,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,538.6,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,674.65,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,64.4,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,136.72,100,,,Fee Schedule,100% of CMS OPPS Rate,141.7,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,26.46,14,,,percent of total billed charges,14% of total billed charges,26.46,674.65,
95870- Needle electromyography/lmt/1 ext,3435480,CDM,510,RC,95870,HCPCS,Outpatient,,,158.23,79.12,,118.67,75,,,percent of total billed charges,75% of total billed charges,118.67,75,,,percent of total billed charges,75% of total billed charges,109.16,100,,,Fee Schedule,100% of CMS OPPS Rate,55.8,100,,,Fee Schedule,100% of WV Medicaid Rate,180.11,165,,,Fee Schedule,165% of CMS OPPS Rate,113.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,313.55,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,430.01,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,538.63,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,55.8,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,109.16,100,,,Fee Schedule,100% of CMS OPPS Rate,113.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,22.15,14,,,percent of total billed charges,14% of total billed charges,22.15,538.63,
95873- Electric stim/w chemodenervation,3435482,CDM,510,RC,95873,HCPCS,Outpatient,,,134.25,67.13,,100.69,75,,,percent of total billed charges,75% of total billed charges,100.69,75,,,percent of total billed charges,75% of total billed charges,42.96,32,,,percent of total billed charges,32% of total billed charges,49.16,100,,,Fee Schedule,100% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.16,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.8,14,,,percent of total billed charges,14% of total billed charges,18.8,100.69,
95874- Needle EMG/chemodenervation,3435483,CDM,510,RC,95874,HCPCS,Outpatient,,,143.71,71.86,,107.78,75,,,percent of total billed charges,75% of total billed charges,107.78,75,,,percent of total billed charges,75% of total billed charges,45.99,32,,,percent of total billed charges,32% of total billed charges,51.62,100,,,Fee Schedule,100% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.62,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.12,14,,,percent of total billed charges,14% of total billed charges,20.12,107.78,
Clinic EMG,3435539,CDM,510,RC,95874,HCPCS,Outpatient,,,143.71,71.86,,107.78,75,,,percent of total billed charges,75% of total billed charges,107.78,75,,,percent of total billed charges,75% of total billed charges,45.99,32,,,percent of total billed charges,32% of total billed charges,51.62,100,,,Fee Schedule,100% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.62,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.12,14,,,percent of total billed charges,14% of total billed charges,20.12,107.78,
95885- Needle electromyography/ea ext/lmt,3435485,CDM,510,RC,95885,HCPCS,Outpatient,,,108.99,54.5,,81.74,75,,,percent of total billed charges,75% of total billed charges,81.74,75,,,percent of total billed charges,75% of total billed charges,34.88,32,,,percent of total billed charges,32% of total billed charges,41.79,100,,,Fee Schedule,100% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.79,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.26,14,,,percent of total billed charges,14% of total billed charges,15.26,81.74,
95886- Needle electromyography/ea ext/com,3435486,CDM,510,RC,95886,HCPCS,Outpatient,,,130.28,65.14,,97.71,75,,,percent of total billed charges,75% of total billed charges,97.71,75,,,percent of total billed charges,75% of total billed charges,41.69,32,,,percent of total billed charges,32% of total billed charges,66.12,100,,,Fee Schedule,100% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.12,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.24,14,,,percent of total billed charges,14% of total billed charges,18.24,97.71,
95887- Needle electromyography/non-ext,3435487,CDM,510,RC,95887,HCPCS,Outpatient,,,116.08,58.04,,87.06,75,,,percent of total billed charges,75% of total billed charges,87.06,75,,,percent of total billed charges,75% of total billed charges,37.15,32,,,percent of total billed charges,32% of total billed charges,57.03,100,,,Fee Schedule,100% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,57.03,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.25,14,,,percent of total billed charges,14% of total billed charges,16.25,87.06,
95907- Nerve conduction study/1-2 study,3435491,CDM,510,RC,95907,HCPCS,Outpatient,,,92.71,46.36,,69.53,75,,,percent of total billed charges,75% of total billed charges,69.53,75,,,percent of total billed charges,75% of total billed charges,136.72,100,,,Fee Schedule,100% of CMS OPPS Rate,61.2,100,,,Fee Schedule,100% of WV Medicaid Rate,225.58,165,,,Fee Schedule,165% of CMS OPPS Rate,141.69,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,392.72,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,538.59,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,674.64,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,61.2,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,136.72,100,,,Fee Schedule,100% of CMS OPPS Rate,141.69,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,12.98,14,,,percent of total billed charges,14% of total billed charges,12.98,674.64,
95908- Nerve conduction study/3-4 study,3435492,CDM,510,RC,95908,HCPCS,Outpatient,,,114.8,57.4,,86.1,75,,,percent of total billed charges,75% of total billed charges,86.1,75,,,percent of total billed charges,75% of total billed charges,263.29,100,,,Fee Schedule,100% of CMS OPPS Rate,76.2,100,,,Fee Schedule,100% of WV Medicaid Rate,434.44,165,,,Fee Schedule,165% of CMS OPPS Rate,272.88,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,756.29,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1037.2,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1299.2,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,76.2,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,263.29,100,,,Fee Schedule,100% of CMS OPPS Rate,272.88,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,16.07,14,,,percent of total billed charges,14% of total billed charges,16.07,1299.2,
95909- Nerve conduction study/5-6 study,3435493,CDM,510,RC,95909,HCPCS,Outpatient,,,137.7,68.85,,103.28,75,,,percent of total billed charges,75% of total billed charges,103.28,75,,,percent of total billed charges,75% of total billed charges,263.29,100,,,Fee Schedule,100% of CMS OPPS Rate,91.93,100,,,Fee Schedule,100% of WV Medicaid Rate,434.44,165,,,Fee Schedule,165% of CMS OPPS Rate,272.88,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,756.29,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1037.2,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1299.2,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,91.93,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,263.29,100,,,Fee Schedule,100% of CMS OPPS Rate,272.88,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,19.28,14,,,percent of total billed charges,14% of total billed charges,19.28,1299.2,
95910- Nerve conduction study/7-8 study,3435494,CDM,510,RC,95910,HCPCS,Outpatient,,,174.83,87.42,,131.12,75,,,percent of total billed charges,75% of total billed charges,131.12,75,,,percent of total billed charges,75% of total billed charges,263.29,100,,,Fee Schedule,100% of CMS OPPS Rate,119.95,100,,,Fee Schedule,100% of WV Medicaid Rate,434.44,165,,,Fee Schedule,165% of CMS OPPS Rate,272.88,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,756.29,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1037.2,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1299.2,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,119.95,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,263.29,100,,,Fee Schedule,100% of CMS OPPS Rate,272.88,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,24.48,14,,,percent of total billed charges,14% of total billed charges,24.48,1299.2,
95911- Nerve conduction study/9-10 study,3435495,CDM,510,RC,95911,HCPCS,Outpatient,,,200.89,100.45,,150.67,75,,,percent of total billed charges,75% of total billed charges,150.67,75,,,percent of total billed charges,75% of total billed charges,454.5,100,,,Fee Schedule,100% of CMS OPPS Rate,144.53,100,,,Fee Schedule,100% of WV Medicaid Rate,749.91,165,,,Fee Schedule,165% of CMS OPPS Rate,471.04,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1305.49,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1790.39,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,2242.64,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,144.53,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,454.5,100,,,Fee Schedule,100% of CMS OPPS Rate,471.04,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,28.12,14,,,percent of total billed charges,14% of total billed charges,28.12,2242.64,
95912- Nerve conduction study/11-12 study,3435496,CDM,510,RC,95912,HCPCS,Outpatient,,,225.67,112.84,,169.25,75,,,percent of total billed charges,75% of total billed charges,169.25,75,,,percent of total billed charges,75% of total billed charges,454.5,100,,,Fee Schedule,100% of CMS OPPS Rate,168.86,100,,,Fee Schedule,100% of WV Medicaid Rate,749.91,165,,,Fee Schedule,165% of CMS OPPS Rate,471.04,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1305.49,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1790.39,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,2242.64,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,168.86,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,454.5,100,,,Fee Schedule,100% of CMS OPPS Rate,471.04,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,31.59,14,,,percent of total billed charges,14% of total billed charges,31.59,2242.64,
95913- Nerve conduction studies/13 >,3435497,CDM,510,RC,95913,HCPCS,Outpatient,,,250.13,125.07,,187.6,75,,,percent of total billed charges,75% of total billed charges,187.6,75,,,percent of total billed charges,75% of total billed charges,454.5,100,,,Fee Schedule,100% of CMS OPPS Rate,195.41,100,,,Fee Schedule,100% of WV Medicaid Rate,749.91,165,,,Fee Schedule,165% of CMS OPPS Rate,471.04,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1305.49,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1790.39,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,2242.64,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,195.41,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,454.5,100,,,Fee Schedule,100% of CMS OPPS Rate,471.04,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,35.02,14,,,percent of total billed charges,14% of total billed charges,35.02,2242.64,
95937- Neuromuscular junc test/ea nerve,3435504,CDM,510,RC,95937,HCPCS,Outpatient,,,172.45,86.23,,129.34,75,,,percent of total billed charges,75% of total billed charges,129.34,75,,,percent of total billed charges,75% of total billed charges,136.72,100,,,Fee Schedule,100% of CMS OPPS Rate,70.05,100,,,Fee Schedule,100% of WV Medicaid Rate,225.58,165,,,Fee Schedule,165% of CMS OPPS Rate,141.69,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,392.72,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,538.59,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,674.64,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,70.05,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,136.72,100,,,Fee Schedule,100% of CMS OPPS Rate,141.69,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,24.14,14,,,percent of total billed charges,14% of total billed charges,24.14,674.64,
95970- VNS evaluation,3435519,CDM,510,RC,95970,HCPCS,Outpatient,,,50.05,25.03,,37.54,75,,,percent of total billed charges,75% of total billed charges,37.54,75,,,percent of total billed charges,75% of total billed charges,109.16,100,,,Fee Schedule,100% of CMS OPPS Rate,13.27,100,,,Fee Schedule,100% of WV Medicaid Rate,180.11,165,,,Fee Schedule,165% of CMS OPPS Rate,113.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,313.55,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,430.01,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,538.63,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,13.27,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,109.16,100,,,Fee Schedule,100% of CMS OPPS Rate,113.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,7.01,14,,,percent of total billed charges,14% of total billed charges,7.01,538.63,
95972 - PF Electronic Analysis Neurostimulator Complex Program by Physician/Health Professional,4331193,CDM,960,RC,95972,HCPCS,Outpatient,,,76.88,38.44,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
95976 - (NPB Global) Electronic analysis of implanted neurostimulator pulse generator/transmitter (e,3635241,CDM,510,RC,95976,HCPCS,Outpatient,,,106,53,,79.5,75,,,percent of total billed charges,75% of total billed charges,79.5,75,,,percent of total billed charges,75% of total billed charges,32.9,100,,,Fee Schedule,100% of CMS OPPS Rate,28.02,100,,,Fee Schedule,100% of WV Medicaid Rate,54.28,165,,,Fee Schedule,165% of CMS OPPS Rate,34.1,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,94.51,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,129.62,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,162.36,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,28.02,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,32.9,100,,,Fee Schedule,100% of CMS OPPS Rate,34.1,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,14.84,14,,,percent of total billed charges,14% of total billed charges,14.84,162.36,
"95976 - (PB Tech) Electronic analysis of implanted neurostimulator pulse generator/transmitter (eg,",3635242,CDM,510,RC,95976,HCPCS,Outpatient,,,102.87,51.44,,77.15,75,,,percent of total billed charges,75% of total billed charges,77.15,75,,,percent of total billed charges,75% of total billed charges,32.9,100,,,Fee Schedule,100% of CMS OPPS Rate,28.02,100,,,Fee Schedule,100% of WV Medicaid Rate,54.28,165,,,Fee Schedule,165% of CMS OPPS Rate,34.1,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,94.51,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,129.62,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,162.36,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,28.02,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,32.9,100,,,Fee Schedule,100% of CMS OPPS Rate,34.1,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,14.4,14,,,percent of total billed charges,14% of total billed charges,14.4,162.36,
"95976 - (PF) Electronic analysis of implanted neurostimulator pulse generator/transmitter (eg, conta",3635243,CDM,510,RC,95976,HCPCS,Outpatient,,,106,53,,79.5,75,,,percent of total billed charges,75% of total billed charges,79.5,75,,,percent of total billed charges,75% of total billed charges,32.9,100,,,Fee Schedule,100% of CMS OPPS Rate,28.02,100,,,Fee Schedule,100% of WV Medicaid Rate,54.28,165,,,Fee Schedule,165% of CMS OPPS Rate,34.1,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,94.51,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,129.62,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,162.36,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,28.02,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,32.9,100,,,Fee Schedule,100% of CMS OPPS Rate,34.1,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,14.84,14,,,percent of total billed charges,14% of total billed charges,14.84,162.36,
"95976- Electronic analysis of implanted neurostimulator pulse generator/transmitter (eg, contact gro",3692914,CDM,510,RC,95976,HCPCS,Outpatient,,,106,53,,79.5,75,,,percent of total billed charges,75% of total billed charges,79.5,75,,,percent of total billed charges,75% of total billed charges,32.9,100,,,Fee Schedule,100% of CMS OPPS Rate,28.02,100,,,Fee Schedule,100% of WV Medicaid Rate,54.28,165,,,Fee Schedule,165% of CMS OPPS Rate,34.1,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,94.51,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,129.62,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,162.36,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,28.02,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,32.9,100,,,Fee Schedule,100% of CMS OPPS Rate,34.1,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,14.84,14,,,percent of total billed charges,14% of total billed charges,14.84,162.36,
"95977 - Electronic analysis of implanted neurostimulator pulse generator/transmitter (eg, contact gr",3715361,CDM,510,RC,95977,HCPCS,Outpatient,,,139.77,69.89,,104.83,75,,,percent of total billed charges,75% of total billed charges,104.83,75,,,percent of total billed charges,75% of total billed charges,93.83,100,,,Fee Schedule,100% of CMS OPPS Rate,36.61,100,,,Fee Schedule,100% of WV Medicaid Rate,154.82,165,,,Fee Schedule,165% of CMS OPPS Rate,97.24,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,269.52,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,369.64,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,463.01,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,36.61,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,93.83,100,,,Fee Schedule,100% of CMS OPPS Rate,97.24,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,19.57,14,,,percent of total billed charges,14% of total billed charges,19.57,463.01,
"95977-  Electronic analysis of implanted neurostimulator pulse generator/transmitter (eg, contact gr",3692915,CDM,510,RC,95977,HCPCS,Outpatient,,,139.77,69.89,,104.83,75,,,percent of total billed charges,75% of total billed charges,104.83,75,,,percent of total billed charges,75% of total billed charges,93.83,100,,,Fee Schedule,100% of CMS OPPS Rate,36.61,100,,,Fee Schedule,100% of WV Medicaid Rate,154.82,165,,,Fee Schedule,165% of CMS OPPS Rate,97.24,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,269.52,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,369.64,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,463.01,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,36.61,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,93.83,100,,,Fee Schedule,100% of CMS OPPS Rate,97.24,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,19.57,14,,,percent of total billed charges,14% of total billed charges,19.57,463.01,
95992 - Epley Maneuver,3575063,CDM,510,RC,95992,HCPCS,Outpatient,,,112.12,56.06,,84.09,75,,,percent of total billed charges,75% of total billed charges,84.09,75,,,percent of total billed charges,75% of total billed charges,35.29,100,,,Fee Schedule,100% of CMS OPPS Rate,25.56,100,,,Fee Schedule,100% of WV Medicaid Rate,58.23,165,,,Fee Schedule,165% of CMS OPPS Rate,34.43,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,125.12,354.54,,,Fee Schedule,354.54% of CMS OPPS Fee Schedule Rate,151.29,428.7,,,Fee Schedule,428.7% of CMS OPPS Fee Schedule Rate,159.09,450.81,,,Fee Schedule,450.81% of CMS OPPS Fee Schedule Rate,25.56,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,35.29,100,,,Fee Schedule,100% of CMS OPPS Rate,34.43,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,15.7,14,,,percent of total billed charges,14% of total billed charges,15.7,159.09,
96105- Asses aphasia/interp/rpt/per hr,3435448,CDM,510,RC,96105,HCPCS,Outpatient,,,254.2,127.1,,190.65,75,,,percent of total billed charges,75% of total billed charges,190.65,75,,,percent of total billed charges,75% of total billed charges,94.19,100,,,Fee Schedule,100% of CMS OPPS Rate,67.84,100,,,Fee Schedule,100% of WV Medicaid Rate,155.41,165,,,Fee Schedule,165% of CMS OPPS Rate,91.89,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,333.94,354.54,,,Fee Schedule,354.54% of CMS OPPS Fee Schedule Rate,403.79,428.7,,,Fee Schedule,428.7% of CMS OPPS Fee Schedule Rate,424.62,450.81,,,Fee Schedule,450.81% of CMS OPPS Fee Schedule Rate,67.84,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,94.19,100,,,Fee Schedule,100% of CMS OPPS Rate,91.89,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,35.59,14,,,percent of total billed charges,14% of total billed charges,35.59,424.62,
96110- Developmental screen/score/documen,3435449,CDM,920,RC,96110,HCPCS,Outpatient,,,26.83,13.42,,20.12,75,,,percent of total billed charges,75% of total billed charges,20.12,75,,,percent of total billed charges,75% of total billed charges,8.59,32,,,percent of total billed charges,32% of total billed charges,6.64,100,,,Fee Schedule,100% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.64,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.76,14,,,percent of total billed charges,14% of total billed charges,3.76,20.12,
96110- Developmental Screening,3437848,CDM,983,RC,96110,HCPCS,Outpatient,,,26.83,13.42,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
96116- Neurobehavioral status exam/hr,3435451,CDM,510,RC,96116,HCPCS,Outpatient,,,245.86,122.93,,184.4,75,,,percent of total billed charges,75% of total billed charges,184.4,75,,,percent of total billed charges,75% of total billed charges,263.29,100,,,Fee Schedule,100% of CMS OPPS Rate,57.76,100,,,Fee Schedule,100% of WV Medicaid Rate,434.44,165,,,Fee Schedule,165% of CMS OPPS Rate,272.88,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,756.29,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1037.2,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1299.2,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,57.76,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,263.29,100,,,Fee Schedule,100% of CMS OPPS Rate,272.88,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,34.42,14,,,percent of total billed charges,14% of total billed charges,34.42,1299.2,
96116- Neuropsychological Assessment,3437849,CDM,983,RC,96116,HCPCS,Outpatient,,,245.86,122.93,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
96125- Stand cognitive perf test/prof I&R,3435455,CDM,510,RC,96125,HCPCS,Outpatient,,,266.64,133.32,,199.98,75,,,percent of total billed charges,75% of total billed charges,199.98,75,,,percent of total billed charges,75% of total billed charges,97.77,100,,,Fee Schedule,100% of CMS OPPS Rate,71.28,100,,,Fee Schedule,100% of WV Medicaid Rate,161.32,165,,,Fee Schedule,165% of CMS OPPS Rate,95.39,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,346.63,354.54,,,Fee Schedule,354.54% of CMS OPPS Fee Schedule Rate,419.14,428.7,,,Fee Schedule,428.7% of CMS OPPS Fee Schedule Rate,440.76,450.81,,,Fee Schedule,450.81% of CMS OPPS Fee Schedule Rate,71.28,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,97.77,100,,,Fee Schedule,100% of CMS OPPS Rate,95.39,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,37.33,14,,,percent of total billed charges,14% of total billed charges,37.33,440.76,
96125- Standardized Cognitive Performance Testing Per Hr,3435456,CDM,510,RC,96125,HCPCS,Outpatient,,,266.64,133.32,,199.98,75,,,percent of total billed charges,75% of total billed charges,199.98,75,,,percent of total billed charges,75% of total billed charges,97.77,100,,,Fee Schedule,100% of CMS OPPS Rate,71.28,100,,,Fee Schedule,100% of WV Medicaid Rate,161.32,165,,,Fee Schedule,165% of CMS OPPS Rate,95.39,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,346.63,354.54,,,Fee Schedule,354.54% of CMS OPPS Fee Schedule Rate,419.14,428.7,,,Fee Schedule,428.7% of CMS OPPS Fee Schedule Rate,440.76,450.81,,,Fee Schedule,450.81% of CMS OPPS Fee Schedule Rate,71.28,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,97.77,100,,,Fee Schedule,100% of CMS OPPS Rate,95.39,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,37.33,14,,,percent of total billed charges,14% of total billed charges,37.33,440.76,
"96127- Brief emotional/behavioral assessment (eg, depression inventory, attention-deficit/hyperactiv",3566798,CDM,510,RC,96127,HCPCS,Outpatient,,,11.38,5.69,,8.54,75,,,percent of total billed charges,75% of total billed charges,8.54,75,,,percent of total billed charges,75% of total billed charges,31.92,100,,,Fee Schedule,100% of CMS OPPS Rate,2.95,100,,,Fee Schedule,100% of WV Medicaid Rate,52.68,165,,,Fee Schedule,165% of CMS OPPS Rate,33.09,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,91.7,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,125.77,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,157.54,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,2.95,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,31.92,100,,,Fee Schedule,100% of CMS OPPS Rate,33.09,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1.59,14,,,percent of total billed charges,14% of total billed charges,1.59,157.54,
96156 - Health Coach Assessment,3635244,CDM,510,RC,96156,HCPCS,Outpatient,,,180.73,90.37,,135.55,75,,,percent of total billed charges,75% of total billed charges,135.55,75,,,percent of total billed charges,75% of total billed charges,71.29,100,,,Fee Schedule,100% of CMS OPPS Rate,60.96,100,,,Fee Schedule,100% of WV Medicaid Rate,117.66,165,,,Fee Schedule,165% of CMS OPPS Rate,73.9,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,204.82,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,280.89,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,351.86,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,60.96,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,71.29,100,,,Fee Schedule,100% of CMS OPPS Rate,73.9,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,25.3,14,,,percent of total billed charges,14% of total billed charges,25.3,351.86,
96158 - Health Coach Initial 30 Mins,3635247,CDM,510,RC,96158,HCPCS,Outpatient,,,121.18,60.59,,90.89,75,,,percent of total billed charges,75% of total billed charges,90.89,75,,,percent of total billed charges,75% of total billed charges,71.29,100,,,Fee Schedule,100% of CMS OPPS Rate,41.79,100,,,Fee Schedule,100% of WV Medicaid Rate,117.66,165,,,Fee Schedule,165% of CMS OPPS Rate,73.9,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,204.82,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,280.89,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,351.86,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,41.79,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,71.29,100,,,Fee Schedule,100% of CMS OPPS Rate,73.9,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,16.97,14,,,percent of total billed charges,14% of total billed charges,16.97,351.86,
96159 - Health Coach Add 15 Mins,3635250,CDM,983,RC,96159,HCPCS,Outpatient,,,40.62,20.31,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
CT RAD Hydration Initial,3348347,CDM,940,RC,96360,HCPCS,Outpatient,,,326.9,163.45,,245.18,75,,,percent of total billed charges,75% of total billed charges,245.18,75,,,percent of total billed charges,75% of total billed charges,194.2,100,,,Fee Schedule,100% of CMS OPPS Rate,21.88,100,,,Fee Schedule,100% of WV Medicaid Rate,320.44,165,,,Fee Schedule,165% of CMS OPPS Rate,201.28,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,557.84,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,765.02,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,958.27,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,21.88,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,194.2,100,,,Fee Schedule,100% of CMS OPPS Rate,201.28,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,45.77,14,,,percent of total billed charges,14% of total billed charges,21.88,958.27,
CT RAD Hydration Add?l Hours,3348349,CDM,940,RC,96361,HCPCS,Outpatient,,,38.16,19.08,,28.62,75,,,percent of total billed charges,75% of total billed charges,28.62,75,,,percent of total billed charges,75% of total billed charges,39.83,100,,,Fee Schedule,100% of CMS OPPS Rate,8.36,100,,,Fee Schedule,100% of WV Medicaid Rate,65.72,165,,,Fee Schedule,165% of CMS OPPS Rate,41.28,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,114.41,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,156.91,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,196.54,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,8.36,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,39.83,100,,,Fee Schedule,100% of CMS OPPS Rate,41.28,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,5.34,14,,,percent of total billed charges,14% of total billed charges,5.34,196.54,
96369 - SUBCUTANEOUS INFUSION INITIAL 1 HR W/PUMP SET-UP,3442011,CDM,940,RC,96369,HCPCS,Outpatient,,,326.9,163.45,,245.18,75,,,percent of total billed charges,75% of total billed charges,245.18,75,,,percent of total billed charges,75% of total billed charges,194.2,100,,,Fee Schedule,100% of CMS OPPS Rate,90.95,100,,,Fee Schedule,100% of WV Medicaid Rate,320.44,165,,,Fee Schedule,165% of CMS OPPS Rate,201.28,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,557.84,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,765.02,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,958.27,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,90.95,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,194.2,100,,,Fee Schedule,100% of CMS OPPS Rate,201.28,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,45.77,14,,,percent of total billed charges,14% of total billed charges,45.77,958.27,
96370 - SUBCUTANEOUS INFUSION EACH ADDITIONAL HOUR,3442012,CDM,940,RC,96370,HCPCS,Outpatient,,,38.16,19.08,,28.62,75,,,percent of total billed charges,75% of total billed charges,28.62,75,,,percent of total billed charges,75% of total billed charges,39.83,100,,,Fee Schedule,100% of CMS OPPS Rate,10.08,100,,,Fee Schedule,100% of WV Medicaid Rate,65.72,165,,,Fee Schedule,165% of CMS OPPS Rate,41.28,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,114.41,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,156.91,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,196.54,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,10.08,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,39.83,100,,,Fee Schedule,100% of CMS OPPS Rate,41.28,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,5.34,14,,,percent of total billed charges,14% of total billed charges,5.34,196.54,
96371 - SUBQ INFUSION ADDITIONAL PUMP INFUSION SITE,3442013,CDM,940,RC,96371,HCPCS,Outpatient,,,129.74,64.87,,97.31,75,,,percent of total billed charges,75% of total billed charges,97.31,75,,,percent of total billed charges,75% of total billed charges,63.43,100,,,Fee Schedule,100% of CMS OPPS Rate,36.38,100,,,Fee Schedule,100% of WV Medicaid Rate,104.66,165,,,Fee Schedule,165% of CMS OPPS Rate,65.74,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,182.2,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,249.87,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,312.99,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,36.38,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,63.43,100,,,Fee Schedule,100% of CMS OPPS Rate,65.74,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,18.16,14,,,percent of total billed charges,14% of total billed charges,18.16,312.99,
96372 - IM/SQ injectin,3918946,CDM,510,RC,96372,HCPCS,Outpatient,,,27.69,13.85,,20.77,75,,,percent of total billed charges,75% of total billed charges,20.77,75,,,percent of total billed charges,75% of total billed charges,63.43,100,,,Fee Schedule,100% of CMS OPPS Rate,9.59,100,,,Fee Schedule,100% of WV Medicaid Rate,104.66,165,,,Fee Schedule,165% of CMS OPPS Rate,65.74,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,182.2,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,249.87,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,312.99,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,9.59,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,63.43,100,,,Fee Schedule,100% of CMS OPPS Rate,65.74,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,3.88,14,,,percent of total billed charges,14% of total billed charges,3.88,312.99,
96373-PF THERAPEUTIC PROPHYLACTIC/DX NJX INTRA-ARTERIAL,4321511,CDM,981,RC,96373,HCPCS,Outpatient,,,33.36,16.68,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
96374-PF THER PROPH/DX NJX IV PUSH SINGLE/1ST SBST/DRUG,4321569,CDM,981,RC,96374,HCPCS,Outpatient,,,68.2,34.1,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
96401-PF CHEMOTX ADMN SUBQ/IM NON-HORMONAL ANTI-NEO,4321567,CDM,981,RC,96401,HCPCS,Outpatient,,,129.58,64.79,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
96402-PF CHEMOTX ADMN SUBQ/IM HORMONAL ANTI-NEO,4321566,CDM,981,RC,96402,HCPCS,Outpatient,,,61.22,30.61,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
Chemotherapy SQ or IM Hormonal Anti-Neoplastic 96402,3427863,CDM,331,RC,96402,HCPCS,Outpatient,,,80.5,40.25,,60.38,75,,,percent of total billed charges,75% of total billed charges,60.38,75,,,percent of total billed charges,75% of total billed charges,63.43,100,,,Fee Schedule,100% of CMS OPPS Rate,21.38,100,,,Fee Schedule,100% of WV Medicaid Rate,104.66,165,,,Fee Schedule,165% of CMS OPPS Rate,65.74,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,182.2,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,249.87,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,312.99,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,21.38,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,63.43,100,,,Fee Schedule,100% of CMS OPPS Rate,65.74,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,11.27,14,,,percent of total billed charges,14% of total billed charges,11.27,312.99,
96409-PF CHEMOTX ADMN IV PUSH TQ 1/1ST SBST/DRUG,4321565,CDM,981,RC,96409,HCPCS,Outpatient,,,179.36,89.68,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
96411-PF CHEMOTX ADMN IV PUSH TQ EA SBST/DRUG,4321564,CDM,981,RC,96411,HCPCS,Outpatient,,,99.18,49.59,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
96413-PF CHEMOTX ADMN IV NFS TQ UP 1 HR 1/1ST SBST/DRUG,4321563,CDM,981,RC,96413,HCPCS,Outpatient,,,231.9,115.95,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
96415-PF CHEMOTHERAPY ADMN IV INFUSION TQ EA HR,4321562,CDM,981,RC,96415,HCPCS,Outpatient,,,51.32,25.66,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
96567- Photodynam tx/pre/malig skin lesio,3437853,CDM,983,RC,96567,HCPCS,Outpatient,,,339.06,169.53,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
96570- Photodynamic endoscop tx/frst 30mi,3437854,CDM,983,RC,96570,HCPCS,Outpatient,,,136.42,68.21,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
96571- Photodynamic endoscop tx/add 15 mi,3437855,CDM,983,RC,96571,HCPCS,Outpatient,,,67.66,33.83,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
96920 Excimer lsr psriasis<250sqcm,3431074,CDM,940,RC,96920,HCPCS,Outpatient,,,125.14,62.57,,93.86,75,,,percent of total billed charges,75% of total billed charges,93.86,75,,,percent of total billed charges,75% of total billed charges,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,43.75,100,,,Fee Schedule,100% of WV Medicaid Rate,280.12,165,,,Fee Schedule,165% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,487.65,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,668.78,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,837.71,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,43.75,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,17.52,14,,,percent of total billed charges,14% of total billed charges,17.52,837.71,
96921- Excimer lsr psriasis 250-500,3431095,CDM,940,RC,96921,HCPCS,Outpatient,,,141.87,70.94,,106.4,75,,,percent of total billed charges,75% of total billed charges,106.4,75,,,percent of total billed charges,75% of total billed charges,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,48.91,100,,,Fee Schedule,100% of WV Medicaid Rate,280.12,165,,,Fee Schedule,165% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,487.65,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,668.78,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,837.71,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,48.91,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,19.86,14,,,percent of total billed charges,14% of total billed charges,19.86,837.71,
97010-HOT/COLD PACKS,3430549,CDM,421,RC,97010,HCPCS,Outpatient,,,12.27,6.14,,9.2,75,,,percent of total billed charges,75% of total billed charges,9.2,75,,,percent of total billed charges,75% of total billed charges,5.95,100,,,Fee Schedule,100% of CMS OPPS Rate,3.93,100,,,Fee Schedule,100% of WV Medicaid Rate,9.82,165,,,Fee Schedule,165% of CMS OPPS Rate,5.81,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,21.1,354.54,,,Fee Schedule,354.54% of CMS OPPS Fee Schedule Rate,25.51,428.7,,,Fee Schedule,428.7% of CMS OPPS Fee Schedule Rate,26.82,450.81,,,Fee Schedule,450.81% of CMS OPPS Fee Schedule Rate,3.93,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,5.95,100,,,Fee Schedule,100% of CMS OPPS Rate,5.81,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,1.72,14,,,percent of total billed charges,14% of total billed charges,1.72,26.82,
97014-PT E-STIM UNATTENDED(WOUND),3430550,CDM,421,RC,97014,HCPCS,Outpatient,,,24.19,12.1,,18.14,75,,,percent of total billed charges,75% of total billed charges,18.14,75,,,percent of total billed charges,75% of total billed charges,7.74,32,,,percent of total billed charges,32% of total billed charges,8.36,100,,,Fee Schedule,100% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.36,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.39,14,,,percent of total billed charges,14% of total billed charges,3.39,18.14,
97026-INFRARED,3430551,CDM,420,RC,97026,HCPCS,Outpatient,,,12.87,6.44,,9.65,75,,,percent of total billed charges,75% of total billed charges,9.65,75,,,percent of total billed charges,75% of total billed charges,6.25,100,,,Fee Schedule,100% of CMS OPPS Rate,4.18,100,,,Fee Schedule,100% of WV Medicaid Rate,10.31,165,,,Fee Schedule,165% of CMS OPPS Rate,6.09,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,22.16,354.54,,,Fee Schedule,354.54% of CMS OPPS Fee Schedule Rate,26.79,428.7,,,Fee Schedule,428.7% of CMS OPPS Fee Schedule Rate,28.18,450.81,,,Fee Schedule,450.81% of CMS OPPS Fee Schedule Rate,4.18,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,6.25,100,,,Fee Schedule,100% of CMS OPPS Rate,6.09,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,1.8,14,,,percent of total billed charges,14% of total billed charges,1.8,28.18,
97035-PT ULTRASOUND(WOUND),3430552,CDM,420,RC,97035,HCPCS,Outpatient,,,27.48,13.74,,20.61,75,,,percent of total billed charges,75% of total billed charges,20.61,75,,,percent of total billed charges,75% of total billed charges,13.66,100,,,Fee Schedule,100% of CMS OPPS Rate,9.59,100,,,Fee Schedule,100% of WV Medicaid Rate,22.54,165,,,Fee Schedule,165% of CMS OPPS Rate,13.33,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,48.43,354.54,,,Fee Schedule,354.54% of CMS OPPS Fee Schedule Rate,58.56,428.7,,,Fee Schedule,428.7% of CMS OPPS Fee Schedule Rate,61.58,450.81,,,Fee Schedule,450.81% of CMS OPPS Fee Schedule Rate,9.59,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,13.66,100,,,Fee Schedule,100% of CMS OPPS Rate,13.33,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,3.85,14,,,percent of total billed charges,14% of total billed charges,3.85,61.58,
97039-LASER/OTHER,3430553,CDM,420,RC,97039,HCPCS,Outpatient,,,57.3,28.65,,42.98,75,,,percent of total billed charges,75% of total billed charges,42.98,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.02,14,,,percent of total billed charges,14% of total billed charges,8.02,42.98,
97597 - PF Debridement Open Wound 20 sq cm/<,4311874,CDM,960,RC,97597,HCPCS,Outpatient,,,72.16,36.08,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
97597- Debrid/select/1st 20 sq cm or less,3430558,CDM,420,RC,97597,HCPCS,Outpatient,,,72.16,36.08,,54.12,75,,,percent of total billed charges,75% of total billed charges,54.12,75,,,percent of total billed charges,75% of total billed charges,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,25.56,100,,,Fee Schedule,100% of WV Medicaid Rate,280.12,165,,,Fee Schedule,165% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,487.65,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,668.77,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,837.71,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,25.56,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,10.1,14,,,percent of total billed charges,14% of total billed charges,10.1,837.71,
97597-PF DEBRIDEMENT OPEN WOUND 20 SQ CM/<,4321561,CDM,981,RC,97597,HCPCS,Outpatient,,,72.16,36.08,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
Selective Debridement <20 sq centimeters,845982,CDM,420,RC,97597,HCPCS,Outpatient,,,72.16,36.08,,54.12,75,,,percent of total billed charges,75% of total billed charges,54.12,75,,,percent of total billed charges,75% of total billed charges,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,25.56,100,,,Fee Schedule,100% of WV Medicaid Rate,280.12,165,,,Fee Schedule,165% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,487.65,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,668.77,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,837.71,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,25.56,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,10.1,14,,,percent of total billed charges,14% of total billed charges,10.1,837.71,
"97598 - Debridement (eg, high pressure waterjet with/without suction, sharp selective debridement wi",3715362,CDM,510,RC,97598,HCPCS,Outpatient,,,50.43,25.22,,37.82,75,,,percent of total billed charges,75% of total billed charges,37.82,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,17.94,100,,,Fee Schedule,100% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.94,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.06,14,,,percent of total billed charges,14% of total billed charges,7.06,37.82,
"97598 - PF Debridement (eg, high pressure waterjet with/without suction, sharp selective debridement",3715337,CDM,960,RC,97598,HCPCS,Outpatient,,,50.43,25.22,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
"97602 -Removal of devitalized tissue from wound(s), non-selective debridement, without anesthesia (e",3641199,CDM,510,RC,97602,HCPCS,Outpatient,,,48.68,24.34,,36.51,75,,,percent of total billed charges,75% of total billed charges,36.51,75,,,percent of total billed charges,75% of total billed charges,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,280.12,165,,,Fee Schedule,165% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,487.65,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,668.78,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,837.71,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,6.82,14,,,percent of total billed charges,14% of total billed charges,6.82,837.71,
Debridement Non-Selective,3428412,CDM,761,RC,97602,HCPCS,Outpatient,,,48.68,24.34,,36.51,75,,,percent of total billed charges,75% of total billed charges,36.51,75,,,percent of total billed charges,75% of total billed charges,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,280.12,165,,,Fee Schedule,165% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,487.65,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,668.78,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,837.71,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,6.82,14,,,percent of total billed charges,14% of total billed charges,6.82,837.71,
97605 Neg press wound tx,3428369,CDM,983,RC,97605,HCPCS,Outpatient,,,48.68,24.34,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
97606- Neg press wound therapy/>50 sq cm,3430560,CDM,510,RC,97606,HCPCS,Outpatient,,,53.34,26.67,,40.01,75,,,percent of total billed charges,75% of total billed charges,40.01,75,,,percent of total billed charges,75% of total billed charges,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,18.93,100,,,Fee Schedule,100% of WV Medicaid Rate,578.73,165,,,Fee Schedule,165% of CMS OPPS Rate,363.52,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1007.47,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1381.67,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1730.68,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,18.93,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,363.52,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,7.47,14,,,percent of total billed charges,14% of total billed charges,7.47,1730.68,
97802- PF Medical Nurtition Assmt&Intrvnt Indv F2F ea 15min,4349185,CDM,960,RC,97802,HCPCS,Outpatient,,,58.72,29.36,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
99151-Moderate Sedation Initial,3432113,CDM,370,RC,99151,HCPCS,Outpatient,,,170.44,85.22,,127.83,75,,,percent of total billed charges,75% of total billed charges,127.83,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,17.45,100,,,Fee Schedule,100% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.45,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.86,14,,,percent of total billed charges,14% of total billed charges,17.45,127.83,
99151-PF Mod Sed Same Phys/QHP <5Yrs,4321559,CDM,981,RC,99151,HCPCS,Outpatient,,,47.82,23.91,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
99152-Moderate Sedation Initial,3432114,CDM,963,RC,99152,HCPCS,Outpatient,,,287.26,143.63,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
"99152-PF Moderate Sedation, Initial 15 Minute",4321558,CDM,981,RC,99152,HCPCS,Outpatient,,,25.04,12.52,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
"99153-PF Moderate Sedation, Each Add 15 Min",4321557,CDM,981,RC,99153,HCPCS,Outpatient,,,19.78,9.89,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
99155-PF MOD SED OTHER PHYS/QHP INITIAL 15 MINS <5 YRS,4321512,CDM,981,RC,99155,HCPCS,Outpatient,,,165.74,82.87,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
99156-PF MOD SED OTHER PHYS/QHP INITIAL 15 MINS 5/> YRS,4321513,CDM,981,RC,99156,HCPCS,Outpatient,,,151.16,75.58,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
99157-PF MOD SED OTHER PHYS/QHP EACH ADDL 15 MINS,4321514,CDM,981,RC,99157,HCPCS,Outpatient,,,121.56,60.78,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
99170- Anogen exam/child/suspect trauma,3437884,CDM,983,RC,99170,HCPCS,Outpatient,,,404.54,202.27,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
99175- Ipecac/sim admin for emesis w/obs,3437887,CDM,983,RC,99175,HCPCS,Outpatient,,,67.45,33.73,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
99183- MD/NPP/sv/hyperbaric O2 tx/ea ses,3437888,CDM,983,RC,99183,HCPCS,Outpatient,,,216.6,108.3,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
99184- Initiate hyperthermia for critically ill nenoate,3437889,CDM,983,RC,99184,HCPCS,Outpatient,,,570.68,285.34,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
99195-PF PHLEBOTOMY THERAPEUTIC SEPARATE PROCEDURE,4321515,CDM,981,RC,99195,HCPCS,Outpatient,,,170.68,85.34,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
99202 Office Outpt visist new StrFrwd or 15 to 29 mins,3572774,CDM,510,RC,99202,HCPCS,Outpatient,,,95.89,47.95,,71.92,75,,,percent of total billed charges,75% of total billed charges,71.92,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,34.17,100,,,Fee Schedule,100% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.17,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.42,14,,,percent of total billed charges,14% of total billed charges,13.42,71.92,
99203 Office Outpt visit new Low or 30 to 44 mins,3572775,CDM,510,RC,99203,HCPCS,Outpatient,,,166.57,83.29,,124.93,75,,,percent of total billed charges,75% of total billed charges,124.93,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,58.25,100,,,Fee Schedule,100% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,58.25,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.32,14,,,percent of total billed charges,14% of total billed charges,23.32,124.93,
99204 Office Outpt visit new Mod or 45 to 59 mins,3572776,CDM,510,RC,99204,HCPCS,Outpatient,,,270.32,135.16,,202.74,75,,,percent of total billed charges,75% of total billed charges,202.74,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,94.39,100,,,Fee Schedule,100% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,94.39,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.84,14,,,percent of total billed charges,14% of total billed charges,37.84,202.74,
99205 Office Outpt visist new High 60 to 74 mins,3572777,CDM,510,RC,99205,HCPCS,Outpatient,,,367.44,183.72,,275.58,75,,,percent of total billed charges,75% of total billed charges,275.58,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,127.82,100,,,Fee Schedule,100% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,127.82,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.44,14,,,percent of total billed charges,14% of total billed charges,51.44,275.58,
99211 Office outpatient visit est  nursing visit only,3572778,CDM,510,RC,99211,HCPCS,Outpatient,,,17.62,8.81,,13.22,75,,,percent of total billed charges,75% of total billed charges,13.22,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.47,14,,,percent of total billed charges,14% of total billed charges,2.47,13.22,
99212 Office Outpt visit est Strtforward or 10 to 19 mins,3572779,CDM,510,RC,99212,HCPCS,Outpatient,,,71.51,35.76,,53.63,75,,,percent of total billed charges,75% of total billed charges,53.63,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.01,14,,,percent of total billed charges,14% of total billed charges,10.01,53.63,
"99212-PF Outpatient Visit, Estab. Level II",4331996,CDM,981,RC,99212,HCPCS,Outpatient,,,71.51,35.76,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
"99212-PF Outpatient Visit, Estab. Level II W/Mod",4331997,CDM,981,RC,99212,HCPCS,Outpatient,,,71.51,35.76,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
99213- Office/OP Est SF 20 Minutes,3572780,CDM,510,RC,99213,HCPCS,Outpatient,,,133.01,66.51,,99.76,75,,,percent of total billed charges,75% of total billed charges,99.76,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.62,14,,,percent of total billed charges,14% of total billed charges,18.62,99.76,
99214- Office/OP Est Mod 30 Minutes,3572781,CDM,510,RC,99214,HCPCS,Outpatient,,,195.91,97.96,,146.93,75,,,percent of total billed charges,75% of total billed charges,146.93,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.43,14,,,percent of total billed charges,14% of total billed charges,27.43,146.93,
99214-PRO FEE ESTABLISHED PATIENT LEVEL 4 (30-39 min),3435840,CDM,983,RC,99214,HCPCS,Outpatient,,,254.68,127.34,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
99215 Office Outpatient visit est High or 40 to 54 minutes,3572782,CDM,510,RC,99215,HCPCS,Outpatient,,,290.72,145.36,,218.04,75,,,percent of total billed charges,75% of total billed charges,218.04,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.7,14,,,percent of total billed charges,14% of total billed charges,40.7,218.04,
99221- Initial Hospital IP/OBS Care SF/Low MDM (40 min),3437912,CDM,983,RC,99221,HCPCS,Outpatient,,,261.44,130.72,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
99222- Initial Hospital IP/OBS Care Mod MDM (55 min),3437914,CDM,983,RC,99222,HCPCS,Outpatient,,,349.73,174.87,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
99223-Initial Hospital IP/OBS Care High MDM (75 min),3437916,CDM,983,RC,99223,HCPCS,Outpatient,,,511.97,255.99,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
99231- Sbsq Hospital IP/OBS Care SF/Low MDM (25 min),3437923,CDM,983,RC,99231,HCPCS,Outpatient,,,100.54,50.27,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
99232- Sbsq Hospital IP/OBS Care Mod MDM (35 min),3437925,CDM,983,RC,99232,HCPCS,Outpatient,,,183.94,91.97,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
99233- Sbsq Hospital IP/OBS Care High MDM (50 min),3437927,CDM,983,RC,99233,HCPCS,Outpatient,,,264.24,132.12,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
99234- Hospital IP/OBS Care Same Date SF/Low MDM (45 min),3437930,CDM,983,RC,99234,HCPCS,Outpatient,,,338.03,169.02,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
99234-PF HOSPITAL IP/OBS CARE SAME DATE SF/LOW MDM 45 MIN,4321516,CDM,981,RC,99234,HCPCS,Outpatient,,,194.12,97.06,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
99235- Hospital IP/OBS Care Same Date Mod MDM (70 min),3437932,CDM,983,RC,99235,HCPCS,Outpatient,,,427.28,213.64,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
99235-PF HOSPITAL IP/OBS CARE SAME DATE MOD MDM 70 MIN,4321517,CDM,981,RC,99235,HCPCS,Outpatient,,,311.6,155.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
99236- Hospital IP/OBS Care Same Date High MDM (85 min),3437934,CDM,983,RC,99236,HCPCS,Outpatient,,,547.82,273.91,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
99236-PF HOSPITAL IP/OBS CARE SAME DATE HIGH MDM 85 MIN,4321520,CDM,981,RC,99236,HCPCS,Outpatient,,,408.68,204.34,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
99238- Hospital IP/OBS Discharge Day Mgmt 30 Min/Less than,3437936,CDM,983,RC,99238,HCPCS,Outpatient,,,183.79,91.9,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
99238-PF HOSPITAL IP/OBS DISCHARGE DAY MGMT 30 MIN/<,4321521,CDM,981,RC,99238,HCPCS,Outpatient,,,156.56,78.28,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
99239- Hospital IP/OBS Discharge Day Mgmt > 30 Min,3437938,CDM,983,RC,99239,HCPCS,Outpatient,,,268.61,134.31,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
99239-PF HOSPITAL IP/OBS DISCHARGE DAY MGMT > 30 MIN,4321522,CDM,981,RC,99239,HCPCS,Outpatient,,,222.66,111.33,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
99242- Office Consult Level 2,3437940,CDM,983,RC,99242,HCPCS,Outpatient,,,275.24,137.62,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
99243- Office Consult New/Est PT Low MDM Level 3 (30 min),3437941,CDM,983,RC,99243,HCPCS,Outpatient,,,585.55,292.78,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
99244- Office Consult New/Est PT Mod MDM Level 4 (40 min),3437942,CDM,983,RC,99244,HCPCS,Outpatient,,,603.67,301.84,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
99245- Office Consult New/Est PT High MDM Level 5 (55 min),3437943,CDM,983,RC,99245,HCPCS,Outpatient,,,848.33,424.17,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
99252- Initl IP/OBS Consult New/Est Pt SF MDM (35 min),3437946,CDM,983,RC,99252,HCPCS,Outpatient,,,202.11,101.06,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
99253- Initl IP/OBV Consult New/Est Pt Low MDM (45 min),3437947,CDM,510,RC,99253,HCPCS,Outpatient,,,425.49,212.75,,319.12,75,,,percent of total billed charges,75% of total billed charges,319.12,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,79.39,100,,,Fee Schedule,100% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,79.39,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,59.57,14,,,percent of total billed charges,14% of total billed charges,59.57,319.12,
99254- Initl IP/OBV Consult New/Est Pt Mod MDM (60 min),3437948,CDM,510,RC,99254,HCPCS,Outpatient,,,612.98,306.49,,459.74,75,,,percent of total billed charges,75% of total billed charges,459.74,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,114.3,100,,,Fee Schedule,100% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,114.3,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,85.82,14,,,percent of total billed charges,14% of total billed charges,85.82,459.74,
99255- Initl IP/OBS Consult New/Est Pt High MDM (80 min),3437949,CDM,983,RC,99255,HCPCS,Outpatient,,,760.57,380.29,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
99281- Emergency dept visit,3437950,CDM,983,RC,99281,HCPCS,Outpatient,,,23.88,11.94,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
99281-PF Emergency Room Brief,4321556,CDM,981,RC,99281,HCPCS,Outpatient,,,23.88,11.94,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
99281-PF Emergency Room Brief W/Mod,4321554,CDM,981,RC,99281,HCPCS,Outpatient,,,23.88,11.94,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
99282- Emergency dept visit,3437951,CDM,983,RC,99282,HCPCS,Outpatient,,,83.86,41.93,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
99282-PF Emer Room Routine,4321555,CDM,981,RC,99282,HCPCS,Outpatient,,,83.86,41.93,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
99282-PF Emer Room Routine W/Mod,4321553,CDM,981,RC,99282,HCPCS,Outpatient,,,83.86,41.93,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
99283- Emergency dept visit,3437952,CDM,983,RC,99283,HCPCS,Outpatient,,,144.28,72.14,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
99283-PF Emer Room Moderate,4321551,CDM,981,RC,99283,HCPCS,Outpatient,,,144.28,72.14,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
99283-PF Emer Room Moderate W/Mod,4321550,CDM,981,RC,99283,HCPCS,Outpatient,,,144.28,72.14,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
99284- Emergency dept visit,3437953,CDM,983,RC,99284,HCPCS,Outpatient,,,242.1,121.05,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
99284-PF Emer Room Intermediate,4321548,CDM,981,RC,99284,HCPCS,Outpatient,,,242.1,121.05,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
99284-PF EMERGENCY DEPARTMENT VISIT HIGH/URGENT SEVERITY-MOD 25,4321547,CDM,981,RC,99284,HCPCS,Outpatient,,,242.1,121.05,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
99285- Emergency dept visit,3437954,CDM,983,RC,99285,HCPCS,Outpatient,,,353.18,176.59,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
99285-PF Emer Room Extended/Comple W/Mod,4321545,CDM,981,RC,99285,HCPCS,Outpatient,,,353.18,176.59,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
99285-PF Emer Room Extended/Complex,4321546,CDM,981,RC,99285,HCPCS,Outpatient,,,353.18,176.59,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
99288-PF PHYS/QHP DIRECTION EMERGENCY MEDICAL SYSTEMS,4321523,CDM,981,RC,99288,HCPCS,Outpatient,,,237,118.5,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
99291- Critical care first hour,3437957,CDM,983,RC,99291,HCPCS,Outpatient,,,571.46,285.73,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
99291-PF Emer Room Critical Care,4321544,CDM,981,RC,99291,HCPCS,Outpatient,,,422.04,211.02,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
99291-PF Emer Room Critical Care - MOD 25,4369281,CDM,981,RC,99291,HCPCS,Outpatient,,,422.04,211.02,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
99292- Critical care addl 30 min,3437958,CDM,983,RC,99292,HCPCS,Outpatient,,,287.08,143.54,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
99292-PF Emer Room Critical Care Add 30Min,4321542,CDM,981,RC,99292,HCPCS,Outpatient,,,212.16,106.08,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
99304PF Initial Nursing Facility Care Per Day Low Level Must,4275109,CDM,960,RC,99304,HCPCS,Outpatient,,,165.34,82.67,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
99305PF Initial Nursing Facility Care Per Day Moderate Level,4275110,CDM,960,RC,99305,HCPCS,Outpatient,,,273.82,136.91,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
99306PF Initial Nursing Facility Care Per Day High Level Mus,4275111,CDM,960,RC,99306,HCPCS,Outpatient,,,374.01,187.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
99307- Sbsq Nursing Facility Care/Day E/M Stable 10 Min,3437960,CDM,983,RC,99307,HCPCS,Outpatient,,,111,55.5,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
99308- Sbsq nf care low mdm 20,3437961,CDM,983,RC,99308,HCPCS,Outpatient,,,148.23,74.12,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
99309- Nursing fac care subseq,3437962,CDM,983,RC,99309,HCPCS,Outpatient,,,230.27,115.14,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
99310- Sbsq Nurs Facil Care/Day Unstabl/New Prob 35 Min,3437964,CDM,983,RC,99310,HCPCS,Outpatient,,,339.88,169.94,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
99315- Nursing fac discharge day,3437965,CDM,983,RC,99315,HCPCS,Outpatient,,,184.59,92.3,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
99316- Nursing fac discharge day,3437966,CDM,983,RC,99316,HCPCS,Outpatient,,,264.36,132.18,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
99366- Team Conference Face-to-Face Nonphysician,3438016,CDM,983,RC,99366,HCPCS,Outpatient,,,114.35,57.18,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
99367- Team conf w/o pat by phys,3438017,CDM,983,RC,99367,HCPCS,Outpatient,,,152.92,76.46,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
99368- Team conf w/o pat by hc pro,3438019,CDM,983,RC,99368,HCPCS,Outpatient,,,99.72,49.86,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
99401 COVID-19 Vaccine Education,3894898,CDM,983,RC,99401,HCPCS,Outpatient,,,99.72,49.86,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
99401- Prevent Med Counsel+/Risk Factor Redj Spx 15 Min,3438044,CDM,983,RC,99401,HCPCS,Outpatient,,,97.06,48.53,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
99402- Prevent Med Counsel+/Risk Factor Redj Spx 30 Min,3438046,CDM,983,RC,99402,HCPCS,Outpatient,,,172.85,86.43,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
99403- Prevent Med Counsel+/Risk Factor Redj Spx 45 Min,3438049,CDM,983,RC,99403,HCPCS,Outpatient,,,240.67,120.34,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
99404- Prevent Med Counsel+/Risk Factor Redj Spx 60 Min,3438051,CDM,983,RC,99404,HCPCS,Outpatient,,,307.16,153.58,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
99406 Tobacco Counseling (as part of MWV),3428377,CDM,983,RC,99406,HCPCS,Outpatient,,,23.89,11.95,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
99406- Tobacco Use Cessation Intermediate 3-10 Minutes,3438055,CDM,983,RC,99406,HCPCS,Outpatient,,,23.89,11.95,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
99406-BEHAV CHNG SMOKING 3-10 MIN,3400474,CDM,510,RC,99406,HCPCS,Outpatient,,,39.3,19.65,,29.48,75,,,percent of total billed charges,75% of total billed charges,29.48,75,,,percent of total billed charges,75% of total billed charges,27.89,100,,,Fee Schedule,100% of CMS OPPS Rate,8.36,100,,,Fee Schedule,100% of WV Medicaid Rate,46.03,165,,,Fee Schedule,165% of CMS OPPS Rate,28.91,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,80.14,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,109.91,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,137.68,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,8.36,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,27.89,100,,,Fee Schedule,100% of CMS OPPS Rate,28.91,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,5.5,14,,,percent of total billed charges,14% of total billed charges,5.5,137.68,
99406-PF TOBACCO USE CESSATION INTERMEDIATE 3-10 MINUTES,4321526,CDM,981,RC,99406,HCPCS,Outpatient,,,23.89,11.95,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
99407- Behav chng smoking > 10 min,3438056,CDM,983,RC,99407,HCPCS,Outpatient,,,66.22,33.11,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
99407- Tobacco Use Cessation Intensive >10 Minutes,3438057,CDM,983,RC,99407,HCPCS,Outpatient,,,66.22,33.11,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
99407-BEHAV CHNG SMOKING > 10 MIN,3537585,CDM,983,RC,99407,HCPCS,Outpatient,,,73.32,36.66,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
99407-PF TOBACCO USE CESSATION INTENSIVE >10 MINUTES,4321527,CDM,981,RC,99407,HCPCS,Outpatient,,,48.98,24.49,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
"99408- Alcohol and/or Substance Abuse Screening, 15-30 Mins",3438058,CDM,983,RC,99408,HCPCS,Outpatient,,,74.47,37.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
"99409- Alcohol and/or Substance Abuse Screening, 30+ Mins",3438061,CDM,983,RC,99409,HCPCS,Outpatient,,,180.84,90.42,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
99417 Office Outpt visit Prolonged each add 15 mins,3572783,CDM,983,RC,99417,HCPCS,Outpatient,,,60.5,30.25,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
99417-PF PROLONGED OUTPATIENT E/M SERVICE EACH 15 MINUTES,4321528,CDM,981,RC,99417,HCPCS,Outpatient,,,60.5,30.25,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
99418 - PROLONGED INPATIENT/OBSERVATION EM SVC EA 15 MIN,4199264,CDM,960,RC,99418,HCPCS,Outpatient,,,63.59,31.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
99441- Phone e/m phys/qhp 5-10 min,3438071,CDM,983,RC,99441,HCPCS,Outpatient,,,70.57,35.29,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
99441- Telephone Est 5 to 10 minutes,3438072,CDM,983,RC,99441,HCPCS,Outpatient,,,70.57,35.29,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
99442- Phone e/m phys/qhp 11-20 min,3438073,CDM,983,RC,99442,HCPCS,Outpatient,,,132.08,66.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
99442- Telephone Est 11 to 20 minutes,3438074,CDM,983,RC,99442,HCPCS,Outpatient,,,132.08,66.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
99443- Phone e/m phys/qhp 21-30 min,3438075,CDM,983,RC,99443,HCPCS,Outpatient,,,195.91,97.96,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
99443- Telephone Est 21 to 30 minutes,3438076,CDM,983,RC,99443,HCPCS,Outpatient,,,195.91,97.96,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
"99446- Interprofessional Phone/Internet Consult, 5-10 minutes",3438080,CDM,983,RC,99446,HCPCS,Outpatient,,,48.45,24.23,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
"99447- Interprofessional Phone/Internet Consult, 11-20 minutes",3438082,CDM,983,RC,99447,HCPCS,Outpatient,,,95.05,47.53,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
"99448- Interprofessional Phone/Internet Consult, 21-30 minutes",3438084,CDM,983,RC,99448,HCPCS,Outpatient,,,142.08,71.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
"99449- Interprofessional Phone/Internet Consult, >=31 minutes",3438086,CDM,983,RC,99449,HCPCS,Outpatient,,,189.93,94.97,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
99451- NTRPROF PH1/NTRNET/EHR 5/>,3514700,CDM,510,RC,99451,HCPCS,Outpatient,,,93.63,46.82,,70.22,75,,,percent of total billed charges,75% of total billed charges,70.22,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,25.07,100,,,Fee Schedule,100% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.07,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.11,14,,,percent of total billed charges,14% of total billed charges,13.11,70.22,
NTRPROF PH1/NTRNET/EHR 5/>,3527886,CDM,960,RC,99451,HCPCS,Outpatient,,,93.63,46.82,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
99452- NTRPROF PH1/NTRNET/EHR RFRL,3514701,CDM,510,RC,99452,HCPCS,Outpatient,,,95.82,47.91,,71.87,75,,,percent of total billed charges,75% of total billed charges,71.87,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,25.56,100,,,Fee Schedule,100% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.56,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.41,14,,,percent of total billed charges,14% of total billed charges,13.41,71.87,
NTRPROF PH1/NTRNET/EHR RFRL,3527887,CDM,960,RC,99452,HCPCS,Outpatient,,,95.82,47.91,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
99460- 1st Hosp/Birthing Center Care Per Day Nml Nb,3438093,CDM,983,RC,99460,HCPCS,Outpatient,,,245.98,122.99,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
99461- 1st Care Pr Day Nml Nb Xcpt Hosp/Birthing Center,3438095,CDM,983,RC,99461,HCPCS,Outpatient,,,232.48,116.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
99462- Subq Hospital Care Per Day E/M Normal Newborn,3438098,CDM,983,RC,99462,HCPCS,Outpatient,,,109.51,54.76,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
99463- Same day nb discharge,3438099,CDM,983,RC,99463,HCPCS,Outpatient,,,281.89,140.95,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
99464- Attn At Delivery+ 1 Stabilization of Newborn,3438101,CDM,983,RC,99464,HCPCS,Outpatient,,,193.28,96.64,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
99465- Delivery/Birthing Room Resuscitation,3438102,CDM,983,RC,99465,HCPCS,Outpatient,,,376.98,188.49,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
99465-PF DELIVERY/BIRTHING ROOM RESUSCITATION,4321529,CDM,981,RC,99465,HCPCS,Outpatient,,,276.66,138.33,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
99466- Critical Care Interfacility Transport 30-74 Min,3438104,CDM,983,RC,99466,HCPCS,Outpatient,,,615.08,307.54,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
99467- Critical Care Interfacility Transport Ea 30 Min,3438106,CDM,983,RC,99467,HCPCS,Outpatient,,,309.89,154.95,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
99468- 1st Inpatient Critical Care Pr Day Age 28 Days/Less than,3438108,CDM,983,RC,99468,HCPCS,Outpatient,,,2372.52,1186.26,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
99469- Neonate crit care subsq,3438110,CDM,983,RC,99469,HCPCS,Outpatient,,,1027.79,513.9,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
99469- Subq I/P Critical Care Pr Day Age 28 Days/Less than,3438111,CDM,983,RC,99469,HCPCS,Outpatient,,,1027.79,513.9,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
99471- Initial Ped Critical Care 29 Days Thru 24 Months,3438112,CDM,983,RC,99471,HCPCS,Outpatient,,,2053.37,1026.69,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
99472- Subsq Ped Critical Care 29 Days Thru 24 Mo,3438115,CDM,983,RC,99472,HCPCS,Outpatient,,,1047.03,523.52,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
99475- Initial Ped Critical Care 2 Thru 5 Years,3438116,CDM,983,RC,99475,HCPCS,Outpatient,,,1475.37,737.69,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
99476- Subsequent Ped Critical Care 2 Thru 5 Years,3438119,CDM,983,RC,99476,HCPCS,Outpatient,,,884.78,442.39,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
99477- Init day hosp neonate care,3438120,CDM,983,RC,99477,HCPCS,Outpatient,,,897.54,448.77,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
99477- Initial Hosp Neonate 28 D/Less than Not Critically Ill,3438121,CDM,983,RC,99477,HCPCS,Outpatient,,,897.54,448.77,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
99478- Ic lbw inf < 1500 gm subsq,3438122,CDM,983,RC,99478,HCPCS,Outpatient,,,354.57,177.29,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
99478- Subsequent Intensive Care Infant Less than 1500 Grams,3438123,CDM,983,RC,99478,HCPCS,Outpatient,,,354.57,177.29,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
99479- Ic lbw inf 1500-2500 g subsq,3438124,CDM,983,RC,99479,HCPCS,Outpatient,,,323.34,161.67,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
99479- Subsequent Intensive Care Infant 1500-2500 Grams,3438125,CDM,983,RC,99479,HCPCS,Outpatient,,,323.34,161.67,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
99480- Ic inf pbw 2501-5000 g subsq,3438126,CDM,983,RC,99480,HCPCS,Outpatient,,,309.89,154.95,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
99480- Subsequent Intensive Care Infant 2501-5000 Grams,3438127,CDM,983,RC,99480,HCPCS,Outpatient,,,309.89,154.95,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
99487- Cmplx chron care w/o pt vsit,3438132,CDM,983,RC,99487,HCPCS,Outpatient,,,181.62,90.81,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
99497 Advanced Directives Counseling (as part of MWV),3428378,CDM,983,RC,99497,HCPCS,Outpatient,,,200.41,100.21,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
99498 - Advanced care plan addl 30 min,3678905,CDM,983,RC,99498,HCPCS,Outpatient,,,190.09,95.05,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
99499- Unlisted e&m service,3438138,CDM,983,RC,99499,HCPCS,Outpatient,,,59.84,29.92,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
0236T-Add on code: Transluminal Peripheral Atherectomy Abd. Aorta,4271209,CDM,481,RC,0236T,HCPCS,Outpatient,,,11283.7,5641.85,,8462.78,75,,,percent of total billed charges,75% of total billed charges,8462.78,75,,,percent of total billed charges,75% of total billed charges,9980.15,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,16467.25,165,,,Fee Schedule,165% of CMS OPPS Rate,10343.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,28666.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,39314,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,49244.77,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,9980.15,100,,,Fee Schedule,100% of CMS OPPS Rate,10343.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1579.72,14,,,percent of total billed charges,14% of total billed charges,1579.72,49244.77,
0236T-PF Add on code: Transluminal Peripheral Atherectomy Abd. Aorta,4271210,CDM,960,RC,0236T,HCPCS,Outpatient,,,11283.7,5641.85,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
0238T-Iliac Atherectomy,4271211,CDM,481,RC,0238T,HCPCS,Outpatient,,,19250.66,9625.33,,14438,75,,,percent of total billed charges,75% of total billed charges,14438,75,,,percent of total billed charges,75% of total billed charges,16149.79,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,26647.16,165,,,Fee Schedule,165% of CMS OPPS Rate,16737.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,46388.09,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,63617.56,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,79687.45,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,16149.79,100,,,Fee Schedule,100% of CMS OPPS Rate,16737.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,2695.09,14,,,percent of total billed charges,14% of total billed charges,2695.09,79687.45,
0238T-PF Iliac Atherectomy,4271212,CDM,960,RC,0238T,HCPCS,Outpatient,,,19250.66,9625.33,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
0338T-PF Renal Denervation Unilateral,4317233,CDM,960,RC,0338T,HCPCS,Outpatient,,,2000,1000,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
0338T-Renal Denervation Unilateral,4317232,CDM,481,RC,0338T,HCPCS,Outpatient,,,2000,1000,,1500,75,,,percent of total billed charges,75% of total billed charges,1500,75,,,percent of total billed charges,75% of total billed charges,4903.32,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,8090.5,165,,,Fee Schedule,165% of CMS OPPS Rate,5081.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,14084.18,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,19315.33,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,24194.41,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,4903.32,100,,,Fee Schedule,100% of CMS OPPS Rate,5081.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,280,14,,,percent of total billed charges,14% of total billed charges,280,24194.41,
Renal Denervation Unilateral,,,481,RC,0338T,HCPCS,Outpatient,,,2000,1000,,1500,75,,,percent of total billed charges,75% of total billed charges,1500,75,,,percent of total billed charges,75% of total billed charges,4903.32,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,8090.5,165,,,Fee Schedule,165% of CMS OPPS Rate,5081.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,14084.18,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,19315.33,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,24194.41,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,4903.32,100,,,Fee Schedule,100% of CMS OPPS Rate,5081.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,280,14,,,percent of total billed charges,14% of total billed charges,280,24194.41,
0339T-PF Renal Denervation Bilateral,4317236,CDM,960,RC,0339T,HCPCS,Outpatient,,,3000,1500,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
0339T-Renal Denervation Bilateral,4317235,CDM,481,RC,0339T,HCPCS,Outpatient,,,3000,1500,,2250,75,,,percent of total billed charges,75% of total billed charges,2250,75,,,percent of total billed charges,75% of total billed charges,4903.32,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,8090.5,165,,,Fee Schedule,165% of CMS OPPS Rate,5081.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,14084.18,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,19315.33,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,24194.41,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,4903.32,100,,,Fee Schedule,100% of CMS OPPS Rate,5081.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,420,14,,,percent of total billed charges,14% of total billed charges,420,24194.41,
Renal Denervation Bilateral,,,481,RC,0339T,HCPCS,Outpatient,,,3000,1500,,2250,75,,,percent of total billed charges,75% of total billed charges,2250,75,,,percent of total billed charges,75% of total billed charges,4903.32,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,8090.5,165,,,Fee Schedule,165% of CMS OPPS Rate,5081.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,14084.18,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,19315.33,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,24194.41,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,4903.32,100,,,Fee Schedule,100% of CMS OPPS Rate,5081.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,420,14,,,percent of total billed charges,14% of total billed charges,420,24194.41,
0421T - Waterjet Prostate Abltj Cmpl,4189302,CDM,960,RC,0421T,HCPCS,Outpatient,,,474.88,237.44,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
0505T-Endovenous Fem/Pop arterial revasc with stent graft placement and closure,4271241,CDM,481,RC,0505T,HCPCS,Outpatient,,,20087,10043.5,,15065.25,75,,,percent of total billed charges,75% of total billed charges,15065.25,75,,,percent of total billed charges,75% of total billed charges,9980.15,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,16467.25,165,,,Fee Schedule,165% of CMS OPPS Rate,10343.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,28666.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,39314,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,49244.77,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,9980.15,100,,,Fee Schedule,100% of CMS OPPS Rate,10343.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,2812.18,14,,,percent of total billed charges,14% of total billed charges,2812.18,49244.77,
0505T-PF Endovenous Fem/Pop arterial revasc with stent graft placement and closure,4271242,CDM,960,RC,0505T,HCPCS,Outpatient,,,20087,10043.5,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
0619T- PF Optilume/cystourethroscopy for BPH,4339431,CDM,960,RC,0619T,HCPCS,Outpatient,,,314.08,157.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
0795T-PF Transcatheter insert dual chamber leadless pacemaker,4361315,CDM,960,RC,0795T,HCPCS,Outpatient,,,721.64,360.82,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
0795T-Transcatheter insert dual chamber leadless pacemaker,4361245,CDM,481,RC,0795T,HCPCS,Outpatient,,,721.64,360.82,,541.23,75,,,percent of total billed charges,75% of total billed charges,541.23,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,101.03,14,,,percent of total billed charges,14% of total billed charges,101.03,541.23,
Transcatheter insert dual chamber leadless pacemaker,,,481,RC,0795T,HCPCS,Outpatient,,,721.64,360.82,,541.23,75,,,percent of total billed charges,75% of total billed charges,541.23,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,101.03,14,,,percent of total billed charges,14% of total billed charges,101.03,541.23,
0796T-PF Upgrade Dual Chamber Leadless (RA only),4361329,CDM,960,RC,0796T,HCPCS,Outpatient,,,933.92,466.96,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
0796T-Upgrade Dual Chamber Leadless (RA only),4361287,CDM,481,RC,0796T,HCPCS,Outpatient,,,933.92,466.96,,700.44,75,,,percent of total billed charges,75% of total billed charges,700.44,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,130.75,14,,,percent of total billed charges,14% of total billed charges,130.75,700.44,
Upgrade Dual Chamber Leadless (RA only),,,481,RC,0796T,HCPCS,Outpatient,,,933.92,466.96,,700.44,75,,,percent of total billed charges,75% of total billed charges,700.44,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,130.75,14,,,percent of total billed charges,14% of total billed charges,130.75,700.44,
0797T-PF Upgrade Dual Chamber Leadless (RV only),4361331,CDM,960,RC,0797T,HCPCS,Outpatient,,,933.92,466.96,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
0797T-Upgrade Dual Chamber Leadless (RV only),4361288,CDM,481,RC,0797T,HCPCS,Outpatient,,,933.92,466.96,,700.44,75,,,percent of total billed charges,75% of total billed charges,700.44,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,130.75,14,,,percent of total billed charges,14% of total billed charges,130.75,700.44,
Upgrade Dual Chamber Leadless (RV only),,,481,RC,0797T,HCPCS,Outpatient,,,933.92,466.96,,700.44,75,,,percent of total billed charges,75% of total billed charges,700.44,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,130.75,14,,,percent of total billed charges,14% of total billed charges,130.75,700.44,
0798T-PF Transcatheter remove dual chamber leadless pacemaker,4361317,CDM,960,RC,0798T,HCPCS,Outpatient,,,1681.18,840.59,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
0798T-Transcatheter remove dual chamber leadless pacemaker,4361256,CDM,481,RC,0798T,HCPCS,Outpatient,,,1681.18,840.59,,1260.89,75,,,percent of total billed charges,75% of total billed charges,1260.89,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,235.37,14,,,percent of total billed charges,14% of total billed charges,235.37,1260.89,
Transcatheter remove dual chamber leadless pacemaker,,,481,RC,0798T,HCPCS,Outpatient,,,1681.18,840.59,,1260.89,75,,,percent of total billed charges,75% of total billed charges,1260.89,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,235.37,14,,,percent of total billed charges,14% of total billed charges,235.37,1260.89,
0799T-PF Transcatheter remove dual chamber leadless pacemaker (RA),4361319,CDM,960,RC,0799T,HCPCS,Outpatient,,,1681.18,840.59,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
0799T-Transcatheter remove dual chamber leadless pacemaker (RA),4361257,CDM,481,RC,0799T,HCPCS,Outpatient,,,1681.18,840.59,,1260.89,75,,,percent of total billed charges,75% of total billed charges,1260.89,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,235.37,14,,,percent of total billed charges,14% of total billed charges,235.37,1260.89,
Transcatheter remove dual chamber leadless pacemaker (RA),,,481,RC,0799T,HCPCS,Outpatient,,,1681.18,840.59,,1260.89,75,,,percent of total billed charges,75% of total billed charges,1260.89,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,235.37,14,,,percent of total billed charges,14% of total billed charges,235.37,1260.89,
0800T-PF Transcatheter remove dual chamber leadless pacemaker (RV),4361321,CDM,960,RC,0800T,HCPCS,Outpatient,,,1681.18,840.59,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
0800T-Transcatheter remove dual chamber leadless pacemaker (RV),4361258,CDM,481,RC,0800T,HCPCS,Outpatient,,,1681.18,840.59,,1260.89,75,,,percent of total billed charges,75% of total billed charges,1260.89,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,235.37,14,,,percent of total billed charges,14% of total billed charges,235.37,1260.89,
Transcatheter remove dual chamber leadless pacemaker (RV),,,481,RC,0800T,HCPCS,Outpatient,,,1681.18,840.59,,1260.89,75,,,percent of total billed charges,75% of total billed charges,1260.89,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,235.37,14,,,percent of total billed charges,14% of total billed charges,235.37,1260.89,
0801T-PF Transcatheter remove/replace dual chamber leadless pacemaker,4361323,CDM,960,RC,0801T,HCPCS,Outpatient,,,691.08,345.54,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
0801T-Transcatheter remove/replace dual chamber leadless pacemaker,4361275,CDM,481,RC,0801T,HCPCS,Outpatient,,,691.08,345.54,,518.31,75,,,percent of total billed charges,75% of total billed charges,518.31,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,96.75,14,,,percent of total billed charges,14% of total billed charges,96.75,518.31,
Transcatheter remove/replace dual chamber leadless pacemaker,,,481,RC,0801T,HCPCS,Outpatient,,,691.08,345.54,,518.31,75,,,percent of total billed charges,75% of total billed charges,518.31,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,96.75,14,,,percent of total billed charges,14% of total billed charges,96.75,518.31,
0802T-PF Transcatheter remove/replace dual chamber leadless pacemaker (RA),4361325,CDM,960,RC,0802T,HCPCS,Outpatient,,,691.08,345.54,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
0802T-Transcatheter remove/replace dual chamber leadless pacemaker (RA),4361285,CDM,481,RC,0802T,HCPCS,Outpatient,,,691.08,345.54,,518.31,75,,,percent of total billed charges,75% of total billed charges,518.31,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,96.75,14,,,percent of total billed charges,14% of total billed charges,96.75,518.31,
Transcatheter remove/replace dual chamber leadless pacemaker (RA),,,481,RC,0802T,HCPCS,Outpatient,,,691.08,345.54,,518.31,75,,,percent of total billed charges,75% of total billed charges,518.31,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,96.75,14,,,percent of total billed charges,14% of total billed charges,96.75,518.31,
0803T-PF Transcatheter remove/replace dual chamber leadless pacemaker (RV),4361327,CDM,960,RC,0803T,HCPCS,Outpatient,,,691.08,345.54,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
0803T-Transcatheter remove/replace dual chamber leadless pacemaker (RV),4361286,CDM,481,RC,0803T,HCPCS,Outpatient,,,691.08,345.54,,518.31,75,,,percent of total billed charges,75% of total billed charges,518.31,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,96.75,14,,,percent of total billed charges,14% of total billed charges,96.75,518.31,
Transcatheter remove/replace dual chamber leadless pacemaker (RV),,,481,RC,0803T,HCPCS,Outpatient,,,691.08,345.54,,518.31,75,,,percent of total billed charges,75% of total billed charges,518.31,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,96.75,14,,,percent of total billed charges,14% of total billed charges,96.75,518.31,
0804T-In-person programming rvw/rprt by prvdr; leadless pacer dual chamber,4361289,CDM,481,RC,0804T,HCPCS,Outpatient,,,52.08,26.04,,39.06,75,,,percent of total billed charges,75% of total billed charges,39.06,75,,,percent of total billed charges,75% of total billed charges,32.9,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,54.29,165,,,Fee Schedule,165% of CMS OPPS Rate,34.1,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,94.51,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,129.62,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,162.36,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,32.9,100,,,Fee Schedule,100% of CMS OPPS Rate,34.1,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,7.29,14,,,percent of total billed charges,14% of total billed charges,7.29,162.36,
0804T-PF In-person programming rvw/rprt by prvdr; leadless pacer dual chamber,4361333,CDM,960,RC,0804T,HCPCS,Outpatient,,,52.08,26.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
In-person programming rvw/rprt by prvdr; leadless pacer dual chamber,,,481,RC,0804T,HCPCS,Outpatient,,,52.08,26.04,,39.06,75,,,percent of total billed charges,75% of total billed charges,39.06,75,,,percent of total billed charges,75% of total billed charges,32.9,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,54.29,165,,,Fee Schedule,165% of CMS OPPS Rate,34.1,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,94.51,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,129.62,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,162.36,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,32.9,100,,,Fee Schedule,100% of CMS OPPS Rate,34.1,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,7.29,14,,,percent of total billed charges,14% of total billed charges,7.29,162.36,
3015F-CERV CANCER SCREEN DOCD Profee,3565240,CDM,983,RC,3015F,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
C9604-PCI IN/VIA SVG/IMA DES CIRC,3352895,CDM,481,RC,C9604,HCPCS,Outpatient,,,1165.18,582.59,,873.89,75,,,percent of total billed charges,75% of total billed charges,873.89,75,,,percent of total billed charges,75% of total billed charges,9980.15,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,16467.25,165,,,Fee Schedule,165% of CMS OPPS Rate,10343.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,28666.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,39314,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,49244.77,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,9980.15,100,,,Fee Schedule,100% of CMS OPPS Rate,10343.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,163.13,14,,,percent of total billed charges,14% of total billed charges,163.13,49244.77,
C9605-ADDL PCI IN/VIA SVG/IMA DES LAD,3352952,CDM,481,RC,C9605,HCPCS,Outpatient,,,1236.51,618.26,,927.38,75,,,percent of total billed charges,75% of total billed charges,927.38,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,173.11,14,,,percent of total billed charges,14% of total billed charges,173.11,927.38,
C9606-PCI AMI TOTAL/SUN DES RCA,3353315,CDM,481,RC,C9606,HCPCS,Outpatient,,,1307.84,653.92,,980.88,75,,,percent of total billed charges,75% of total billed charges,980.88,75,,,percent of total billed charges,75% of total billed charges,1307.84,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,1307.84,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1307.84,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1307.84,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1307.84,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1307.84,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,1307.84,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1307.84,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,183.1,14,,,percent of total billed charges,14% of total billed charges,183.1,1307.84,
C9772-PF Shockwave Tibial/Peroneal Arteries,4271214,CDM,960,RC,C9772,HCPCS,Outpatient,,,10256,5128,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
C9772-Shockwave Tibial/Peroneal Arteries,4271213,CDM,481,RC,C9772,HCPCS,Outpatient,,,10256,5128,,7692,75,,,percent of total billed charges,75% of total billed charges,7692,75,,,percent of total billed charges,75% of total billed charges,9980.15,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,16467.25,165,,,Fee Schedule,165% of CMS OPPS Rate,10343.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,28666.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,39314,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,49244.77,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,9980.15,100,,,Fee Schedule,100% of CMS OPPS Rate,10343.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1435.84,14,,,percent of total billed charges,14% of total billed charges,1435.84,49244.77,
C9773-PF Shockwave with stent Tibial/Peroneal Arteries,4271216,CDM,960,RC,C9773,HCPCS,Outpatient,,,10256,5128,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
C9773-Shockwave with stent Tibial/Peroneal Arteries,4271215,CDM,481,RC,C9773,HCPCS,Outpatient,,,10256,5128,,7692,75,,,percent of total billed charges,75% of total billed charges,7692,75,,,percent of total billed charges,75% of total billed charges,16149.79,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,26647.16,165,,,Fee Schedule,165% of CMS OPPS Rate,16737.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,46388.09,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,63617.56,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,79687.45,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,16149.79,100,,,Fee Schedule,100% of CMS OPPS Rate,16737.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1435.84,14,,,percent of total billed charges,14% of total billed charges,1435.84,79687.45,
C9774-PF Shockwave with atherectomy Tibial/Peroneal Arteries,4271218,CDM,960,RC,C9774,HCPCS,Outpatient,,,10256,5128,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
C9774-Shockwave with atherectomy Tibial/Peroneal Arteries,4271217,CDM,481,RC,C9774,HCPCS,Outpatient,,,10256,5128,,7692,75,,,percent of total billed charges,75% of total billed charges,7692,75,,,percent of total billed charges,75% of total billed charges,16149.79,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,26647.16,165,,,Fee Schedule,165% of CMS OPPS Rate,16737.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,46388.09,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,63617.56,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,79687.45,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,16149.79,100,,,Fee Schedule,100% of CMS OPPS Rate,16737.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1435.84,14,,,percent of total billed charges,14% of total billed charges,1435.84,79687.45,
C9775-PF Shockwave with stent with atherectomy Tibial/Peroneal Arteries,4271220,CDM,960,RC,C9775,HCPCS,Outpatient,,,10256,5128,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
C9775-Shockwave with stent with atherectomy Tibial/Peroneal Arteries,4271219,CDM,481,RC,C9775,HCPCS,Outpatient,,,10256,5128,,7692,75,,,percent of total billed charges,75% of total billed charges,7692,75,,,percent of total billed charges,75% of total billed charges,16149.79,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,26647.16,165,,,Fee Schedule,165% of CMS OPPS Rate,16737.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,46388.09,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,63617.56,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,79687.45,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,16149.79,100,,,Fee Schedule,100% of CMS OPPS Rate,16737.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1435.84,14,,,percent of total billed charges,14% of total billed charges,1435.84,79687.45,
C9779 - PF ESD Endoscopic Submucosal Dissection,4347164,CDM,960,RC,C9779,HCPCS,Outpatient,,,667.21,333.61,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
G0102 Prostate Cancer Screening; Digital Rectal Exam,3555130,CDM,510,RC,G0102,HCPCS,Outpatient,,,56.36,28.18,,42.27,75,,,percent of total billed charges,75% of total billed charges,42.27,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.89,14,,,percent of total billed charges,14% of total billed charges,7.89,42.27,
G0104 - Colorectal cancer screening; flexible sigmoidoscopy,3899095,CDM,983,RC,G0104,HCPCS,Outpatient,,,462.14,231.07,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
G0105 - PF Colorectal Scrn; Hi Risk Ind,4311873,CDM,960,RC,G0105,HCPCS,Outpatient,,,425.49,212.75,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
G0121 - PF Colon Ca Scrn Not Hi Rsk Ind,4311872,CDM,960,RC,G0121,HCPCS,Outpatient,,,426.51,213.26,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
G0124 - Screen C/V Thin Layer by MD,3899096,CDM,983,RC,G0124,HCPCS,Outpatient,,,55.05,27.53,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
G0168-PF WOUND CLOSURE BY ADHESIVE,4321532,CDM,981,RC,G0168,HCPCS,Outpatient,,,30.24,15.12,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
G0180- Home Health Certification,3438154,CDM,983,RC,G0180,HCPCS,Outpatient,,,104.39,52.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
"G0180- Home health certification, physician",3435920,CDM,960,RC,G0180,HCPCS,Outpatient,,,104.39,52.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
"G0250- Phys Revw,Intrp/Mngmt Home Inr",3435922,CDM,960,RC,G0250,HCPCS,Outpatient,,,21.62,10.81,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
G0269 - PF Placement of occlusive device in vein or art,4197110,CDM,960,RC,G0269,HCPCS,Outpatient,,,2982.25,1491.13,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
G0269 - Placement of occlusive device in vein or art,4197109,CDM,481,RC,G0269,HCPCS,Outpatient,,,2982.25,1491.13,,2236.69,75,,,percent of total billed charges,75% of total billed charges,2236.69,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,417.52,14,,,percent of total billed charges,14% of total billed charges,417.52,2236.69,
"G0278 - Iliac Art Angio, Cardiac Cath",4201240,CDM,983,RC,G0278,HCPCS,Outpatient,,,30.17,15.09,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
"G0289- Arthroscopy,Knee,Remove Fb",3435317,CDM,510,RC,G0289,HCPCS,Outpatient,,,226.6,113.3,,169.95,75,,,percent of total billed charges,75% of total billed charges,169.95,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.72,14,,,percent of total billed charges,14% of total billed charges,31.72,169.95,
G0296 - Counseling Visit to discuss need for LDCT for Lung Cancer Screening,3571392,CDM,770,RC,G0296,HCPCS,Outpatient,,,53.36,26.68,,40.02,75,,,percent of total billed charges,75% of total billed charges,40.02,75,,,percent of total billed charges,75% of total billed charges,71.29,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,117.66,165,,,Fee Schedule,165% of CMS OPPS Rate,73.9,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,204.82,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,280.89,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,351.86,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,71.29,100,,,Fee Schedule,100% of CMS OPPS Rate,73.9,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,7.47,14,,,percent of total billed charges,14% of total billed charges,7.47,351.86,
G0399- Home Sleep Test 3,3430575,CDM,920,RC,G0399,HCPCS,Outpatient,,,250,125,,187.5,75,,,percent of total billed charges,75% of total billed charges,187.5,75,,,percent of total billed charges,75% of total billed charges,136.72,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,225.58,165,,,Fee Schedule,165% of CMS OPPS Rate,141.69,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,392.72,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,538.59,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,674.64,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,136.72,100,,,Fee Schedule,100% of CMS OPPS Rate,141.69,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,35,14,,,percent of total billed charges,14% of total billed charges,35,674.64,
G0400 - Home Sleep Test/Type 4 Portable-Unattended,4347086,CDM,510,RC,G0400,HCPCS,Outpatient,,,109.83,54.92,,82.37,75,,,percent of total billed charges,75% of total billed charges,82.37,75,,,percent of total billed charges,75% of total billed charges,263.29,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,434.44,165,,,Fee Schedule,165% of CMS OPPS Rate,272.88,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,756.29,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1037.2,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1299.2,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,263.29,100,,,Fee Schedule,100% of CMS OPPS Rate,272.88,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,15.38,14,,,percent of total billed charges,14% of total billed charges,15.38,1299.2,
G0443 Face-to-face behavioral counseling for alcohol misuse 15 minutes,3555131,CDM,510,RC,G0443,HCPCS,Outpatient,,,67.95,33.98,,50.96,75,,,percent of total billed charges,75% of total billed charges,50.96,75,,,percent of total billed charges,75% of total billed charges,71.29,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,117.66,165,,,Fee Schedule,165% of CMS OPPS Rate,73.9,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,204.82,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,280.89,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,351.86,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,71.29,100,,,Fee Schedule,100% of CMS OPPS Rate,73.9,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,9.51,14,,,percent of total billed charges,14% of total billed charges,9.51,351.86,
G0444 Depression Screening (as part of MWV),3428460,CDM,510,RC,G0444,HCPCS,Outpatient,,,45.32,22.66,,33.99,75,,,percent of total billed charges,75% of total billed charges,33.99,75,,,percent of total billed charges,75% of total billed charges,27.89,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,46.03,165,,,Fee Schedule,165% of CMS OPPS Rate,28.91,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,80.14,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,109.91,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,137.68,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,27.89,100,,,Fee Schedule,100% of CMS OPPS Rate,28.91,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,6.34,14,,,percent of total billed charges,14% of total billed charges,6.34,137.68,
"G0445 High-intensity behavioral counseling to prevent STIs, performed semi-annually, 30 minutes",3555132,CDM,510,RC,G0445,HCPCS,Outpatient,,,70.32,35.16,,52.74,75,,,percent of total billed charges,75% of total billed charges,52.74,75,,,percent of total billed charges,75% of total billed charges,71.29,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,117.66,165,,,Fee Schedule,165% of CMS OPPS Rate,73.9,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,204.82,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,280.89,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,351.86,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,71.29,100,,,Fee Schedule,100% of CMS OPPS Rate,73.9,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,9.84,14,,,percent of total billed charges,14% of total billed charges,9.84,351.86,
G0446- Intensive Behavioral Therapy for Cardiovasc Risk,3435926,CDM,510,RC,G0446,HCPCS,Outpatient,,,67.95,33.98,,50.96,75,,,percent of total billed charges,75% of total billed charges,50.96,75,,,percent of total billed charges,75% of total billed charges,27.89,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,46.03,165,,,Fee Schedule,165% of CMS OPPS Rate,28.91,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,80.14,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,109.91,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,137.68,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,27.89,100,,,Fee Schedule,100% of CMS OPPS Rate,28.91,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,9.51,14,,,percent of total billed charges,14% of total billed charges,9.51,137.68,
G0447- Behavior Counsel Obesity 15M,3435927,CDM,510,RC,G0447,HCPCS,Outpatient,,,67.95,33.98,,50.96,75,,,percent of total billed charges,75% of total billed charges,50.96,75,,,percent of total billed charges,75% of total billed charges,71.29,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,117.66,165,,,Fee Schedule,165% of CMS OPPS Rate,73.9,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,204.82,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,280.89,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,351.86,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,71.29,100,,,Fee Schedule,100% of CMS OPPS Rate,73.9,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,9.51,14,,,percent of total billed charges,14% of total billed charges,9.51,351.86,
G0500-PF MOD SEDAT ENDO SERVICE >5YRS,4321533,CDM,981,RC,G0500,HCPCS,Outpatient,,,10.82,5.41,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
G2211 Visit complexity inherent to evaluation and management associated with medical care services t,3623805,CDM,983,RC,G2211,HCPCS,Outpatient,,,33.14,16.57,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
G2213-PF NITIAT MED ASSIST TX IN ER,4321534,CDM,981,RC,G2213,HCPCS,Outpatient,,,125.98,62.99,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
S2083 - PF Adjustment Gastric Band,4311871,CDM,960,RC,S2083,HCPCS,Outpatient,,,519.99,260,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
S2900 Robotic Surgery,4311870,CDM,960,RC,S2900,HCPCS,Outpatient,,,3561.6,1780.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
S2900- Surgical techniques requiring use of robotic surgical system (list separately in addition to,3566799,CDM,510,RC,S2900,HCPCS,Outpatient,,,1,0.5,,0.75,75,,,percent of total billed charges,75% of total billed charges,0.75,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,0.75,0.75,
"10005 - Fine needle aspiration biopsy, including ultrasound",3572795,CDM,983,RC,10005,HCPCS,Outpatient,,,195.76,97.88,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
Read,4345736,CDM,972,RC,10005,HCPCS,Outpatient,,,145.6,72.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
Read,4345738,CDM,972,RC,10005,HCPCS,Outpatient,,,145.6,72.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
10006-MSA FNA BIOPSY W/ ULTSND GD ADD LES,3428647,CDM,960,RC,10006,HCPCS,Outpatient,,,156.74,78.37,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
10007-MSA FNA BIOPSY W/ FLUORO GD 1ST LES,3428648,CDM,960,RC,10007,HCPCS,Outpatient,,,183.1,91.55,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
10008-MSA FNA BIOPSY W/ FLUORO GD ADD LES,3428649,CDM,960,RC,10008,HCPCS,Outpatient,,,107.17,53.59,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
10021- Fine needle asp w/o image guide,3431472,CDM,960,RC,10021,HCPCS,Outpatient,,,111.98,55.99,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
"10035 Placement of soft tissue localization device(s) (eg, clip, metallic pellet, wire/needle, radio",3621199,CDM,960,RC,10035,HCPCS,Outpatient,,,223.36,111.68,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
10040- Acne surgery,3431474,CDM,960,RC,10040,HCPCS,Outpatient,,,287.12,143.56,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
10060- Abscess/simple/single/I  & D,3431475,CDM,960,RC,10060,HCPCS,Outpatient,,,208.61,104.31,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
10060-PF I & D Abscess Simple/SinglE,4345252,CDM,983,RC,10060,HCPCS,Outpatient,,,208.61,104.31,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
"10061- I&D ,Abscess, Complex or S",3428656,CDM,960,RC,10061,HCPCS,Outpatient,,,366.63,183.32,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
"10061- Incision and Drainage, Complex",3428467,CDM,960,RC,10061,HCPCS,Outpatient,,,366.63,183.32,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
10061-PF I & D Abscess Complicated/Multiple,4345253,CDM,983,RC,10061,HCPCS,Outpatient,,,366.63,183.32,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
"10080- Incision and Drainage( IND) Pilonidal Cyst, Simple",3428657,CDM,960,RC,10080,HCPCS,Outpatient,,,208.5,104.25,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
10081- I & D/pilonidal cyst/complicated,3431476,CDM,960,RC,10081,HCPCS,Outpatient,,,347.49,173.75,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
10120- Incision/rmv FB/SQ tis/simple,3431477,CDM,960,RC,10120,HCPCS,Outpatient,,,207.49,103.75,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
10121- Incision/rmv FB/SQ tis/complicat,3431478,CDM,960,RC,10121,HCPCS,Outpatient,,,369.64,184.82,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
"10140- Incision and Drainage of hematoma, seroma or fluid collection",4346598,CDM,983,RC,10140,HCPCS,Outpatient,,,235.62,117.81,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
10160- Punc asp/abscess/hema/bulla/cyst,3428658,CDM,960,RC,10160,HCPCS,Outpatient,,,191.33,95.67,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
"10180- Incision and Drainage, Compex post-op wound infection",4346593,CDM,983,RC,10180,HCPCS,Outpatient,,,361.23,180.62,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
10180- Postop wound infection/complex/I&D,3431479,CDM,960,RC,10180,HCPCS,Outpatient,,,361.23,180.62,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
10180-PF I & D Complex PO Wound Infection,4345254,CDM,983,RC,10180,HCPCS,Outpatient,,,361.23,180.62,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
11000- Debrid ecz/inf skin up tp 10% body,3428659,CDM,960,RC,11000,HCPCS,Outpatient,,,56.46,28.23,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
11001 - DBRDMT EXTNSVE ECZEMA/INFECT SKN EA 10% BDY SURF,4037472,CDM,983,RC,11001,HCPCS,Outpatient,,,30.19,15.1,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
11004- Debride skn/sq/musc/ext genit/peri,3431480,CDM,960,RC,11004,HCPCS,Outpatient,,,1530.74,765.37,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
11005- Debride skn/sq/musc/abd wall,3431481,CDM,960,RC,11005,HCPCS,Outpatient,,,2101.66,1050.83,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
11011- Debride/rmv FB/open fx/skin/sq/mus,3431484,CDM,960,RC,11011,HCPCS,Outpatient,,,610.39,305.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
11042-DEB SUBQ Tissue 20 SQ CM/<,3574980,CDM,960,RC,11042,HCPCS,Outpatient,,,122.24,61.12,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
11042-PF Dbrdmt Subcutaneous Tissue 20 Sq Cm/<,4345255,CDM,983,RC,11042,HCPCS,Outpatient,,,122.24,61.12,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
11043 Deb Musc Fascia 20 Sq Cm less than,3572727,CDM,960,RC,11043,HCPCS,Outpatient,,,313,156.5,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
11043-PF Dbdmt Muscle & Fascia 20 Sq Cm/<,4345256,CDM,983,RC,11043,HCPCS,Outpatient,,,313,156.5,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
"11044 Debridement, bone (includes epidermis, dermis, subcutaneous tissue, muscle and/or fascia, if p",3621458,CDM,960,RC,11044,HCPCS,Outpatient,,,462.97,231.49,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
11044-PF Dbrdmt Bone Muscle & Fascia 20 Sq Cm/<,4345257,CDM,983,RC,11044,HCPCS,Outpatient,,,462.7,231.35,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
11045 Debride subq tiss ea add 20sq cm,3570187,CDM,960,RC,11045,HCPCS,Outpatient,,,52.28,26.14,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
11045-PF Debrdmt Subcutaneous Tissue Ea Addl 20 Sq Cm,4345258,CDM,983,RC,11045,HCPCS,Outpatient,,,52.28,26.14,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
11046 Deb Mus Fasica Add On,3550404,CDM,960,RC,11046,HCPCS,Outpatient,,,113.61,56.81,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
11046-PF Dbrdmt Muscle & Fascia Ea Addl 20 Sq Cm,4345259,CDM,983,RC,11046,HCPCS,Outpatient,,,113.61,56.81,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
11047- Debridement/bone/ea add 20 sq cm,3431488,CDM,960,RC,11047,HCPCS,Outpatient,,,201.02,100.51,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
11047-PF Dbrdmt Bone Each Additional 20 Sq Cm,4345260,CDM,983,RC,11047,HCPCS,Outpatient,,,201.02,100.51,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
11055- Trim hyperkeratotic lesion/sng,3431489,CDM,960,RC,11055,HCPCS,Outpatient,,,31.86,15.93,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
11056- Trim hyperkeratotic lesion/2-4,3431490,CDM,960,RC,11056,HCPCS,Outpatient,,,44.99,22.5,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
11057- Trim hyperkeratotic lesion/>4,3431491,CDM,960,RC,11057,HCPCS,Outpatient,,,58.72,29.36,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
11102 Shave Biopsy,3428674,CDM,960,RC,11102,HCPCS,Outpatient,,,75.62,37.81,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
11103 Additional Shave Biopsy,3428675,CDM,960,RC,11103,HCPCS,Outpatient,,,43.84,21.92,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
11104 Punch Biopsy with Suture,3428676,CDM,960,RC,11104,HCPCS,Outpatient,,,94.4,47.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
11105 Add'l Punch Biospy with suture,3428677,CDM,960,RC,11105,HCPCS,Outpatient,,,51.75,25.88,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
11106 Wedge Biopsy with Suture,3428678,CDM,960,RC,11106,HCPCS,Outpatient,,,114.46,57.23,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
11107 Add'l Wedge Biopsy with suture,3428679,CDM,960,RC,11107,HCPCS,Outpatient,,,61.9,30.95,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
11200- Remove skin tags </= 15,3431493,CDM,960,RC,11200,HCPCS,Outpatient,,,149.01,74.51,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
11201- Remove skin tags/ea add 10 lesions,3431494,CDM,960,RC,11201,HCPCS,Outpatient,,,32.48,16.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
"11300- Shave Skin Lesion,0.5Cm Or Less",3431495,CDM,960,RC,11300,HCPCS,Outpatient,,,68.48,34.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
"11301- Shave Skin Lesion,0.6-1.0Cm",3431496,CDM,960,RC,11301,HCPCS,Outpatient,,,102.84,51.42,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
"11302- Shave Skin Lesion,1.1-2.0Cm",3431497,CDM,960,RC,11302,HCPCS,Outpatient,,,119.57,59.79,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
11303- Shave epi/derm sng lesion/trunk/arm/leg/>2.0cm,3431498,CDM,960,RC,11303,HCPCS,Outpatient,,,142.8,71.4,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
"11305- Shave Skin Lesion, .5Cm Or Less",3431499,CDM,960,RC,11305,HCPCS,Outpatient,,,76.36,38.18,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
"11306- Shave Skin Lesion,0.6-1.0 Cm",3431500,CDM,960,RC,11306,HCPCS,Outpatient,,,98.9,49.45,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
"11307- Shave Skin Lesion,1.1-2.0 Cm",3431501,CDM,960,RC,11307,HCPCS,Outpatient,,,126.12,63.06,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
11308- Shave epi/derm sng lesion/scalp/neck/hnd/ft/genit/>2.0cm,3431502,CDM,960,RC,11308,HCPCS,Outpatient,,,142.1,71.05,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
11310- Shave epi/derm sng lesion/face/ear/lid/nose/lip/0.5cm or <,3431503,CDM,960,RC,11310,HCPCS,Outpatient,,,91.39,45.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
11311- Shave epi/derm sng lesion/face/ear/lid/nose/lip/0.6-1.0cm,3431504,CDM,960,RC,11311,HCPCS,Outpatient,,,125.76,62.88,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
11312- Shave epi/derm sng lesion/face/ear/lid/nose/lip/1.1-2.0cm,3431505,CDM,960,RC,11312,HCPCS,Outpatient,,,148.68,74.34,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
11313- Shave epi/derm sng lesion/face/ear/lid/nose/lip/>2.0cm,3431506,CDM,960,RC,11313,HCPCS,Outpatient,,,192.84,96.42,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
11400- Exc Tr-Ext Benign+Marg 0.5 < Cm,3431507,CDM,960,RC,11400,HCPCS,Outpatient,,,165.13,82.57,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
11401- Exc tr-ext benign+marg 0.6-1 cm,3431508,CDM,960,RC,11401,HCPCS,Outpatient,,,208.37,104.19,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
11402- Exc tr-ext benign+marg 1.1-2 cm,3431509,CDM,960,RC,11402,HCPCS,Outpatient,,,228.94,114.47,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
11403- Exc tr-ext bengin+marg 2.1-3cm,3431510,CDM,960,RC,11403,HCPCS,Outpatient,,,296.93,148.47,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
11404- Exc tr-ext benign+marg 3.1-4 cm,3431511,CDM,960,RC,11404,HCPCS,Outpatient,,,329.05,164.53,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
11406- Exc tr-ext bengin+marg >4.0 cm,3431512,CDM,960,RC,11406,HCPCS,Outpatient,,,503.48,251.74,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
11420- Exc h-f-nk-sp benign+marg 0.5/<,3431513,CDM,960,RC,11420,HCPCS,Outpatient,,,161.54,80.77,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
Clinic Excision Benign Lesion 0.5- 11420,4351219,CDM,960,RC,11420,HCPCS,Outpatient,,,161.54,80.77,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
11421- Exc h-f-nk-sp benign+marg 0.6-1,3431514,CDM,960,RC,11421,HCPCS,Outpatient,,,216.52,108.26,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
Clinic Excision Benign Lesion 0.6-1.0-  11421,4351220,CDM,960,RC,11421,HCPCS,Outpatient,,,216.52,108.26,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
11422- Exc h-f-nk-sp benign1.1-2,3431515,CDM,960,RC,11422,HCPCS,Outpatient,,,268.29,134.15,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
Clinic Excision Benign Lesion 1.1-2.0 - 11422,4351221,CDM,960,RC,11422,HCPCS,Outpatient,,,268.29,134.15,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
11423- Exc h-f-nk-sp benign+marg 2.1-3,3431516,CDM,960,RC,11423,HCPCS,Outpatient,,,312.19,156.1,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
Clinic Excision Benign Lesion 2.1-3.0 - 11423,4351222,CDM,960,RC,11423,HCPCS,Outpatient,,,312.19,156.1,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
11424- Exc benign les/see area/3.1-4.0cm,3431517,CDM,960,RC,11424,HCPCS,Outpatient,,,362.56,181.28,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
Clinic Excision Benign Lesion 3.1-4.0 - 11424,4351223,CDM,960,RC,11424,HCPCS,Outpatient,,,362.56,181.28,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
11426- Exc h-f-nk-sp benign+marg >4 cm,3431518,CDM,960,RC,11426,HCPCS,Outpatient,,,542.08,271.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
Clinic Excision Benign Lesion over 4.0 - 11426,4351224,CDM,960,RC,11426,HCPCS,Outpatient,,,542.08,271.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
11440- Exc face-mm benign+marg 0.5 cm/<,3431519,CDM,960,RC,11440,HCPCS,Outpatient,,,207.53,103.77,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
11441- Exc face-mm benign+marg 0.6-1 cm,3431520,CDM,960,RC,11441,HCPCS,Outpatient,,,262.35,131.18,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
11442- Exc face-mm benign+marg 1.1-2 cm,3431521,CDM,960,RC,11442,HCPCS,Outpatient,,,290.48,145.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
11443- Exc face-mm benign+marg 2.1-3 cm,3431522,CDM,960,RC,11443,HCPCS,Outpatient,,,356.01,178.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
11444- Exc/benign les/see area/3.1-4.0cm,3431523,CDM,960,RC,11444,HCPCS,Outpatient,,,451.24,225.62,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
11446- Exc benign lesion/see area/>4.0cm,3431524,CDM,960,RC,11446,HCPCS,Outpatient,,,638.48,319.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
11450- Exc/hidradenitis/axilla/smp/im rpr,3431525,CDM,960,RC,11450,HCPCS,Outpatient,,,530.15,265.08,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
11451- Exc/hidradenitis/axilla/comp rpr,3431526,CDM,960,RC,11451,HCPCS,Outpatient,,,673.08,336.54,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
11462- Exc/hidradenitis/ingun/smp/imt rpr,3431527,CDM,960,RC,11462,HCPCS,Outpatient,,,503.35,251.68,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
11463- Exc/hidradenitis/inguinal/comp rpr,3431528,CDM,960,RC,11463,HCPCS,Outpatient,,,674.75,337.38,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
11470- Exc hidradenit/perianal/neal/sp/in,3431529,CDM,960,RC,11470,HCPCS,Outpatient,,,580.73,290.37,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
11471- Exc hidradenitis/perianal/neal/com,3431530,CDM,960,RC,11471,HCPCS,Outpatient,,,712.09,356.05,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
11600- Exc/malig/trunk/arms/legs <0.5cm,3431531,CDM,960,RC,11600,HCPCS,Outpatient,,,243.02,121.51,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
11601- Exc malig/trunk/arm/leg 0.6-1.0cm,3431532,CDM,960,RC,11601,HCPCS,Outpatient,,,294.28,147.14,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
11602- Exc tr-ext mal+marg 1.1-2 cm,3431533,CDM,960,RC,11602,HCPCS,Outpatient,,,318.93,159.47,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
11603- Exc tr-ext mal+marg 2.1-3 cm,3431534,CDM,960,RC,11603,HCPCS,Outpatient,,,383.4,191.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
11604- Exc tr-ext mal+marg 3.1-4 cm,3431535,CDM,960,RC,11604,HCPCS,Outpatient,,,424.06,212.03,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
11606- Exc tr-ext mal+marg >4 cm,3431536,CDM,960,RC,11606,HCPCS,Outpatient,,,642.59,321.3,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
11620- Exc/malig/see area/0.5cm or less,3431537,CDM,960,RC,11620,HCPCS,Outpatient,,,245.22,122.61,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
11621- Exc H-F-Nk-Sp Mlg+Marg 0.6-1.0 Cm,3431538,CDM,960,RC,11621,HCPCS,Outpatient,,,295.91,147.96,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
11622- Exc s/n/h/f/g mal+mrg 1.1-2,3431539,CDM,960,RC,11622,HCPCS,Outpatient,,,335.96,167.98,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
11623- Exc H-F-Nk-Sp Mlg+Marg 2.1-3 Cm,3431540,CDM,960,RC,11623,HCPCS,Outpatient,,,416.86,208.43,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
11624- Exc s/n/h/f/g mal+mrg 3.1-4,3431541,CDM,960,RC,11624,HCPCS,Outpatient,,,477.13,238.57,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
11626- Exc s/n/h/f/g mal+mrg >4 cm,3431542,CDM,960,RC,11626,HCPCS,Outpatient,,,589.34,294.67,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
11640- Exc/malg/fac/ear/lid/nos/lip<0.5cm,3431543,CDM,960,RC,11640,HCPCS,Outpatient,,,250.84,125.42,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
11641- Exc f/e/e/n/l mal+mrg 0.6-1,3431544,CDM,960,RC,11641,HCPCS,Outpatient,,,308.46,154.23,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
11642- Exc Face-Mm Malig+Marg 1.1-2,3431545,CDM,960,RC,11642,HCPCS,Outpatient,,,362.33,181.17,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
11643- Exc f/e/e/n/l mal+mrg 2.1-3,3431546,CDM,960,RC,11643,HCPCS,Outpatient,,,454.1,227.05,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
11644- Exc Face-Mm Malig+Marg 3.1-4.0,3431547,CDM,960,RC,11644,HCPCS,Outpatient,,,565.09,282.55,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
11646- Exc/malig/fac/ear/lid/nose/lip>4cm,3431548,CDM,960,RC,11646,HCPCS,Outpatient,,,787.05,393.53,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
11721 - DEB NAIL 6 OR MORE Profee,3435765,CDM,983,RC,11721,HCPCS,Outpatient,,,48.36,24.18,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
11721- Debride/nails/any method/6 or more,3431551,CDM,960,RC,11721,HCPCS,Outpatient,,,48.36,24.18,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
11721-PF Dbrdmt Nail Any Method 6/>,4345261,CDM,983,RC,11721,HCPCS,Outpatient,,,48.36,24.18,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
11730- Avulsion/nail plate/simple/single,3431552,CDM,960,RC,11730,HCPCS,Outpatient,,,108.73,54.37,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
11730-PF Nail avulsion; single,4345262,CDM,983,RC,11730,HCPCS,Outpatient,,,108.73,54.37,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
11732- Avulsion/nail plate/simple/ea add,3431553,CDM,960,RC,11732,HCPCS,Outpatient,,,34.53,17.27,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
11732-PF Nail avulsion; each additional,4345263,CDM,983,RC,11732,HCPCS,Outpatient,,,34.53,17.27,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
11750- Excise/nail/matrix/perm removal,3431555,CDM,960,RC,11750,HCPCS,Outpatient,,,258.92,129.46,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
11900- Intralesional injection/</=7,3431563,CDM,960,RC,11900,HCPCS,Outpatient,,,60.21,30.11,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
11901- Inj/intralesional/> 7 lesions,3431564,CDM,960,RC,11901,HCPCS,Outpatient,,,91.05,45.53,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
11950 - Subcutaneous injection filling material,3572729,CDM,983,RC,11950,HCPCS,Outpatient,,,135.38,67.69,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
11950- Subq inj/fill material/1cc or <,3431566,CDM,960,RC,11950,HCPCS,Outpatient,,,106.02,53.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
11951- Subq inj/fill material/1.1-5.0 cc,3431567,CDM,960,RC,11951,HCPCS,Outpatient,,,148.44,74.22,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
11980- Hormone pellet implant/subq,3431570,CDM,960,RC,11980,HCPCS,Outpatient,,,132.8,66.4,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
11981- Insert/drug delivery implant,3431571,CDM,960,RC,11981,HCPCS,Outpatient,,,165.86,82.93,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
11982- Remove/drug delivery implant,3431572,CDM,960,RC,11982,HCPCS,Outpatient,,,156.69,78.35,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
12001 - SIMPLE REPAIR SCALP/NECK/AX/GENIT/TRUNK 2.5CM/<,4037467,CDM,983,RC,12001,HCPCS,Outpatient,,,93.47,46.74,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
12002- Rep Superfic Wound 2.6-7.5Cm,3431575,CDM,960,RC,12002,HCPCS,Outpatient,,,123.43,61.72,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
12004- Rep Superific Wound 7.6-12.5 cm,3431576,CDM,960,RC,12004,HCPCS,Outpatient,,,154.93,77.47,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
12005- Rep Superfic Wound 12.6-20.0Cm,3431577,CDM,960,RC,12005,HCPCS,Outpatient,,,201.29,100.65,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
"12006- Simple Repair, scalp/neck/axillae/trunk/genital/extrem, 2.5 - 7.5 cm",3428737,CDM,960,RC,12006,HCPCS,Outpatient,,,245.31,122.66,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
12007- Smpl rpr/scalp/neck/ax/ext genit/trnk/extrem/inc hnd/ft/>30cm,3431578,CDM,960,RC,12007,HCPCS,Outpatient,,,304.05,152.03,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
12011-EYE RPR SPR WND FACE <2.5CM,3428738,CDM,960,RC,12011,HCPCS,Outpatient,,,116.45,58.23,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
12013- Rep Superfic Wounds 2.6-5.0Cm,3431580,CDM,960,RC,12013,HCPCS,Outpatient,,,123.04,61.52,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
12014 - Simple repair of superficial wound of eyelid,3428739,CDM,983,RC,12014,HCPCS,Outpatient,,,204.72,102.36,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
12015- Rep Superfic Wounds 7.6-12.5Cm,3431581,CDM,960,RC,12015,HCPCS,Outpatient,,,200.19,100.1,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
12016- Smp rp fac/ear/no/lip/lid 12.6-20,3428740,CDM,960,RC,12016,HCPCS,Outpatient,,,271.32,135.66,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
12018- Smpl rpr/face/ear/lid/nose/lip/>30.0cm,3431582,CDM,960,RC,12018,HCPCS,Outpatient,,,369.73,184.87,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
12020 - Treatment of superficial wound dehiscence; simple cl,4231108,CDM,960,RC,12020,HCPCS,Outpatient,,,378,189,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
12020 -OCC CLOSURE OF SPLIT WOUND,3568838,CDM,983,RC,12020,HCPCS,Outpatient,,,483.59,241.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
12020- Tx superfic wnd dehise/smp close,3431583,CDM,960,RC,12020,HCPCS,Outpatient,,,378,189,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
12021- Tx superficial wnd dehise/smp/pack,3431584,CDM,960,RC,12021,HCPCS,Outpatient,,,282.55,141.28,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
12031- Int rp scalp/ax/trunk/ext 2.5 or <,3428743,CDM,960,RC,12031,HCPCS,Outpatient,,,299,149.5,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
"12032- Intermed Rpr, Scalp, Axillae, Trunk, Extremities 2.6-7.5cm",3431585,CDM,960,RC,12032,HCPCS,Outpatient,,,374.71,187.36,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
12034- Itmed rpr/scalp/ax/trnk/extrem/exclu hnd/ft/7.6-12.5c,3431586,CDM,960,RC,12034,HCPCS,Outpatient,,,409.54,204.77,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
12035- Int rp scalp/ax/trunk/ext 12.6-20,3428744,CDM,960,RC,12035,HCPCS,Outpatient,,,487.35,243.68,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
"12037 - Repair, intermediate, wounds of scalp, axillae, trunk and/or extremities (excluding hands an",3715279,CDM,960,RC,12037,HCPCS,Outpatient,,,671.36,335.68,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
12041- Itmed rpr/neck/hand/ft/ext genit/2.5 cm or <,3431587,CDM,960,RC,12041,HCPCS,Outpatient,,,288.91,144.46,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
12042- Itmed rpr/neck/hand/ft/ext genit/2.6-7.5 cm,3431588,CDM,960,RC,12042,HCPCS,Outpatient,,,388.17,194.09,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
12044- Int rp neck/hand/feet/gen 7.6-12.5,3428745,CDM,960,RC,12044,HCPCS,Outpatient,,,429.43,214.72,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
12045- Itmed rpr/neck/hnd/ft/ext genit/12.6-20.0cm,3431589,CDM,960,RC,12045,HCPCS,Outpatient,,,550.35,275.18,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
12046- Itmed rpr/neck/hnd/ft/ext genit/20.1-30.0cm,3431590,CDM,960,RC,12046,HCPCS,Outpatient,,,651.05,325.53,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
12047- Itmed rpr/neck/hnd/ft/ext genit/> 30.0 cm,3431591,CDM,960,RC,12047,HCPCS,Outpatient,,,724.43,362.22,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
12051- Itmed rpr/face/ear/lid/nose/lip/2.5 cm or<,3431592,CDM,960,RC,12051,HCPCS,Outpatient,,,336.44,168.22,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
12052- Itmed rpr/face/ear/lid/nose/lip/2.6-5.0 cm,3431593,CDM,960,RC,12052,HCPCS,Outpatient,,,396.16,198.08,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
12053- Int rp fac/ear/lid/nos/lip 5.1-7.5,3428750,CDM,960,RC,12053,HCPCS,Outpatient,,,428.81,214.41,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
12054- In rp fac/ear/lid/nos/lip 7.6-12.5,3428751,CDM,960,RC,12054,HCPCS,Outpatient,,,444.86,222.43,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
12055- Itmed rpr/face 2.6-20.0cm,3428752,CDM,960,RC,12055,HCPCS,Outpatient,,,611.13,305.57,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
12056- Int rp fac/ear/lid/nos/lip 20.1-30,3428755,CDM,960,RC,12056,HCPCS,Outpatient,,,772.15,386.08,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
12057- Itmed rpr/face/ear/lid/nose/lip/>30.0cm,3431594,CDM,960,RC,12057,HCPCS,Outpatient,,,846.26,423.13,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
13101- Complex repair/trunk/2.6-7.5 cm,3431595,CDM,960,RC,13101,HCPCS,Outpatient,,,487.66,243.83,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
"13102 - Repair, complex, trunk; each additional 5 cm or less",4037473,CDM,983,RC,13102,HCPCS,Outpatient,,,145.88,72.94,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
13120- Repair/comp/scalp/arm/leg/1.1-2.5c,3431596,CDM,960,RC,13120,HCPCS,Outpatient,,,457.5,228.75,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
13121- Cmplx rpr s/a/l 2.6-7.5 cm,3431597,CDM,960,RC,13121,HCPCS,Outpatient,,,513.25,256.63,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
"13122 - Repair, complex, scalp, arms, and/or legs; each additional 5 cm or less (List separately in",3715283,CDM,960,RC,13122,HCPCS,Outpatient,,,167.59,83.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
13131- Cmplx rpr f/c/c/m/n/ax/g/h/f; 1.1 cm to 2.5 cm,3431598,CDM,960,RC,13131,HCPCS,Outpatient,,,482.19,241.1,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
13132- Cmplx rpr f/c/c/m/n/ax/g/h/f; 2.6 cm to 7.5 cm,3431599,CDM,960,RC,13132,HCPCS,Outpatient,,,602.31,301.16,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
13151- Cmplx rpr e/n/e/l; 1.1-2.5 cm,3431601,CDM,960,RC,13151,HCPCS,Outpatient,,,554.7,277.35,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
13152- Cmplx rpr e/n/e/l; 2.6-7.5 cm,3431602,CDM,960,RC,13152,HCPCS,Outpatient,,,669.92,334.96,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
13160- Secondary clos/surg wound/ext/comp,3431603,CDM,960,RC,13160,HCPCS,Outpatient,,,1612.56,806.28,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
14001- Skin Tiss Transfer 10.1-30Sq Cm,3431604,CDM,960,RC,14001,HCPCS,Outpatient,,,1314.46,657.23,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
14020- Skin Tissue Trnfr 10Sq Cm Less,3431605,CDM,960,RC,14020,HCPCS,Outpatient,,,1124.34,562.17,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
14021- Skin Tissue Trnfr 10.1-30Sq Cm,3431606,CDM,960,RC,14021,HCPCS,Outpatient,,,1410.33,705.17,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
14040- Tis trnfr f/c/c/m/n/a/g/h/f; defect 10 sq cm or less,3431607,CDM,960,RC,14040,HCPCS,Outpatient,,,1239.78,619.89,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
14041- Adj tis trans/see area/10.1-30sqcm,3431608,CDM,960,RC,14041,HCPCS,Outpatient,,,1514.25,757.13,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
14060- Tis trnfr e/n/e/l 10 sq cm/<,3431609,CDM,960,RC,14060,HCPCS,Outpatient,,,1514.25,757.13,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
"15040 - Harvest of skin for tissue cultured skin autograft, 100 sq cm or less",3715286,CDM,960,RC,15040,HCPCS,Outpatient,,,255.71,127.86,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
15101- Skin Split Graft Addl 100Sq Cm,3431614,CDM,960,RC,15101,HCPCS,Outpatient,,,226.37,113.19,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
15110- Epidrm Autogrft Trnk/Arm/Leg,3431615,CDM,960,RC,15110,HCPCS,Outpatient,,,1459.07,729.54,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
15111- Epiderm autograft/specified areas/ea add 100sq cm/ea add 1% body area infant/child,3431616,CDM,960,RC,15111,HCPCS,Outpatient,,,212.17,106.09,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
15115- Epiderm autograft/specified areas/first 100sq cm or </1% body area/infant/child,3431617,CDM,960,RC,15115,HCPCS,Outpatient,,,1415.57,707.79,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
15120 - SPLIT AGRFT F/S/N/H/F/G/M/D GT 1ST 100 CM/,4037474,CDM,983,RC,15120,HCPCS,Outpatient,,,1392.29,696.15,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
15200- Full thick graft/trunk/</=20 sq cm,3431619,CDM,960,RC,15200,HCPCS,Outpatient,,,1353.32,676.66,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
15220- Full thick gft/scalp/arm/leg/20sqcm or<,3431620,CDM,960,RC,15220,HCPCS,Outpatient,,,1213.83,606.92,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
15221- Full thick gft/scalp/arm/leg/add 20sqcm,3431621,CDM,960,RC,15221,HCPCS,Outpatient,,,140.94,70.47,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
15240- Full Thick Graft w/close donor site face/neck/ax/genit/hnd/ft <=20sqcm,3431622,CDM,960,RC,15240,HCPCS,Outpatient,,,1578.13,789.07,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
15241- Skin Full Graft Add 20Sq Cm,3431623,CDM,960,RC,15241,HCPCS,Outpatient,,,218.23,109.12,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
15260- Full thick gft/nose/ear/lid/lip/20sqcm or<,3431624,CDM,960,RC,15260,HCPCS,Outpatient,,,1673.85,836.93,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
15261- Skin Full Graft Add 20 Sq Cm,3431625,CDM,960,RC,15261,HCPCS,Outpatient,,,272.7,136.35,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
15271-PF App Skn Sub Grft T/A/L Area/100 Sq Cm/<1st 25,4345264,CDM,983,RC,15271,HCPCS,Outpatient,,,171.15,85.58,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
15272-PF App Skn Sub Grft T/A/L Area/100 Sq Cm Ea Adl 25sqc,4345265,CDM,983,RC,15272,HCPCS,Outpatient,,,34.73,17.37,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
15273- Skin Sub Grft Trnk Arm Lg Child,3431626,CDM,960,RC,15273,HCPCS,Outpatient,,,401.51,200.76,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
15273-PF App Skn Subgrft T/A/L Area 100 Sq Cm 1st 100 Sq Cm,4345266,CDM,983,RC,15273,HCPCS,Outpatient,,,401.51,200.76,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
15274-PF App Skn Sub Grft T/A/L Area>=100sqc Adl 100sqc,4345267,CDM,983,RC,15274,HCPCS,Outpatient,,,92.2,46.1,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
"15275 Application of skin substitute graft to face, scalp, eyelids, mouth, neck, ears, orbits, genit",3621205,CDM,960,RC,15275,HCPCS,Outpatient,,,189.49,94.75,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
15275-PF Sub Grft F/S/N/H/F/G/M/D <100 Sq Cm 1st 25 Sq Cm,4345268,CDM,983,RC,15275,HCPCS,Outpatient,,,189.49,94.75,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
15276-PF Sub Grft F/S/N/H/F/G/M/D<100 Sq Cm Ea Addl 25sqc,4345269,CDM,983,RC,15276,HCPCS,Outpatient,,,51.37,25.69,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
15760- Composite graft/pri close/don area,3431628,CDM,960,RC,15760,HCPCS,Outpatient,,,1394.05,697.03,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
"15788 - Chemical peel, facial; epidermal",3715288,CDM,960,RC,15788,HCPCS,Outpatient,,,419.21,209.61,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
"15789 - Chemical peel, facial; dermal",3715293,CDM,960,RC,15789,HCPCS,Outpatient,,,805.26,402.63,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
"15792 -Chemical peel, nonfacial; epidermal",3715294,CDM,960,RC,15792,HCPCS,Outpatient,,,406.23,203.12,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
"15793 - Chemical peel, nonfacial; dermal",3715296,CDM,960,RC,15793,HCPCS,Outpatient,,,699.07,349.54,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
"15820 - Blepharoplasty, lower eyelid;",3712914,CDM,960,RC,15820,HCPCS,Outpatient,,,1002.38,501.19,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
"15851 - Removal of sutures under anesthesia (other than local), other surgeon",3715463,CDM,960,RC,15851,HCPCS,Outpatient,,,131.14,65.57,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
16020- Dress/debride pt-thick burn/<5% BS,3431631,CDM,960,RC,16020,HCPCS,Outpatient,,,111.26,55.63,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
16025- Dress/debride pt-tck burn/5-10% BS,3431632,CDM,960,RC,16025,HCPCS,Outpatient,,,226.01,113.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
17000- Destruct premalig lesion/1st les,3431633,CDM,960,RC,17000,HCPCS,Outpatient,,,107.14,53.57,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
17003- DERM DESTRUCT PREMALG LES 2-14,3514645,CDM,960,RC,17003,HCPCS,Outpatient,,,3.96,1.98,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
17004- Destroy premal lesions 15/>,3428770,CDM,960,RC,17004,HCPCS,Outpatient,,,194.55,97.28,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
17110- Destruct benign lesion 1-14,3431075,CDM,983,RC,17110,HCPCS,Outpatient,,,132.86,66.43,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
17111- Destruct lesion 15 or more,3431076,CDM,983,RC,17111,HCPCS,Outpatient,,,162.75,81.38,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
17250- Chemical cautery of granulated tissue,3431077,CDM,983,RC,17250,HCPCS,Outpatient,,,75.03,37.52,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
17250-PF Chemical Cauterization if Granulation Tissue,4345270,CDM,983,RC,17250,HCPCS,Outpatient,,,75.03,37.52,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
17260- Destruction of skin lesions,3431078,CDM,983,RC,17260,HCPCS,Outpatient,,,139.33,69.67,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
17261- Destruction of skin lesions,3431079,CDM,983,RC,17261,HCPCS,Outpatient,,,172.72,86.36,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
17262- Destruction of skin lesions,3431080,CDM,983,RC,17262,HCPCS,Outpatient,,,219.23,109.62,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
17263- Destruction of skin lesions,3431081,CDM,983,RC,17263,HCPCS,Outpatient,,,242.85,121.43,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
17264- Destruction of skin lesions,3431082,CDM,983,RC,17264,HCPCS,Outpatient,,,259.89,129.95,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
17266- Destruction of skin lesions,3431083,CDM,983,RC,17266,HCPCS,Outpatient,,,305.13,152.57,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
17270- Destruction of skin lesions,3431084,CDM,983,RC,17270,HCPCS,Outpatient,,,189.76,94.88,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
17271- Destruction of skin lesions,3431085,CDM,983,RC,17271,HCPCS,Outpatient,,,208.48,104.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
17272- Destruction of skin lesions,3431086,CDM,983,RC,17272,HCPCS,Outpatient,,,240.85,120.43,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
17273- Destruction of skin lesions,3431087,CDM,983,RC,17273,HCPCS,Outpatient,,,272.65,136.33,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
17274- Destruction of skin lesions,3431088,CDM,983,RC,17274,HCPCS,Outpatient,,,333.31,166.66,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
17276- Destruction of skin lesions,3431089,CDM,983,RC,17276,HCPCS,Outpatient,,,403.39,201.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
17280- Destruction of skin lesions,3431090,CDM,983,RC,17280,HCPCS,Outpatient,,,172.12,86.06,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
17281- Destruction of skin lesions,3431091,CDM,983,RC,17281,HCPCS,Outpatient,,,235,117.5,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
17282- Destruction of skin lesions,3431092,CDM,983,RC,17282,HCPCS,Outpatient,,,271.36,135.68,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
"17283- Destruct Skin Lesions,2.1-3.0 cm",3431634,CDM,960,RC,17283,HCPCS,Outpatient,,,340.43,170.22,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
17284- Destruction of skin lesions,3431093,CDM,983,RC,17284,HCPCS,Outpatient,,,396.61,198.31,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
17286- Destruction of skin lesions,3431094,CDM,983,RC,17286,HCPCS,Outpatient,,,539.99,270,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
"17999 Unlisted procedure, skin, mucous membrane and subcutan",3623321,CDM,960,RC,17999,HCPCS,Outpatient,,,340,170,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
19000- Drainage Of Breast Lesion,3431635,CDM,960,RC,19000,HCPCS,Outpatient,,,112.81,56.41,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
19001- Punc asp breast cyst ea additional,3428771,CDM,960,RC,19001,HCPCS,Outpatient,,,56,28,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
19020-,3428772,CDM,960,RC,19020,HCPCS,Outpatient,,,813.04,406.52,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
19081- Bx breast 1st lesion w/o US,3428775,CDM,960,RC,19081,HCPCS,Outpatient,,,1264.59,632.3,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
"19082 Biopsy, breast, with placement of breast localization device(s) (eg, clip, metallic pellet), w",3621196,CDM,960,RC,19082,HCPCS,Outpatient,,,217.96,108.98,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
19083- Biopsy/breast/1st lesion/US guide,3431636,CDM,960,RC,19083,HCPCS,Outpatient,,,409,204.5,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
"19084 Biopsy, breast, with placement of breast localization device(s)",3621149,CDM,960,RC,19084,HCPCS,Outpatient,,,202.3,101.15,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
"19084 Biopsy, breast, with placement of breast localization device(s) ProFee",3621150,CDM,960,RC,19084,HCPCS,Outpatient,,,202.3,101.15,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
19100- Bx breast percut w/o image,3428778,CDM,960,RC,19100,HCPCS,Outpatient,,,188.95,94.48,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
"19110 Nipple exploration, with or without excision of a solitary lactiferous duct or a papilloma lac",3621652,CDM,960,RC,19110,HCPCS,Outpatient,,,921.54,460.77,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
19120- Removal of breast lesion,3428780,CDM,960,RC,19120,HCPCS,Outpatient,,,1349.16,674.58,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
"19303- Mastectomy, simple, complete",3569390,CDM,960,RC,19303,HCPCS,Outpatient,,,2571.8,1285.9,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
21011- Ex SQ tumor/face or scalp < 2 cm,3434682,CDM,960,RC,21011,HCPCS,Outpatient,,,518.64,259.32,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
21012- Ex SQ tumor/face or scalp 2 cm/>,3434683,CDM,960,RC,21012,HCPCS,Outpatient,,,688.11,344.06,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
21013- Exc IM tumor/face & scalp < 2 cm,3434684,CDM,960,RC,21013,HCPCS,Outpatient,,,811.54,405.77,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
21552- Exc SQ tum/neck/ant thorax 3cm/>,3434705,CDM,960,RC,21552,HCPCS,Outpatient,,,938.8,469.4,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
24065 Biopsy arm/elbow soft tissue  (the CPT code is built without a description),3428318,CDM,983,RC,24065,HCPCS,Outpatient,,,325.87,162.94,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
25075- Exc SQ tumor/forearm/wrist/<3cm,3434889,CDM,960,RC,25075,HCPCS,Outpatient,,,652.9,326.45,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
26115- Exc hand les sc < 1.5 cm,3434907,CDM,960,RC,26115,HCPCS,Outpatient,,,852.37,426.19,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
"27040 - Biopsy, soft tissue of pelvis and hip area; superficial",4037478,CDM,983,RC,27040,HCPCS,Outpatient,,,512.44,256.22,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
27337- Exc SQ tumor/thigh/knee area 3cm/>,3435004,CDM,960,RC,27337,HCPCS,Outpatient,,,1108.71,554.36,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
"27596 - (PF) Amputation, thigh, through femur, any level; re-amputation",3634896,CDM,960,RC,27596,HCPCS,Outpatient,,,1907.11,953.56,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
"27602 Decompression fasciotomy, leg; anterior and/or lateral, and posterior compartment(s)",3621977,CDM,960,RC,27602,HCPCS,Outpatient,,,1285.76,642.88,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
"27613 - Biopsy, soft tissue of leg or ankle area; superficial",3715297,CDM,960,RC,27613,HCPCS,Outpatient,,,411.56,205.78,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
28122- Part exc/tarsal/metatarsal,3435162,CDM,960,RC,28122,HCPCS,Outpatient,,,1489.07,744.54,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
28190- Remove foreign body/foot/subq,3435165,CDM,960,RC,28190,HCPCS,Outpatient,,,339.68,169.84,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
"28810 Amputation, metatarsal, with toe, single",3621667,CDM,960,RC,28810,HCPCS,Outpatient,,,1109.8,554.9,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
29260-PF Strapng Elbow/Wrist,4345271,CDM,983,RC,29260,HCPCS,Outpatient,,,38.22,19.11,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
29280-PF Strapng Hand/Finger,4345272,CDM,983,RC,29280,HCPCS,Outpatient,,,41.28,20.64,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
29405-PF App. Short Leg Cast Below Knee-Toe,4345273,CDM,983,RC,29405,HCPCS,Outpatient,,,117.83,58.92,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
29425-PF App. Short Leg Cast Walking/Ambulatory,4345274,CDM,983,RC,29425,HCPCS,Outpatient,,,108.46,54.23,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
29445-PF App. Rigid Total Contact Leg Cast,4345275,CDM,983,RC,29445,HCPCS,Outpatient,,,200.11,100.06,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
29540-PF Strapping Ankle & or Foot,4345276,CDM,983,RC,29540,HCPCS,Outpatient,,,35.23,17.62,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
29580 Application of Unna Boot,4135334,CDM,983,RC,29580,HCPCS,Outpatient,,,54.23,27.12,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
29580-PF Application of Paste Boot,4345278,CDM,983,RC,29580,HCPCS,Outpatient,,,54.23,27.12,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
29580-PF Application of Paste Boot - Bilateral,4345277,CDM,983,RC,29580,HCPCS,Outpatient,,,54.23,27.12,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
29581-PF Appl Mltlayr Compres Leg Below Knee W/Ankle Foot,4345280,CDM,983,RC,29581,HCPCS,Outpatient,,,53.34,26.67,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
29581-PF Appl Mltlayr Compres Leg Below Knee W/Ankle Foot - Bilateral,4345279,CDM,983,RC,29581,HCPCS,Outpatient,,,53.34,26.67,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
29584-PF Appl Mltlayr Compres Sys Uparm Lwarm Hand&Fing,4345281,CDM,983,RC,29584,HCPCS,Outpatient,,,31.21,15.61,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
31231- Nasal endoscopy dx,3431300,CDM,960,RC,31231,HCPCS,Outpatient,,,1000.27,500.14,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
31254 - NASAL/SINUS NDSC W/PARTIAL ETHMOIDECTOMY,4037482,CDM,983,RC,31254,HCPCS,Outpatient,,,638.37,319.19,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
31575 - DIAGNOSTIC LARYNGOSCOPY,3908940,CDM,983,RC,31575,HCPCS,Outpatient,,,285.02,142.51,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
"31600 - (PF) Tracheostomy, planned (separate procedure);",3634897,CDM,960,RC,31600,HCPCS,Outpatient,,,817.75,408.88,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
33238 - (PF) Removal of permanent transvenous electrode(s) by thoracotomy,3634898,CDM,960,RC,33238,HCPCS,Outpatient,,,2521.79,1260.9,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
33340 - PF - Percutaneous transcatheter closure of the left atrial appendage with endocardial implan,3640908,CDM,960,RC,33340,HCPCS,Outpatient,,,2110.39,1055.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
"33418 Transcatheter mitral valve repair, percutaneous approach, including transseptal puncture when",3623384,CDM,960,RC,33418,HCPCS,Outpatient,,,4824.81,2412.41,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
33426- TMVR w/prosthetic ring,3430652,CDM,960,RC,33426,HCPCS,Outpatient,,,4948.42,2474.21,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
33735 - (PF) Atrial septectomy or septostomy; closed heart (Blalock-Hanlon type operation),3634899,CDM,960,RC,33735,HCPCS,Outpatient,,,3466.59,1733.3,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
34703 Endovascular repair of infrarenal aorta and/or iliac artery(ies) by deployment of an aorto-uni,3623200,CDM,960,RC,34703,HCPCS,Outpatient,,,3726.28,1863.14,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
"35305 Thromboendarterectomy, including patch graft, if performed; tibial or peroneal artery, initial",3622973,CDM,960,RC,35305,HCPCS,Outpatient,,,3328.55,1664.28,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
"35351 - (PF) Thromboendarterectomy, including patch graft, if performed; iliac",3634901,CDM,960,RC,35351,HCPCS,Outpatient,,,3494.35,1747.18,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
35531 Bypass graft with vein aortoceliac or aortomesenteri,3623346,CDM,960,RC,35531,HCPCS,Outpatient,,,5325.01,2662.51,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
"35570 Bypass graft, with vein; tibial-tibial, peroneal-tibial, or tibial/peroneal trunk-tibial",3623374,CDM,960,RC,35570,HCPCS,Outpatient,,,4017,2008.5,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
"35646 - (PF) Bypass graft, with other than vein; aortobifemoral",3634902,CDM,960,RC,35646,HCPCS,Outpatient,,,4635.95,2317.98,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
"35671 Bypass graft, with other than vein; popliteal-tibial or -peroneal artery",3622963,CDM,960,RC,35671,HCPCS,Outpatient,,,3068.12,1534.06,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
"35697 - (PF) Bypass graft, with other than vein; aortofemoral",3634903,CDM,960,RC,35697,HCPCS,Outpatient,,,400.79,200.4,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
"35701 Exploration not followed by surgical repair, artery; neck (eg, carotid, subclavian)",3621969,CDM,960,RC,35701,HCPCS,Outpatient,,,1155.4,577.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
"36010 - PF - Introduction of catheter, superior or inferior vena cava",3640894,CDM,960,RC,36010,HCPCS,Outpatient,,,291.78,145.89,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
"36012 - PF - Selective catheter placement, venous system; second order, or more selective, branch (e",3640913,CDM,960,RC,36012,HCPCS,Outpatient,,,463.26,231.63,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
"36248 - (PF) Selective catheter placement, arterial system; additional second order, third order,",3634905,CDM,960,RC,36248,HCPCS,Outpatient,,,127.2,63.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
36410 - Non-routine bl draw 3/> yrs,4241827,CDM,960,RC,36410,HCPCS,Outpatient,,,18.53,9.27,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
36465-PF NJX Noncmpnd Sclerosant Single Incmptnt Vein,4345282,CDM,983,RC,36465,HCPCS,Outpatient,,,246.39,123.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
36466-PF NJX Noncmpnd Sclerosant Multiple Incmptnt Veins,4345283,CDM,983,RC,36466,HCPCS,Outpatient,,,314.31,157.16,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
36468-PF Tx of symptomatic spider veins sclerotherapy,4345284,CDM,983,RC,36468,HCPCS,Outpatient,,,213.27,106.64,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
36470-PF Injection Sclerosant Single Incmptnt Vein,4345285,CDM,983,RC,36470,HCPCS,Outpatient,,,79.1,39.55,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
36471-PF Injection Sclerosant Multiple Incmptnt Veins,4345286,CDM,983,RC,36471,HCPCS,Outpatient,,,157.62,78.81,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
36475- Endo abl/incom vein/ext/rad fre/#1,3430716,CDM,960,RC,36475,HCPCS,Outpatient,,,576.05,288.03,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
36475 Endovenous rf 1st vein,3428319,CDM,983,RC,36475,HCPCS,Outpatient,,,576.05,288.03,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
36475-PF Radiofrequency ablation vein,4345287,CDM,983,RC,36475,HCPCS,Outpatient,,,576.05,288.03,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
36478-PF Endoven AbltJ Incmptnt Vein XTR Laser 1st Vein,4345288,CDM,983,RC,36478,HCPCS,Outpatient,,,574.1,287.05,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
36482-PF Endoven Ablti Ther Chem Adhesive 1st Vein,4345289,CDM,983,RC,36482,HCPCS,Outpatient,,,371.83,185.92,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
36483-PF Endoven Ablti Ther Chem Adhesive Sbsq Vein,4345290,CDM,983,RC,36483,HCPCS,Outpatient,,,184.5,92.25,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
36561- Insert tunn CVC w/sub-q port 5yr>,3430722,CDM,960,RC,36561,HCPCS,Outpatient,,,880,440,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
"36571 - (PF) Insertion of peripherally inserted central venous access device, with subcutaneous port",3634907,CDM,960,RC,36571,HCPCS,Outpatient,,,829.3,414.65,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
"36575 - (PF) Repair of tunneled or non-tunneled central venous access catheter, without subcutaneous",3634908,CDM,960,RC,36575,HCPCS,Outpatient,,,89.43,44.72,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
"36582 - (PF) Replacement, complete, of a tunneled centrally inserted central venous access device,",3634909,CDM,960,RC,36582,HCPCS,Outpatient,,,760.91,380.46,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
36589- Rmv tunnel cent ven access cath,3430724,CDM,960,RC,36589,HCPCS,Outpatient,,,358.34,179.17,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
36590- Rmv tun cen ven acces cath/SQ port,3430725,CDM,960,RC,36590,HCPCS,Outpatient,,,500.7,250.35,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
"36595 Mechanical removal of pericatheter obstructive material (eg, fibrin sheath) from central venou",3621453,CDM,960,RC,36595,HCPCS,Outpatient,,,477.14,238.57,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
"36901 - PF - Introduction of needle(s) and/or catheter(s), dialysis circuit, with diagnostic angiogr",3640895,CDM,960,RC,36901,HCPCS,Outpatient,,,447.25,223.63,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
"36902 - PF - Introduction of needle(s) and/or catheter(s), dialysis circuit, with diagnostic angiogr",3640896,CDM,960,RC,36902,HCPCS,Outpatient,,,635.55,317.78,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
"36903 - PF - Introduction of needle(s) and/or catheter(s), dialysis circuit, with diagnostic angiogr",3640897,CDM,960,RC,36903,HCPCS,Outpatient,,,840.93,420.47,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
36904 - PERQ THRMBC/NFS DIALYSIS CIRCUIT IMG DX ANGRPH,4037512,CDM,983,RC,36904,HCPCS,Outpatient,,,974.65,487.33,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
"36905 - PF - Percutaneous transluminal mechanical thrombectomy and/or infusion for thrombolysis, dia",3640914,CDM,960,RC,36905,HCPCS,Outpatient,,,1175.34,587.67,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
36906 - PERQ THRMBC/NFS DIAL CIRCUIT TCAT PLMT IV STENT,4037522,CDM,983,RC,36906,HCPCS,Outpatient,,,1353.17,676.59,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
"36908 - (PF) Transcatheter placement of intravascular stent(s), central dialysis segment, performed",3634910,CDM,960,RC,36908,HCPCS,Outpatient,,,552.63,276.32,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
"37217 - PF - Transcatheter placement of intravascular stent(s), intrathoracic common carotid artery",3640915,CDM,960,RC,37217,HCPCS,Outpatient,,,2922.56,1461.28,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
"37222 - PF - Revascularization, endovascular, open or percutaneous, iliac artery, each additional ip",3640916,CDM,960,RC,37222,HCPCS,Outpatient,,,504.09,252.05,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
37226 - REVSC OPN/PRQ FEM/POP W/STNT/ANGIOP SM VSL,4037523,CDM,983,RC,37226,HCPCS,Outpatient,,,1101.81,550.91,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
37231 - REVSC OPN/PRQ TIB/PERO W/STNT/ATHR/ANGIOP SM VSL,4037542,CDM,975,RC,37231,HCPCS,Outpatient,,,1543.81,771.91,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
"37238 - PF - Transcatheter placement of an intravascular stent(s), open or percutaneous, including r",3640917,CDM,960,RC,37238,HCPCS,Outpatient,,,820.98,410.49,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
"37239 - PF - Transcatheter placement of an intravascular stent(s), open or percutaneous, including r",3640918,CDM,960,RC,37239,HCPCS,Outpatient,,,405.33,202.67,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
"37241 Vascular embolization or occlusion, inclusive of all radiological supervision and interpretati",3621881,CDM,960,RC,37241,HCPCS,Outpatient,,,1142.52,571.26,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
37246 - PF - Transluminal balloon angioplasty (except lower extremity artery(ies) for occlusive dise,3640899,CDM,960,RC,37246,HCPCS,Outpatient,,,930.15,465.08,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
37247 Transcatheter placement of an intravascular stent(s) (except lower extremity artery(s) for occ,3621308,CDM,960,RC,37247,HCPCS,Outpatient,,,460.22,230.11,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
"37248 - PF - Transluminal balloon angioplasty (except dialysis circuit), open or percutaneous, inclu",3640900,CDM,960,RC,37248,HCPCS,Outpatient,,,788.33,394.17,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
37252 - PF - Intravascular ultrasound (noncoronary vessel) during diagnostic evaluation and/or thera,3640919,CDM,960,RC,37252,HCPCS,Outpatient,,,238.67,119.34,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
37253 - PF - Intravascular ultrasound (noncoronary vessel) during diagnostic evaluation and/or thera,3640920,CDM,960,RC,37253,HCPCS,Outpatient,,,188.51,94.26,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
37609- Ligation/biopsy/temporal artery,3430918,CDM,960,RC,37609,HCPCS,Outpatient,,,537.61,268.81,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
"37722 - (PF) Ligation, division, and stripping, long (greater) saphenous veins from saphenofemoral",3634911,CDM,960,RC,37722,HCPCS,Outpatient,,,1258.4,629.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
37765- Stab phlebectomy/1 ext/10-20 incis,3430749,CDM,960,RC,37765,HCPCS,Outpatient,,,724.9,362.45,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
38505 - BX/EXC LYMPH NODE NEEDLE SUPERFICIAL,4037465,CDM,983,RC,38505,HCPCS,Outpatient,,,198.72,99.36,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
38505- Bx/exc lymph node/needle/superfic,3431451,CDM,960,RC,38505,HCPCS,Outpatient,,,222.57,111.29,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
38525- Bx/exc lymph node/open/deep axilla,3431453,CDM,960,RC,38525,HCPCS,Outpatient,,,1172.13,586.07,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
38570- Laparoscopy/surg/retroper lymph bx,3431456,CDM,960,RC,38570,HCPCS,Outpatient,,,1360.33,680.17,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
38792- Lymphangiography/sentinel node,3431465,CDM,960,RC,38792,HCPCS,Outpatient,,,87.88,43.94,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
38900- Intraop map/sentinel node/inj dye,3431466,CDM,960,RC,38900,HCPCS,Outpatient,,,373.61,186.81,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
"39010 - PF - Mediastinotomy with exploration, drainage, removal of foreign body, or biopsy; transtho",3640921,CDM,960,RC,39010,HCPCS,Outpatient,,,2104.86,1052.43,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
"43233- Esophagogastroduodenoscopy, flexible, transoral; with dilation of esophagus with balloon (30",3621459,CDM,983,RC,43233,HCPCS,Outpatient,,,603.37,301.69,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
43239- EGD w/biopsy/single/multiple,3431169,CDM,983,RC,43239,HCPCS,Outpatient,,,358.69,179.35,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
43251- EGD/remove tumor/polyp/w snare,3431180,CDM,983,RC,43251,HCPCS,Outpatient,,,510.29,255.15,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
"43279 - (PF) Laparoscopy, surgical, esophagomyotomy (Heller type), with fundoplasty, when",3634912,CDM,960,RC,43279,HCPCS,Outpatient,,,3475.34,1737.67,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
"43280-Laparoscopy, surgical, esophagogastric fundoplasty (eg, Nissen, Toupet procedures)",3622755,CDM,983,RC,43280,HCPCS,Outpatient,,,2914.67,1457.34,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
43450- Dilate esoph/unguide sound/bougie,3431204,CDM,983,RC,43450,HCPCS,Outpatient,,,204.29,102.15,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
"43499 - PF Unlisted procedure, esophagus",3641211,CDM,960,RC,43499,HCPCS,Outpatient,,,531.87,265.94,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
"43633- Gastrectomy, partial, distal; with Roux-en-Y reconstruction",3623575,CDM,983,RC,43633,HCPCS,Outpatient,,,5205.31,2602.66,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
43762-MSA CHANGE GASTROSTOMY TUBE W/O REV,3429902,CDM,960,RC,43762,HCPCS,Outpatient,,,567.08,283.54,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
Clinic Adjustment Gastric Band - S2083,4311851,CDM,983,RC,43999,HCPCS,Outpatient,,,519.99,260,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
"44125- Colectomy, partial; with coloproctostomy (low pelvic anastomosis",3622968,CDM,983,RC,44125,HCPCS,Outpatient,,,3166.96,1583.48,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
"44130- Enteroenterostomy, anastomosis of intestine, with or without cutaneous enterostomy (separ",3622980,CDM,983,RC,44130,HCPCS,Outpatient,,,3543.12,1771.56,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
"44145- Colectomy, partial; with coloproctostomy (low pelvic anastomosis",3623381,CDM,983,RC,44145,HCPCS,Outpatient,,,4423.53,2211.77,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
"44147 - (PF) Colectomy, partial; abdominal and transanal approach",3634913,CDM,960,RC,44147,HCPCS,Outpatient,,,5200.83,2600.42,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
"44150 - (PF) Colectomy, total, abdominal, without proctectomy; with ileostomy or ileoproctostomy",3634914,CDM,960,RC,44150,HCPCS,Outpatient,,,4946.61,2473.31,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
"44157 - (PF) Colectomy, total, abdominal, with proctectomy; with ileoanal anastomosis, includes loop",3635060,CDM,960,RC,44157,HCPCS,Outpatient,,,5901.29,2950.65,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
"44188 - (PF) Laparoscopy, surgical, colostomy or skin level cecostomy",3635061,CDM,960,RC,44188,HCPCS,Outpatient,,,3236.21,1618.11,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
"44202 - (PF) Laparoscopy, surgical; enterectomy, resection of small intestine, single resection",3635062,CDM,960,RC,44202,HCPCS,Outpatient,,,3734.9,1867.45,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
"44208- Laparoscopy, surgical; colectomy, partial, with anastomosis, with coloproctostomy (low pelvic",3623578,CDM,960,RC,44208,HCPCS,Outpatient,,,5254.12,2627.06,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
"44300- Placement, enterostomy or cecostomy, tube open (eg, for feeding or decompression) (separate p",3622392,CDM,960,RC,44300,HCPCS,Outpatient,,,2267.21,1133.61,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
44340 - (PF) Revision of colostomy; simple (release of superficial scar) (separate proc,3635063,CDM,960,RC,44340,HCPCS,Outpatient,,,1657.43,828.72,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
"44361 - (PF) Small intestinal endoscopy, enteroscopy beyond second portion of duodenum, not includ",3635065,CDM,960,RC,44361,HCPCS,Outpatient,,,412.28,206.14,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
"44373 - (PF) Small intestinal endoscopy, enteroscopy beyond second portion of duodenum, not includ",3635064,CDM,960,RC,44373,HCPCS,Outpatient,,,500.4,250.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
"44380 - (PF) Ileoscopy, through stoma; diagnostic, including collection of specimen(s) by brushing",3635066,CDM,960,RC,44380,HCPCS,Outpatient,,,144.77,72.39,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
"44388 - Colonoscopy through stoma; diagnostic, including collection of specimen(s) by brushing or wa",3572804,CDM,983,RC,44388,HCPCS,Outpatient,,,409.69,204.85,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
"44394 - (PF) Colonoscopy through stoma; with removal of tumor(s), polyp(s), or other lesion(s) by",3635067,CDM,960,RC,44394,HCPCS,Outpatient,,,592.29,296.15,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
44404 - COLONOSCOPY STOMA W/SUBMUCOSAL INJECTION,4037561,CDM,983,RC,44404,HCPCS,Outpatient,,,449.96,224.98,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
"44603- Suture of small intestine (enterorrhaphy) for perforated ulcer, diverticulum, wound, injury o",3618862,CDM,960,RC,44603,HCPCS,Outpatient,,,4353.35,2176.68,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
"44626 - (PF) Closure of enterostomy, large or small intestine; with resection and colorectal anas",3635068,CDM,960,RC,44626,HCPCS,Outpatient,,,4295.18,2147.59,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
44640 - PF - Closure of intestinal cutaneous fistula,3640922,CDM,960,RC,44640,HCPCS,Outpatient,,,3760.05,1880.03,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
44660- Closure of enterovesical fistula; without intestinal or bladder resection,3622986,CDM,960,RC,44660,HCPCS,Outpatient,,,3551.58,1775.79,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
"44799- Unlisted procedure, small intestine",3623581,CDM,960,RC,44799,HCPCS,Outpatient,,,2659.33,1329.67,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
44955- Appendectomy w/ other major procedure,3431236,CDM,983,RC,44955,HCPCS,Outpatient,,,224.56,112.28,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
"44979 - (PF) Unlisted laparoscopy procedure, appendix",3635069,CDM,960,RC,44979,HCPCS,Outpatient,,,1637.88,818.94,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
45100- Biopsy of rectum,3431238,CDM,983,RC,45100,HCPCS,Outpatient,,,784.55,392.28,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
"45110 - (PF) Proctectomy; complete, combined abdominoperineal, with colostomy",3635070,CDM,960,RC,45110,HCPCS,Outpatient,,,4830.35,2415.18,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
"45111 - (PF) Proctectomy; partial resection of rectum, transabdominal approach",3635071,CDM,960,RC,45111,HCPCS,Outpatient,,,2893.57,1446.79,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
"45171 - (PF) Excision of rectal tumor, transanal approach; not including muscularis propria",3635072,CDM,960,RC,45171,HCPCS,Outpatient,,,1611.42,805.71,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
"45300 - Proctosigmoidoscopy, rigid; diagnostic, with or without collection of specimen(s) by brushin",3572805,CDM,983,RC,45300,HCPCS,Outpatient,,,124.45,62.23,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
"45303 - (PF) Proctosigmoidoscopy, rigid; with dilation",3635073,CDM,960,RC,45303,HCPCS,Outpatient,,,221.79,110.9,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
"45305 Proctosigmoidoscopy, rigid; with biopsy, single or multiple",3621146,CDM,960,RC,45305,HCPCS,Outpatient,,,190.27,95.14,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
"45338 - (PF) Sigmoidoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by",3635074,CDM,960,RC,45338,HCPCS,Outpatient,,,312.55,156.28,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
"45381 COLONSCOPE, SUBMUCOUS INJ",3429965,CDM,960,RC,45381,HCPCS,Outpatient,,,522.05,261.03,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
45385- Colonoscopy/snare rmv/tumor/polyp,3431250,CDM,983,RC,45385,HCPCS,Outpatient,,,664.87,332.44,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
45905 - (PF) Dilation of anal sphincter (separate procedure) under anesthesia other than,3635075,CDM,960,RC,45905,HCPCS,Outpatient,,,439.93,219.97,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
45910 - (PF) Dilation of rectal stricture (separate procedure) under anesthesia other than,3635076,CDM,960,RC,45910,HCPCS,Outpatient,,,506.13,253.07,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
46020- Placement of seton,3566790,CDM,960,RC,46020,HCPCS,Outpatient,,,305,152.5,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
46050-MSA INCISION OF ANAL ABSCESS,3429979,CDM,960,RC,46050,HCPCS,Outpatient,,,259.02,129.51,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
"46080- Sphincterotomy, anal, division of sphincter (separate procedure)",3621307,CDM,983,RC,46080,HCPCS,Outpatient,,,418.89,209.45,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
46083-Incise external hemorrhoid,3431258,CDM,983,RC,46083,HCPCS,Outpatient,,,212.94,106.47,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
"46200- Fissurectomy, including sphincterotomy, when performed",3621646,CDM,983,RC,46200,HCPCS,Outpatient,,,860.66,430.33,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
46220-HKBT EXC PERIANAL SKIN TAG,3435933,CDM,983,RC,46220,HCPCS,Outpatient,,,235.42,117.71,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
46221 - PF Ligation of hemorroid(s),3700932,CDM,960,RC,46221,HCPCS,Outpatient,,,721.34,360.67,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
46221-Ligation of hemorrhoid(s),3431259,CDM,983,RC,46221,HCPCS,Outpatient,,,497.87,248.94,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
"46255 - Hemorrhoidectomy, internal and external, single column/group;",3572807,CDM,960,RC,46255,HCPCS,Outpatient,,,835.39,417.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
46320-Removal of hemorrhoid clot,3431262,CDM,983,RC,46320,HCPCS,Outpatient,,,295.51,147.76,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
46600-Diagnostic anoscopy spx,3430923,CDM,960,RC,46600,HCPCS,Outpatient,,,104.75,52.38,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
46606- Anoscopy/diag/w biopsy/single/mult,3431263,CDM,983,RC,46606,HCPCS,Outpatient,,,197.54,98.77,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
46916 - Cryosurgery Anal Les,4327324,CDM,983,RC,46916,HCPCS,Outpatient,,,281.6,140.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
"46999 - PF Unlisted procedure, anus",3641212,CDM,960,RC,46999,HCPCS,Outpatient,,,664.83,332.42,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
47100-PF WEDGE BIOPSY OF LIVER,3429984,CDM,960,RC,47100,HCPCS,Outpatient,,,2272.42,1136.21,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
47562- Cholecystectomy/laparoscopy,3431265,CDM,983,RC,47562,HCPCS,Outpatient,,,1778.76,889.38,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
47605- Cholecystectomy; with cholangiography,3622764,CDM,983,RC,47605,HCPCS,Outpatient,,,3045.49,1522.75,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
"48140 - (PF) Pancreatectomy, distal subtotal, with or without splenectomy; without pancreaticoj",3635077,CDM,960,RC,48140,HCPCS,Outpatient,,,4222.05,2111.03,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
"49060 - (PF) Drainage of retroperitoneal abscess, open",3635078,CDM,960,RC,49060,HCPCS,Outpatient,,,2954.19,1477.1,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
"49084 - (PF) Peritoneal lavage, including imaging guidance, when performed",3635079,CDM,960,RC,49084,HCPCS,Outpatient,,,288.8,144.4,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
"49255 - (PF) Omentectomy, epiploectomy, resection of omentum (separate proc",3635080,CDM,960,RC,49255,HCPCS,Outpatient,,,2105.96,1052.98,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
"49321-PF LAPAROSCOPY, BIOPSY",3430016,CDM,960,RC,49321,HCPCS,Outpatient,,,918.78,459.39,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
"49326 - (PF) Laparoscopy, surgical; with omentopexy (omental tacking procedure)",3635081,CDM,960,RC,49326,HCPCS,Outpatient,,,516.55,258.28,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
"49329-MA AST UNLISTED LAP ABD,PERIT,OMENT",3430021,CDM,960,RC,49329,HCPCS,Outpatient,,,461.21,230.61,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
"49421- Insertion of tunneled intraperitoneal catheter for dialysis, open",3621513,CDM,960,RC,49421,HCPCS,Outpatient,,,616.62,308.31,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
"49520- Repair recurrent inguinal hernia, any age; reducible",3622240,CDM,960,RC,49520,HCPCS,Outpatient,,,1706.37,853.19,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
"49521 - (PF) Repair recurrent inguinal hernia, any age; incarcerated or strangulated",3635082,CDM,960,RC,49521,HCPCS,Outpatient,,,1931.01,965.51,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
"49650 - PF - Laparoscopy, surgical; repair initial inguinal hernia",3640923,CDM,960,RC,49650,HCPCS,Outpatient,,,1154.79,577.4,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
"49999 - PF Unlisted procedure, abdomen, peritoneum and omentum",3641213,CDM,960,RC,49999,HCPCS,Outpatient,,,3723.06,1861.53,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
"50080 - Percutaneous nephrostolithotomy or pyelostolithotomy, with or without dilation, endoscopy, l",3572811,CDM,983,RC,50080,HCPCS,Outpatient,,,2266.36,1133.18,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
"50432 - PF Placement of nephrostomy catheter, percutaneous, including diagnostic nephrostogram and/o",3641210,CDM,960,RC,50432,HCPCS,Outpatient,,,529.89,264.95,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
50694 - PLMT URTRL STNT PRQ NEW ACESS W/O SEP NFROS CATH,4037566,CDM,983,RC,50694,HCPCS,Outpatient,,,688.31,344.16,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
51700- Bladder irrigate/lavage/instill,3435948,CDM,983,RC,51700,HCPCS,Outpatient,,,70.95,35.48,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
AMB Bladder Irrigation Charge:Bladder Irrigation- 51700,3444232,CDM,960,RC,51700,HCPCS,Outpatient,,,70.95,35.48,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
51701- Insert/non-indwelling bladder cath,3435949,CDM,983,RC,51701,HCPCS,Outpatient,,,59.82,29.91,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
51702- Insert temp indwell blad cath/simp,3435950,CDM,983,RC,51702,HCPCS,Outpatient,,,58.79,29.4,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
51703- Insert temp indwell blad cath/comp,3435951,CDM,983,RC,51703,HCPCS,Outpatient,,,178.12,89.06,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
51705- Change Cystostomy (Bladder) Tube,4363185,CDM,983,RC,51705,HCPCS,Outpatient,,,118.91,59.46,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
51720- Bladder instill/anticancer agent,3435955,CDM,983,RC,51720,HCPCS,Outpatient,,,102.67,51.34,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
AMB Bladder Instill/Anticarcin:Bladder Instill/Anticarcin-51720,3444225,CDM,960,RC,51720,HCPCS,Outpatient,,,102.67,51.34,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
Clinic Cystometrogram Simple,3550630,CDM,960,RC,51725,HCPCS,Outpatient,,,497.91,248.96,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
Clinic Cystometrogram Complex,3550631,CDM,960,RC,51726,HCPCS,Outpatient,,,651.01,325.51,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
Clinic Compl Cystometrogram Void Press Stu - 51728,4305354,CDM,983,RC,51728,HCPCS,Outpatient,,,214.59,107.3,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
51729- Comp cystometrogram/void/uret pres,3435958,CDM,983,RC,51729,HCPCS,Outpatient,,,838.74,419.37,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
51736 Urine flow measurement,4267409,CDM,983,RC,51736,HCPCS,Outpatient,,,30.25,15.13,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
Clinic Complex Uroflometry - 51741,4305355,CDM,983,RC,51741,HCPCS,Outpatient,,,17.74,8.87,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
Clinic EMG stds Anal/Urtl Sphnctr Other/Thn Ndl -51784,4305356,CDM,983,RC,51784,HCPCS,Outpatient,,,76.93,38.47,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
51797- Voiding pressure study/intra-abd,3435962,CDM,983,RC,51797,HCPCS,Outpatient,,,411.58,205.79,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
51798- PVR urine/bladder capacity/US,3435963,CDM,983,RC,51798,HCPCS,Outpatient,,,22.46,11.23,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
51860-PF REPAIR OF BLADDER WOUND,3430085,CDM,960,RC,51860,HCPCS,Outpatient,,,1959.81,979.91,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
Clinic Cystoscopy,3550628,CDM,960,RC,52000,HCPCS,Outpatient,,,186.75,93.38,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
52005- Cystourethroscop/cath/exc rad serv,3435968,CDM,983,RC,52005,HCPCS,Outpatient,,,324.28,162.14,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
52204- Cystourethroscopy with biopsy,3430089,CDM,960,RC,52204,HCPCS,Outpatient,,,324.06,162.03,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
Clinic Cysto Calib Dilat Urtl Strix/Stenosis 52281,4301628,CDM,983,RC,52281,HCPCS,Outpatient,,,312.51,156.26,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
52287- Cystoscopy chemodenervation,3435976,CDM,983,RC,52287,HCPCS,Outpatient,,,392.66,196.33,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
Clinic Cystoscopy w/stent removal,3550633,CDM,960,RC,52310,HCPCS,Outpatient,,,349.63,174.82,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
"52341- Cystourethroscopy; with treatment of ureteral stricture (eg, balloon dilation, laser, electro",3621519,CDM,960,RC,52341,HCPCS,Outpatient,,,739,369.5,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
"52345 Cystourethroscopy with ureteroscopy; with treatment of ureteropelvic junction stricture (eg, b",3621659,CDM,960,RC,52345,HCPCS,Outpatient,,,1028.58,514.29,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
53200 Biopsy of urethra,3621304,CDM,960,RC,53200,HCPCS,Outpatient,,,370.29,185.15,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
"53505 - PF Urethrorrhaphy, suture of urethral wound or injury; penile",3641188,CDM,960,RC,53505,HCPCS,Outpatient,,,1263.34,631.67,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
53600-Dilate urethra stricture,3435998,CDM,983,RC,53600,HCPCS,Outpatient,,,149.97,74.99,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
53601 -Dilation Urethral Stricture Passage of Sound/Urethral,4271221,CDM,983,RC,53601,HCPCS,Outpatient,,,123.59,61.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
53605- Dilate urethral stricture/anesth,3435999,CDM,983,RC,53605,HCPCS,Outpatient,,,150.75,75.38,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
53620- Dilation/urethral strict/male/ini,3436000,CDM,983,RC,53620,HCPCS,Outpatient,,,200.9,100.45,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
53621- Dilation/urethral strict/male/subs,3436001,CDM,983,RC,53621,HCPCS,Outpatient,,,166.78,83.39,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
53660- Dilation/female urethra/initial,3436002,CDM,983,RC,53660,HCPCS,Outpatient,,,96.38,48.19,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
53661- Dilation/female urethra/subsequent,3436003,CDM,983,RC,53661,HCPCS,Outpatient,,,94.4,47.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
54055- Destruct penis les/smp/electrodesi,3431643,CDM,960,RC,54055,HCPCS,Outpatient,,,217.54,108.77,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
54056- Cryosurgery/penis lesion(s),3431644,CDM,960,RC,54056,HCPCS,Outpatient,,,248.84,124.42,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
54060- Destruct penis lesion/smp/excision,3431645,CDM,960,RC,54060,HCPCS,Outpatient,,,298.98,149.49,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
54065 - Dstr lesion penis extensive,4241824,CDM,983,RC,54065,HCPCS,Outpatient,,,347.53,173.77,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
54100- Biopsy of penis,3431646,CDM,960,RC,54100,HCPCS,Outpatient,,,242.27,121.14,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
54150- Circumcision/clamp/other device,3431648,CDM,960,RC,54150,HCPCS,Outpatient,,,226.78,113.39,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
54160- Circumcise/surg/28 days or <,3431649,CDM,960,RC,54160,HCPCS,Outpatient,,,335.86,167.93,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
54161- Circumcise/surg/> 28 days of age,3431650,CDM,960,RC,54161,HCPCS,Outpatient,,,454.58,227.29,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
54200- Peyronie disease/injection proc,3431654,CDM,960,RC,54200,HCPCS,Outpatient,,,216.44,108.22,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
AMB Injection Procedure -> Initial Admin: 54200,3561577,CDM,960,RC,54200,HCPCS,Outpatient,,,216.44,108.22,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
AMB Injection Procedure -> Subsequent Admin: 54200-58,3561578,CDM,960,RC,54200,HCPCS,Outpatient,,,216.44,108.22,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
54235- Corpora cavernosa injection,3431656,CDM,960,RC,54235,HCPCS,Outpatient,,,185.91,92.96,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
54360 Plastic operation on penis to correct angulation,3622376,CDM,960,RC,54360,HCPCS,Outpatient,,,1881.45,940.73,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
"54406 - (PF) Removal of all components of a multi-component, inflatable penile prosthesis without",3635228,CDM,960,RC,54406,HCPCS,Outpatient,,,1907.19,953.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
"54408 - PF - Repair of component(s) of a multi-component, inflatable penile prosthesis",3640924,CDM,960,RC,54408,HCPCS,Outpatient,,,2061.67,1030.84,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
"54435 Corpora cavernosa-glans penis fistulization (eg, biopsy needle, Winter procedure, rongeur, or",3621664,CDM,960,RC,54435,HCPCS,Outpatient,,,1071.52,535.76,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
54450 - PF Foreskin manipulation including lysis of preputial adhesions and stretching,3699545,CDM,983,RC,54450,HCPCS,Outpatient,,,119.14,59.57,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
54512 Excision of extraparenchymal lesion of testis,3622072,CDM,960,RC,54512,HCPCS,Outpatient,,,1399.81,699.91,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
Clinic Puncture Asp of Hydrocele,3550632,CDM,960,RC,55000,HCPCS,Outpatient,,,194.3,97.15,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
55100- Drainage of scrotal wall abscess,3430108,CDM,960,RC,55100,HCPCS,Outpatient,,,383.64,191.82,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
Clinic Vasectomy,3550629,CDM,960,RC,55250,HCPCS,Outpatient,,,521.56,260.78,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
55700- Bx/prostate/needle/punch/sng/mul,3431675,CDM,960,RC,55700,HCPCS,Outpatient,,,301.59,150.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
"55725 Prostatotomy, external drainage of prostatic abscess, any approach; complicated",3622080,CDM,960,RC,55725,HCPCS,Outpatient,,,1546.74,773.37,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
55876- Place interstitdevice/rad tx guide/prostate/sng/mult,3431680,CDM,960,RC,55876,HCPCS,Outpatient,,,116.64,58.32,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
"55899 - PF Unlisted procedure, male genital system",3641214,CDM,960,RC,55899,HCPCS,Outpatient,,,2659.33,1329.67,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
55899- Unlisted proc/male genital system,3431681,CDM,960,RC,55899,HCPCS,Outpatient,,,3343.24,1671.62,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
56405- Vulva/perineal abscess/ I & D,3431352,CDM,960,RC,56405,HCPCS,Outpatient,,,327.34,163.67,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
56420- Bartholin's gland abscess/I & D,3431353,CDM,960,RC,56420,HCPCS,Outpatient,,,256.2,128.1,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
"56501-MA DESTROY, VULVA LESIONS",3430122,CDM,960,RC,56501,HCPCS,Outpatient,,,265.32,132.66,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
56605- BX vulva or perineum/1 lesion,3431357,CDM,960,RC,56605,HCPCS,Outpatient,,,158.21,79.11,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
56606- Bx vulva or perineum/ea add lesion,3431358,CDM,960,RC,56606,HCPCS,Outpatient,,,77.92,38.96,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
56625-PF COMPLETE REMOVAL OF VULVA,3430126,CDM,960,RC,56625,HCPCS,Outpatient,,,1749.47,874.74,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
56630-PF EXTENSIVE VULVA SURG,3430128,CDM,960,RC,56630,HCPCS,Outpatient,,,2526.02,1263.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
"56631 - PF Vulvectomy, radical, partial; with unilateral inguinofemoral lymphadenectomy",3641189,CDM,960,RC,56631,HCPCS,Outpatient,,,3125.22,1562.61,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
57061-MA DESTROY VAG LESIONS,3430142,CDM,960,RC,57061,HCPCS,Outpatient,,,229.09,114.55,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
57100 - Bx vaginal mucosa; simple,3431363,CDM,960,RC,57100,HCPCS,Outpatient,,,137.46,68.73,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
57135-MA REMOVE VAGINA LESION,3430152,CDM,960,RC,57135,HCPCS,Outpatient,,,489.83,244.92,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
57156 - Insertion of a vaginal radiation afterloading appara,3938956,CDM,960,RC,57156,HCPCS,Outpatient,,,388.84,194.42,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
57200- Colporrhapy/vag injury sut/non OB,3431371,CDM,960,RC,57200,HCPCS,Outpatient,,,866.27,433.14,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
"57240 Anterior colporrhaphy, repair of cystocele with or without repair of urethrocele, including cy",3622085,CDM,960,RC,57240,HCPCS,Outpatient,,,1620.01,810.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
"57425-PF LAPAROSCOPY, SURG COLPOPEXY",3430189,CDM,960,RC,57425,HCPCS,Outpatient,,,2587.48,1293.74,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
57454- Colposcopy/cervix/biopsy/curettage,3431388,CDM,960,RC,57454,HCPCS,Outpatient,,,312.35,156.18,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
57500- Biopsy/cervix/single/multiple,3431393,CDM,983,RC,57500,HCPCS,Outpatient,,,174.04,87.02,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
57505- Endocervical curettage,3431394,CDM,960,RC,57505,HCPCS,Outpatient,,,280,140,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
58100- EMB w/o cervical dilation,3431398,CDM,960,RC,58100,HCPCS,Outpatient,,,170.52,85.26,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
58110- EMB w/colposcopy,3431399,CDM,960,RC,58110,HCPCS,Outpatient,,,94.93,47.47,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
58300- Insertion/intrauterine device,3431410,CDM,960,RC,58300,HCPCS,Outpatient,,,179.5,89.75,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
AMB IUD Admin Charge:Insert Intrauterine Device 58300,3444234,CDM,960,RC,58300,HCPCS,Outpatient,,,179.27,89.64,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
"58543 Laparoscopy, surgical, supracervical hysterectomy, for uterus greater than 250 g;",3622389,CDM,960,RC,58543,HCPCS,Outpatient,,,2244.77,1122.39,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
"58545 Laparoscopy, surgical, myomectomy, excision; 1 to 4 intramural myomas with total weight of 250",3622563,CDM,960,RC,58545,HCPCS,Outpatient,,,2401.35,1200.68,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
"58546 Laparoscopy, surgical, myomectomy, excision; 5 or more intramural myomas and/or intramural myo",3622758,CDM,960,RC,58546,HCPCS,Outpatient,,,2978.1,1489.05,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
"58560 Hysteroscopy, surgical; with division or resection of intrauterine septum (any method)",3621643,CDM,960,RC,58560,HCPCS,Outpatient,,,833.68,416.84,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
"58572 Laparoscopy, surgical, with total hysterectomy, for uterus greater than 250 g;",3622748,CDM,960,RC,58572,HCPCS,Outpatient,,,2752.62,1376.31,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
"58952 - (PF) Resection (initial) of ovarian, tubal or primary peritoneal malignancy with bilateral",3635229,CDM,960,RC,58952,HCPCS,Outpatient,,,4354.52,2177.26,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
58958-PF RESECT RECUR GYN MAL W/LYM,3430294,CDM,960,RC,58958,HCPCS,Outpatient,,,4425.47,2212.74,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
Clinic NST,3428544,CDM,960,RC,59025,HCPCS,Outpatient,,,124.16,62.08,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
"59300 - Episiotomy or vaginal repair, by other than attending",4037736,CDM,983,RC,59300,HCPCS,Outpatient,,,394.67,197.34,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
59899 Unlisted procedure maternity care and delivery Bakri,3623306,CDM,960,RC,59899,HCPCS,Outpatient,,,6648.32,3324.16,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
60300- Thyroid cyst/aspiration and/or inj,3431285,CDM,983,RC,60300,HCPCS,Outpatient,,,270.06,135.03,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
"61885 Insertion or replacement of cranial neurostimulator pulse generator or receiver, direct or ind",3622067,CDM,960,RC,61885,HCPCS,Outpatient,,,1386.02,693.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
Clinic Lumbar Puncture,3435540,CDM,960,RC,62270,HCPCS,Outpatient,,,126.32,63.16,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
64425- Inj/anest/ilioing/hypogastric nerv,3435387,CDM,960,RC,64425,HCPCS,Outpatient,,,143.34,71.67,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
64450- Inj/anesth/other perph nerv/branch,3435391,CDM,960,RC,64450,HCPCS,Outpatient,,,110.52,55.26,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
64561(50) Percutaneous neurostimulator,3623710,CDM,983,RC,64561,HCPCS,Outpatient,,,706.19,353.1,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
Clinic PNE,3550634,CDM,960,RC,64561,HCPCS,Outpatient,,,706.19,353.1,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
64595- Rev/rmv prph sac/gstr npgr,3621302,CDM,960,RC,64595,HCPCS,Outpatient,,,325.61,162.81,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
64612- Chemodenerv/facial nerv musc/uni,3435409,CDM,960,RC,64612,HCPCS,Outpatient,,,238.73,119.37,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
65220- Removal/FB/corneal/slit lamp,3431305,CDM,960,RC,65220,HCPCS,Outpatient,,,83.34,41.67,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
65222- Rmv FB/extern eye/cornea/slit lamp,3431306,CDM,960,RC,65222,HCPCS,Outpatient,,,98.83,49.42,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
67700- Drainage of eyelid abscess,3431315,CDM,960,RC,67700,HCPCS,Outpatient,,,224.66,112.33,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
67800- Excision of chalazion/single,3431316,CDM,960,RC,67800,HCPCS,Outpatient,,,199,99.5,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
"67801 Excision of chalazion; multiple, same lid",3621303,CDM,960,RC,67801,HCPCS,Outpatient,,,256.56,128.28,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
67805- EXCIS CHALAZION MULT BOTH,3431317,CDM,983,RC,67805,HCPCS,Outpatient,,,317.85,158.93,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
67810- Incisional biopsy/eyelid,3586925,CDM,983,RC,67810,HCPCS,Outpatient,,,175.2,87.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
67820- Revise eyelashes,3431319,CDM,960,RC,67820,HCPCS,Outpatient,,,43.21,21.61,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
67840-EYE RMV EYELID LESION -NOT CHAL,3430499,CDM,960,RC,67840,HCPCS,Outpatient,,,305.03,152.52,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
67840-OCC Exc eyelid lesion/excpt chalazion,3536978,CDM,983,RC,67840,HCPCS,Outpatient,,,393,196.5,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
67850- Destruction/lid lesion/up to 1 cm,3431321,CDM,960,RC,67850,HCPCS,Outpatient,,,255.86,127.93,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
67875- Temp eyelid closure/suture,3431322,CDM,960,RC,67875,HCPCS,Outpatient,,,186.79,93.4,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
67880- Revision of eyelid,3431323,CDM,960,RC,67880,HCPCS,Outpatient,,,712.32,356.16,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
67903 -OCC Blepharoptosis/levator resct/int,3548670,CDM,983,RC,67903,HCPCS,Outpatient,,,1200.32,600.16,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
67904 - PF Repair of blepharoptosis; (tarso) levator resecti,3641193,CDM,960,RC,67904,HCPCS,Outpatient,,,1157.12,578.56,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
67909- Revise eyelid defect,3431327,CDM,960,RC,67909,HCPCS,Outpatient,,,846.9,423.45,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
67935- Eyelid/recent wound sut/full thick,3431332,CDM,960,RC,67935,HCPCS,Outpatient,,,857.79,428.9,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
67938- Removal of embedded FB/eyelid,3431333,CDM,960,RC,67938,HCPCS,Outpatient,,,226.2,113.1,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
67961- Exc/rpr eyelid/to 1/4 lid margin,3431335,CDM,960,RC,67961,HCPCS,Outpatient,,,879.65,439.83,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
68720 -OCC Dacryocystorhinostomy,3548682,CDM,983,RC,68720,HCPCS,Outpatient,,,2028.62,1014.31,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
68761- Close lacrimal punctum/plug/each,3431340,CDM,960,RC,68761,HCPCS,Outpatient,,,224.95,112.48,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
68801- Dilation of lacrimal punctum,3431341,CDM,960,RC,68801,HCPCS,Outpatient,,,151.9,75.95,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
"68811 - Probing of nasolacrimal duct, with or without irrigation; requiring general anesthesia",3699550,CDM,960,RC,68811,HCPCS,Outpatient,,,262.12,131.06,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
68815- Probe/nasolacrimal/tube/stent,3431342,CDM,960,RC,68815,HCPCS,Outpatient,,,429.19,214.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
68840- Probe lacrimal canaliculi,3431343,CDM,960,RC,68840,HCPCS,Outpatient,,,225.17,112.59,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
69100- Biopsy external ear,3430622,CDM,960,RC,69100,HCPCS,Outpatient,,,93.28,46.64,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
"73206(26)- Computed tomographic angiography, upper extremity, with contrast material(s), including n",3621200,CDM,960,RC,73206,HCPCS,Outpatient,,,225.46,112.73,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
"74740 - PF - Hysterosalpingography, radiological supervision and interpretation",3640903,CDM,960,RC,74740,HCPCS,Outpatient,,,48.24,24.12,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
75557 - (PF) Cardiac magnetic resonance imaging for morphology and function without contrast mat,3635232,CDM,960,RC,75557,HCPCS,Outpatient,,,291.73,145.87,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
75559 - (PF) Cardiac magnetic resonance imaging for morphology and function without contrast mat,3635233,CDM,960,RC,75559,HCPCS,Outpatient,,,363.05,181.53,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
75561(26)- Cardiac magnetic resonance imaging for morphology and function without contrast material(,3621301,CDM,960,RC,75561,HCPCS,Outpatient,,,322.95,161.48,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
75565 (26) Cardiac MRI for velocity flow mapping,3620978,CDM,960,RC,75565,HCPCS,Outpatient,,,31.23,15.62,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
"75572 - (PF) Computed tomography, heart, with contrast mater",3635236,CDM,960,RC,75572,HCPCS,Outpatient,,,218.84,109.42,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
"75574(26)- Computed tomographic angiography, heart, coronary arteries and bypass grafts (when presen",3621300,CDM,960,RC,75574,HCPCS,Outpatient,,,298.21,149.11,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
"75625(26)- Aortography, abdominal, by serialography, radiological supervision and interpretation",3621145,CDM,960,RC,75625,HCPCS,Outpatient,,,169.79,84.9,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
"75630 - PF - Aortography, abdominal plus bilateral iliofemoral lower extremity, catheter, by serialo",3640904,CDM,960,RC,75630,HCPCS,Outpatient,,,191.18,95.59,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
Peripheral Angio Aortagram w Runoff,3427191,CDM,960,RC,75630,HCPCS,Outpatient,,,191.1,95.55,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
"75710 - Angiography, extremity, unilateral, radiological supervision and interpretation",3640905,CDM,960,RC,75710,HCPCS,Outpatient,,,169.68,84.84,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
Peripheral Angio Lower Extremity LT,3427218,CDM,960,RC,75710,HCPCS,Outpatient,,,169.68,84.84,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
Peripheral Angio Lower Extremity RT,3427219,CDM,960,RC,75710,HCPCS,Outpatient,,,169.68,84.84,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
Peripheral Angio Tibal Peroneal,3427225,CDM,960,RC,75710,HCPCS,Outpatient,,,169.68,84.84,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
"75716 - PF - Angiography, extremity, bilateral, radiological supervision and interpretation",3640906,CDM,960,RC,75716,HCPCS,Outpatient,,,247.87,123.94,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
75825 - Venography caval inferior w/ serial,4241822,CDM,983,RC,75825,HCPCS,Outpatient,,,133.27,66.64,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
75894-PF XR Transcatheter Embolization Any Meth RS&I,4345291,CDM,983,RC,75894,HCPCS,Outpatient,,,147.64,73.82,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
"76376(26)- 3D rendering with interpretation and reporting of computed tomography, magnetic resonance",3620958,CDM,960,RC,76376,HCPCS,Outpatient,,,25.03,12.52,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
76536- US head and neck,3430613,CDM,972,RC,76536,HCPCS,Outpatient,,,571.2,285.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
Read,4345734,CDM,972,RC,76536,HCPCS,Outpatient,,,201.94,100.97,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
Read,4345740,CDM,972,RC,76536,HCPCS,Outpatient,,,201.94,100.97,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
SCSN US Thyroid,3370964,CDM,972,RC,76536,HCPCS,Outpatient,,,571.2,285.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
US Neck Including Thyroid:Read,596514,CDM,972,RC,76536,HCPCS,Outpatient,,,274.97,137.49,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
76641 - (TC) US Breast Complete,3896992,CDM,960,RC,76641,HCPCS,Outpatient,,,92.11,46.06,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
76641 - US Breast Complete,3896999,CDM,960,RC,76641,HCPCS,Outpatient,,,92.11,46.06,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
76641- US  breast complete,3430614,CDM,972,RC,76641,HCPCS,Outpatient,,,92.11,46.06,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
Read,3370897,CDM,402,RC,76641,HCPCS,Outpatient,,,255.87,127.94,,191.9,75,,,percent of total billed charges,75% of total billed charges,191.9,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,68.33,100,,,Fee Schedule,100% of WV Medicaid Rate,165.8,165,,,Fee Schedule,165% of CMS OPPS Rate,104.14,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.83,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,68.33,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.14,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,35.82,14,,,percent of total billed charges,14% of total billed charges,35.82,495.81,
Read,3370899,CDM,402,RC,76641,HCPCS,Outpatient,,,255.87,127.94,,191.9,75,,,percent of total billed charges,75% of total billed charges,191.9,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,68.33,100,,,Fee Schedule,100% of WV Medicaid Rate,165.8,165,,,Fee Schedule,165% of CMS OPPS Rate,104.14,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.83,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,68.33,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.14,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,35.82,14,,,percent of total billed charges,14% of total billed charges,35.82,495.81,
76642 - (26) US Breast Limited,3897005,CDM,960,RC,76642,HCPCS,Outpatient,,,85.96,42.98,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
76642 - (TC) US Breast Limited,3897012,CDM,960,RC,76642,HCPCS,Outpatient,,,85.96,42.98,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
76642 - US Breast Limited,3897019,CDM,960,RC,76642,HCPCS,Outpatient,,,85.96,42.98,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
76642- US  breast limited,3430615,CDM,972,RC,76642,HCPCS,Outpatient,,,85.96,42.98,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
"76700 (26) Ultrasound, abdominal, real time with image documentation; complete",3621069,CDM,983,RC,76700,HCPCS,Outpatient,,,101.84,50.92,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
76700- US abdommen complete,3430616,CDM,983,RC,76700,HCPCS,Outpatient,,,101.84,50.92,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
Read,3575253,CDM,983,RC,76700,HCPCS,Outpatient,,,101.84,50.92,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
"76705 (26) Ultrasound, abdominal, real time with image documentation; limited (eg, single organ, qua",3621066,CDM,960,RC,76705,HCPCS,Outpatient,,,75.28,37.64,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
"76705 Ultrasound, abdominal, real time with image documentation; limited (eg, single organ, qua",3715135,CDM,960,RC,76705,HCPCS,Outpatient,,,75.28,37.64,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
Read,,,972,RC,76705,HCPCS,Outpatient,,,161.44,80.72,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
Read,3575225,CDM,972,RC,76705,HCPCS,Outpatient,,,161.44,80.72,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
Read,3575309,CDM,972,RC,76705,HCPCS,Outpatient,,,161.44,80.72,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
US Biliary Tree:Read,3351906,CDM,972,RC,76705,HCPCS,Outpatient,,,161.44,80.72,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
US HKBT Abdomen Limited:Read,3317839,CDM,972,RC,76705,HCPCS,Outpatient,,,161.44,80.72,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
76770- US abdomen back wall complete,3430617,CDM,972,RC,76770,HCPCS,Outpatient,,,96.06,48.03,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
Read,3370929,CDM,972,RC,76770,HCPCS,Outpatient,,,93.06,46.53,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
Read,3562999,CDM,972,RC,76770,HCPCS,Outpatient,,,93.06,46.53,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
Read,3569770,CDM,972,RC,76770,HCPCS,Outpatient,,,93.06,46.53,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
Read,3575227,CDM,972,RC,76770,HCPCS,Outpatient,,,93.06,46.53,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
Read,3575257,CDM,972,RC,76770,HCPCS,Outpatient,,,93.06,46.53,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
SCSN US Renal Bilat Interp,3575303,CDM,972,RC,76770,HCPCS,Outpatient,,,93.06,46.53,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
76775- Us exam abdo back wall lim,3430507,CDM,972,RC,76775,HCPCS,Outpatient,,,130.63,65.32,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
CL Renal Artery Ultrasound LT,3427573,CDM,972,RC,76775,HCPCS,Outpatient,,,130.63,65.32,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
CL Renal Artery Ultrasound RT,3427574,CDM,972,RC,76775,HCPCS,Outpatient,,,130.63,65.32,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
Read,3370925,CDM,972,RC,76775,HCPCS,Outpatient,,,130.63,65.32,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
Read,3370955,CDM,972,RC,76775,HCPCS,Outpatient,,,130.63,65.32,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
Read,3569772,CDM,972,RC,76775,HCPCS,Outpatient,,,130.63,65.32,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
Read,3569774,CDM,972,RC,76775,HCPCS,Outpatient,,,130.63,65.32,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
Read,3575255,CDM,972,RC,76775,HCPCS,Outpatient,,,130.63,65.32,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
Read,3575301,CDM,972,RC,76775,HCPCS,Outpatient,,,130.63,65.32,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
SCSN US Renal LT Interp,3575305,CDM,972,RC,76775,HCPCS,Outpatient,,,130.63,65.32,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
SCSN US Renal LT Interp,3575307,CDM,972,RC,76775,HCPCS,Outpatient,,,130.63,65.32,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
URMC US Kidney:Read,3370977,CDM,972,RC,76775,HCPCS,Outpatient,,,130.63,65.32,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
"76830- US Transvaginal, non-ob",3430618,CDM,972,RC,76830,HCPCS,Outpatient,,,87.65,43.83,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
"76831 - PF - Saline infusion sonohysterography (SIS), including color flow Doppler, when performed",3640911,CDM,960,RC,76831,HCPCS,Outpatient,,,70.85,35.43,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
Read,3575335,CDM,972,RC,76857,HCPCS,Outpatient,,,107.63,53.82,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
76870- Us exam scrotum,3430514,CDM,972,RC,76870,HCPCS,Outpatient,,,219.21,109.61,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
"76872 Ultrasound, transrectal",3430515,CDM,960,RC,76872,HCPCS,Outpatient,,,426.34,213.17,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
URMC US Prostate w/o Biopsy:URMC US Exam,3575341,CDM,972,RC,76872,HCPCS,Outpatient,,,426.34,213.17,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
76937-MA US GUIDE VASCULAR ACCESS,3430516,CDM,960,RC,76937,HCPCS,Outpatient,,,36.14,18.07,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
"76942 - Ultrasonic guidance for needle placement (eg, biopsy, aspiration, injection, localization de",3676896,CDM,972,RC,76942,HCPCS,Outpatient,,,129.6,64.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
"76942- Ultrasonic guidance for needle placement (eg, biopsy, aspiration, injection, localizati",3676897,CDM,960,RC,76942,HCPCS,Outpatient,,,81.09,40.55,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
Read,4345730,CDM,972,RC,76942,HCPCS,Outpatient,,,129.6,64.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
Read,4345732,CDM,972,RC,76942,HCPCS,Outpatient,,,129.6,64.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
76965 (26) Ultrasonic guidance for interstitial radioelement application,3621073,CDM,960,RC,76965,HCPCS,Outpatient,,,172.75,86.38,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
"77001 (26) Fluoroscopic guidance for central venous access device placement, replacement (catheter o",3620979,CDM,960,RC,77001,HCPCS,Outpatient,,,48.86,24.43,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
"77001 Fluoroscopic guidance for central venous access device placement, replacement (catheter only o",3620980,CDM,960,RC,77001,HCPCS,Outpatient,,,48.86,24.43,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
77065 (26) - DIAGNOSTIC MAMMOGRAPHY COMPUTER-AIDED DETCJ UNI,4037790,CDM,983,RC,77065,HCPCS,Outpatient,,,101.84,50.92,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
"77080- Dual-energy X-ray absorptiometry (DXA), bone density study, 1 or more sites; axial skelet",3623708,CDM,960,RC,77080,HCPCS,Outpatient,,,25.03,12.52,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
"77080(26)- Dual-energy X-ray absorptiometry (DXA), bone density study, 1 or more sites; axial skelet",3620959,CDM,960,RC,77080,HCPCS,Outpatient,,,25.03,12.52,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
77316 - (TC) Brachytx Isodose Plan Simple,3898899,CDM,960,RC,77316,HCPCS,Outpatient,,,188.84,94.42,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
77316-(26)-BRACHYTX ISODOSE PLAN SIMPLE,3537568,CDM,983,RC,77316,HCPCS,Outpatient,,,168.58,84.29,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
77317 - (TC) Brachytx Isodose Intermed,3898920,CDM,960,RC,77317,HCPCS,Outpatient,,,249.1,124.55,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
77318 - (TC) Bractx Isodose Complex,3898940,CDM,960,RC,77318,HCPCS,Outpatient,,,391.94,195.97,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
77387 26 Guidance for localization of target volume for de,3623293,CDM,960,RC,77387,HCPCS,Outpatient,,,66.48,33.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
77387-GUIDANCE FOR RADJ TX DLVR,3400461,CDM,983,RC,77387,HCPCS,Outpatient,,,66.48,33.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
Hospital Outpatient Clinic Visit,3400485,CDM,983,RC,77427,HCPCS,Outpatient,,,445.2,222.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
77770 - (26) Remote afterloading high dose rate radionuclide,3938961,CDM,960,RC,77770,HCPCS,Outpatient,,,264.86,132.43,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
77770 - Remote afterloading high dose rate radionuclide brac,3938960,CDM,960,RC,77770,HCPCS,Outpatient,,,264.86,132.43,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
77771 - (26) Remote afterloading high dose rate radionuclide,3938958,CDM,960,RC,77771,HCPCS,Outpatient,,,511.39,255.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
77771 - Remote afterloading high dose rate radionuclide brac,3938957,CDM,960,RC,77771,HCPCS,Outpatient,,,511.39,255.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
78428 (26) - Cardiac shunt detection,4037737,CDM,974,RC,78428,HCPCS,Outpatient,,,96.73,48.37,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
82962 Gluc Bld Cluc Mntr Dev Cleared FDA Spec Home Use,3436058,CDM,761,RC,82962,HCPCS,Outpatient,,,19.47,9.74,,14.6,75,,,percent of total billed charges,75% of total billed charges,14.6,75,,,percent of total billed charges,75% of total billed charges,3.28,100,,,Fee Schedule,100% of CMS OPPS Rate,2.95,100,,,Fee Schedule,100% of WV Medicaid Rate,3.28,100,,,Fee Schedule,100% of CMS OPPS Rate,3.28,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,11.62,354.54,,,Fee Schedule,354.54% of CMS OPPS Fee Schedule Rate,14.06,428.7,,,Fee Schedule,428.7% of CMS OPPS Fee Schedule Rate,14.78,450.81,,,Fee Schedule,450.81% of CMS OPPS Fee Schedule Rate,2.95,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,3.28,100,,,Fee Schedule,100% of CMS OPPS Rate,3.28,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,2.73,14,,,percent of total billed charges,14% of total billed charges,2.73,14.78,
Smear Review Pathology,649497,CDM,971,RC,85060,HCPCS,Outpatient,,,55.51,27.76,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
88305- Tissue exam by pathologist; Level IV,3430541,CDM,960,RC,88305,HCPCS,Outpatient,,,83.51,41.76,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
Pathology Billing Surgical Pathology Level IV Complexity,295352,CDM,971,RC,88305,HCPCS,Outpatient,,,155.81,77.91,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
"91035 Esophagus, gastroesophageal reflux test; with mucosal attached telemetry pH electrode pla",3696909,CDM,960,RC,91035,HCPCS,Outpatient,,,876.09,438.05,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
AMB Covid-19 Charge -> 0.3 mL Covid-19 Inj (6m<5y) CVX 308,4303191,CDM,636,RC,91318,HCPCS,Outpatient,,,319.99,160,,239.99,75,,,percent of total billed charges,75% of total billed charges,239.99,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.8,14,,,percent of total billed charges,14% of total billed charges,44.8,239.99,
92060- Sensorimotor exam/mult measure/I&R,3435585,CDM,962,RC,92060,HCPCS,Outpatient,,,72.16,36.08,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
92925 Percutaneous transluminal coronary atherectomy with c,3623286,CDM,960,RC,92925,HCPCS,Outpatient,,,808.89,404.45,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
92929 Percutaneous transcatheter placement of intracoronary,3623279,CDM,960,RC,92929,HCPCS,Outpatient,,,794.67,397.34,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
92938 Percutaneous transluminal revascularization of or thro,3622807,CDM,960,RC,92938,HCPCS,Outpatient,,,793.82,396.91,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
"92944 - (PF) Percutaneous transluminal revascularization of chronic total occlusion, coronary artery",3635238,CDM,960,RC,92944,HCPCS,Outpatient,,,893.79,446.9,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
Cardioversion,604545,CDM,960,RC,92960,HCPCS,Outpatient,,,214.35,107.18,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
92978 (26) Endoluminal imaging of coronary vessel or graft using intravascular ultrasound (IVUS) or,3621299,CDM,960,RC,92978,HCPCS,Outpatient,,,252.87,126.44,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
92979 (26) Endoluminal imaging of coronary vessel or graft using intravascular ultrasound (IVUS) or,3623711,CDM,960,RC,92979,HCPCS,Outpatient,,,201.76,100.88,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
Clinic EKG,3527352,CDM,960,RC,93000,HCPCS,Outpatient,,,28.01,14.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
EKG Pre/Post Unit,645285,CDM,960,RC,93005,HCPCS,Outpatient,,,21.49,10.75,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
Electrocardiogram-Outpatient,604550,CDM,960,RC,93005,HCPCS,Outpatient,,,14.52,7.26,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
PAT EKG,653557,CDM,960,RC,93005,HCPCS,Outpatient,,,21.49,10.75,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
Stress Test,,,960,RC,93017,HCPCS,Outpatient,,,68.26,34.13,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
CL Holter Monitor 24-48 hour,3430958,CDM,960,RC,93225,HCPCS,Outpatient,,,33.24,16.62,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
93228- MCT/rec/to 30 days/interp/rept,3430961,CDM,960,RC,93228,HCPCS,Outpatient,,,49.86,24.93,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
93242 - Ext ECG >48HR <7D Recording,3896947,CDM,960,RC,93242,HCPCS,Outpatient,,,21.88,10.94,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
93244 - External electrocardiographic recording for more than 48 hours up to 7 days by continuous rh,3635239,CDM,960,RC,93244,HCPCS,Outpatient,,,46.13,23.07,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
93246 - EXT ECG>7D<15D RECORDING,3997218,CDM,960,RC,93246,HCPCS,Outpatient,,,21.88,10.94,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
CardioMEMS recalibration,3427124,CDM,960,RC,93264,HCPCS,Outpatient,,,72.14,36.07,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
93270- Ext pt/auto ECG/30 day/MD interp,3430766,CDM,960,RC,93270,HCPCS,Outpatient,,,15.29,7.65,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
Event Monitoring,604570,CDM,985,RC,93270,HCPCS,Outpatient,,,15.29,7.65,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
93279- PPM eval/test/program/sgn lead,3430968,CDM,960,RC,93279,HCPCS,Outpatient,,,61.33,30.67,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
93280- PPM eval/test/program/dual lead,3430969,CDM,960,RC,93280,HCPCS,Outpatient,,,72.65,36.33,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
93281- PPM eval/test/program/multi lead,3430970,CDM,960,RC,93281,HCPCS,Outpatient,,,81.54,40.77,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
93282- ICD eval/test/program/single lead,3430971,CDM,960,RC,93282,HCPCS,Outpatient,,,81.54,40.77,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
93283- ICD eval/test/program/dual lead,3430972,CDM,960,RC,93283,HCPCS,Outpatient,,,109.86,54.93,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
93284- ICD eval/test/program/mult lead,3430973,CDM,960,RC,93284,HCPCS,Outpatient,,,119.19,59.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
93285- ILR eval/test/program,3430974,CDM,960,RC,93285,HCPCS,Outpatient,,,49.93,24.97,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
93288 - Interrogation Eval in Person 1/Dual/Mlt Lead Pm,3430977,CDM,960,RC,93288,HCPCS,Outpatient,,,40.34,20.17,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
93289- ICD interr/in person/sng/dual/mult,3430978,CDM,960,RC,93289,HCPCS,Outpatient,,,71.59,35.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
ICD Generator Testing,3427177,CDM,960,RC,93289,HCPCS,Outpatient,,,71.59,35.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
93291- Internal loop rec/interr/in person,3430980,CDM,960,RC,93291,HCPCS,Outpatient,,,34.98,17.49,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
93296- PM remote trans/90 day/tech review,3430985,CDM,960,RC,93296,HCPCS,Outpatient,,,38.63,19.32,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
93306- TTE/2D/M-mode/spec dop/color flow,3430992,CDM,960,RC,93306,HCPCS,Outpatient,,,136.49,68.25,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
CL Adult Echocardiogram,3334933,CDM,960,RC,93306,HCPCS,Outpatient,,,136.49,68.25,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
Echocardiogram,604555,CDM,960,RC,93306,HCPCS,Outpatient,,,136.49,68.25,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
MCNH Echo Transthoracic Complete,3805223,CDM,960,RC,93306,HCPCS,Outpatient,,,136.49,68.25,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
93308- TTE/2D/M-mode/follow-up/limited  (GLOBAL),3430994,CDM,960,RC,93308,HCPCS,Outpatient,,,49.42,24.71,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
CL Limited Echocardiogram,3334936,CDM,960,RC,93308,HCPCS,Outpatient,,,49.42,24.71,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
Dobutamine Valve Study,4179565,CDM,960,RC,93308,HCPCS,Outpatient,,,49.42,24.71,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
Limited Study-Echo,645295,CDM,960,RC,93308,HCPCS,Outpatient,,,49.42,24.71,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
93325 Doppler echo color flow,4061247,CDM,960,RC,93325,HCPCS,Outpatient,,,6.06,3.03,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
93325- Doppler echo color flow,3431006,CDM,960,RC,93325,HCPCS,Outpatient,,,6.06,3.03,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
Color Flow Mapping,604586,CDM,985,RC,93325,HCPCS,Outpatient,,,6.06,3.03,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
93350 (26)- Stress Echo w/ I&R (PRO FEE),3431007,CDM,960,RC,93350,HCPCS,Outpatient,,,136.49,68.25,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
93350- Stress echo/2D/M-mode/I&R,3431008,CDM,960,RC,93350,HCPCS,Outpatient,,,136.49,68.25,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
CL Exercise Stress Echocardiogram,3334934,CDM,960,RC,93350,HCPCS,Outpatient,,,136.49,68.25,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
CVS Charge Stress Echo,1157011,CDM,960,RC,93350,HCPCS,Outpatient,,,136.49,68.25,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
Stress Echocardiogram,604568,CDM,960,RC,93350,HCPCS,Outpatient,,,136.49,68.25,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
Myocardial Strain Imaging,3824895,CDM,960,RC,93356,HCPCS,Outpatient,,,23.3,11.65,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
93454- Coronary angiogram,3430771,CDM,960,RC,93454,HCPCS,Outpatient,,,488.09,244.05,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
Coronary Angiography,604572,CDM,960,RC,93454,HCPCS,Outpatient,,,488.09,244.05,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
AV Nodal Ablation,3427172,CDM,960,RC,93650,HCPCS,Outpatient,,,1191.21,595.61,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
AV Node Ablation,651265,CDM,960,RC,93650,HCPCS,Outpatient,,,1191.21,595.61,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
INR POC,3444194,CDM,960,RC,93793,HCPCS,Outpatient,,,28.72,14.36,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
Prothrombin and INR POC,3444204,CDM,960,RC,93793,HCPCS,Outpatient,,,28.72,14.36,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
93880 - Duplex scan of extracranial arteries; complete bilat,3898967,CDM,983,RC,93880,HCPCS,Outpatient,,,76.98,38.49,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
CL Carotid Duplex Complete BILAT,3427518,CDM,960,RC,93880,HCPCS,Outpatient,,,76.98,38.49,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
CL Carotid Duplex Complete LT,3427513,CDM,960,RC,93880,HCPCS,Outpatient,,,76.98,38.49,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
CL Carotid Duplex Complete RT,3427515,CDM,960,RC,93880,HCPCS,Outpatient,,,76.98,38.49,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
Read,3370901,CDM,972,RC,93880,HCPCS,Outpatient,,,76.98,38.49,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
Read,3370939,CDM,972,RC,93880,HCPCS,Outpatient,,,76.98,38.49,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
93882- Dup scan/extracran art/unilat/ltd,3435543,CDM,960,RC,93882,HCPCS,Outpatient,,,48.63,24.32,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
CL Carotid Duplex Limited BILAT,3427517,CDM,960,RC,93882,HCPCS,Outpatient,,,48.63,24.32,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
CL Carotid Duplex Limited LT,3427514,CDM,960,RC,93882,HCPCS,Outpatient,,,48.63,24.32,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
CL Carotid Duplex Limited RT,3427516,CDM,960,RC,93882,HCPCS,Outpatient,,,48.63,24.32,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
CL Limited Carotid Post Procedure BILAT,3427524,CDM,960,RC,93882,HCPCS,Outpatient,,,48.63,24.32,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
CL Limited Carotid Post Procedure LT,3427522,CDM,960,RC,93882,HCPCS,Outpatient,,,48.63,24.32,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
CL Limited Carotid Post Procedure RT,3427523,CDM,960,RC,93882,HCPCS,Outpatient,,,48.63,24.32,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
93922-PF Non-Invas Physiologic STD Extremity Art 2 Level,4345293,CDM,983,RC,93922,HCPCS,Outpatient,,,24.32,12.16,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
93923 - Non-Invasive Physiologic Study Extremity 3 Lvls,3897046,CDM,983,RC,93923,HCPCS,Outpatient,,,44.56,22.28,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
93923- Upr/lxtr art stdy 3+ lvls,3430796,CDM,960,RC,93923,HCPCS,Outpatient,,,44.56,22.28,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
CL Lower Extrem Art Physiologic BILAT,3427525,CDM,960,RC,93923,HCPCS,Outpatient,,,44.56,22.28,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
CL Lower Extrem Art Physiologic LT,3427526,CDM,960,RC,93923,HCPCS,Outpatient,,,44.56,22.28,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
CL Lower Extrem Art Physiologic RT,3427527,CDM,960,RC,93923,HCPCS,Outpatient,,,44.56,22.28,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
CL Lower Periph Art Duplex wo Exer BILAT,3427532,CDM,960,RC,93923,HCPCS,Outpatient,,,44.56,22.28,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
CL Lower Periph Art Duplex wo Exer LT,3427528,CDM,960,RC,93923,HCPCS,Outpatient,,,44.56,22.28,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
CL Lower Periph Art Duplex wo Exer RT,3427530,CDM,960,RC,93923,HCPCS,Outpatient,,,44.56,22.28,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
CL US Lower Extrem Art Comp w ABI BILAT,3427501,CDM,960,RC,93923,HCPCS,Outpatient,,,44.56,22.28,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
CL US Lower Extrem Art Complete LT,3427503,CDM,960,RC,93923,HCPCS,Outpatient,,,44.56,22.28,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
CL US Lower Extrem Art Complete RT,3427505,CDM,960,RC,93923,HCPCS,Outpatient,,,44.56,22.28,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
93924 - Lwr xtr vasc stdy bilat,3435544,CDM,960,RC,93924,HCPCS,Outpatient,,,48.63,24.32,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
CL Lower Ext Art Physio w Exer BILAT,3569307,CDM,960,RC,93924,HCPCS,Outpatient,,,48.63,24.32,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
CL Lower Periph Art Duplex w Exer BILAT,3427533,CDM,960,RC,93924,HCPCS,Outpatient,,,48.63,24.32,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
CL Lower Periph Art Duplex w Exer LT,3427529,CDM,960,RC,93924,HCPCS,Outpatient,,,48.63,24.32,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
CL Lower Periph Art Duplex w Exer RT,3427531,CDM,960,RC,93924,HCPCS,Outpatient,,,48.63,24.32,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
93925 - PF Duplex scan of lower extremity arteries or arterial bypass grafts; complete bilateral stu,3641209,CDM,960,RC,93925,HCPCS,Outpatient,,,101.08,50.54,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
93925 26 Duplex scan of lower extremity arteries or arteri,3622799,CDM,960,RC,93925,HCPCS,Outpatient,,,101.08,50.54,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
93925- Dup scan/LE art/graft/bilat/comp,3435545,CDM,960,RC,93925,HCPCS,Outpatient,,,101.08,50.54,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
93926 - Duplex scan of lower extremity arteries or arterial bypass grafts; unilateral or limited,3620984,CDM,960,RC,93926,HCPCS,Outpatient,,,47.11,23.56,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
93926 (26) Duplex scan of lower extremity arteries or arterial bypass grafts; unilateral or limited,3620983,CDM,960,RC,93926,HCPCS,Outpatient,,,47.11,23.56,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
93926- Dup scan/LE art/graft/unilat/ltd,3435546,CDM,960,RC,93926,HCPCS,Outpatient,,,47.11,23.56,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
CL Femoral Groin Artery BILAT,3427521,CDM,960,RC,93926,HCPCS,Outpatient,,,47.11,23.56,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
CL Femoral Groin Artery LT,3427519,CDM,960,RC,93926,HCPCS,Outpatient,,,47.11,23.56,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
CL Femoral Groin Artery RT,3427520,CDM,960,RC,93926,HCPCS,Outpatient,,,47.11,23.56,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
Read,3370912,CDM,972,RC,93926,HCPCS,Outpatient,,,47.11,23.56,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
Read,3569748,CDM,972,RC,93926,HCPCS,Outpatient,,,47.11,23.56,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
Read,3569750,CDM,972,RC,93926,HCPCS,Outpatient,,,47.11,23.56,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
SCSN US Arterial w Seg Pressures LT,3575261,CDM,972,RC,93926,HCPCS,Outpatient,,,47.11,23.56,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
US Lower Ext Arterial Rt Complete:Read,3374601,CDM,972,RC,93926,HCPCS,Outpatient,,,47.11,23.56,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
93930- Dup scan/UE art/graft/bilat/comp,3435547,CDM,960,RC,93930,HCPCS,Outpatient,,,102.49,51.25,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
93931- Dup scan/UE/art/graft/unilat/ltd,3435548,CDM,960,RC,93931,HCPCS,Outpatient,,,63.38,31.69,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
93970- Dup scan/extremity vein/bilat/comp,3435549,CDM,960,RC,93970,HCPCS,Outpatient,,,66.72,33.36,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
93970-CL Periph Venous US Lower BILAT,3432087,CDM,960,RC,93970,HCPCS,Outpatient,,,66.72,33.36,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
93970-CL Periph Venous US Upper BILAT,3432088,CDM,960,RC,93970,HCPCS,Outpatient,,,66.72,33.36,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
93970-CL Upper Periph Arterial Duplex BILAT,3432089,CDM,960,RC,93970,HCPCS,Outpatient,,,66.72,33.36,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
93970-CL US Vein Map Mark Lower Extrem BILAT,3432090,CDM,960,RC,93970,HCPCS,Outpatient,,,66.72,33.36,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
93970-CL US Vein Map Mark Upper Extrem BILAT,3432091,CDM,960,RC,93970,HCPCS,Outpatient,,,66.72,33.36,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
93970-CL US Venous Insuff Lower Extrem BILAT,3432092,CDM,960,RC,93970,HCPCS,Outpatient,,,66.72,33.36,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
93970-CL US Venous Insuff Upper Extrem BILAT,3432093,CDM,960,RC,93970,HCPCS,Outpatient,,,66.72,33.36,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
93970-PF Dup-Scan XTR Veins Complete Bilateral Study,4345294,CDM,983,RC,93970,HCPCS,Outpatient,,,66.72,33.36,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
CL Periph Venous US Lower BILAT,3427536,CDM,960,RC,93970,HCPCS,Outpatient,,,66.72,33.36,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
CL Periph Venous US Upper BILAT,3427537,CDM,960,RC,93970,HCPCS,Outpatient,,,66.72,33.36,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
CL Upper Periph Arterial Duplex BILAT,3427571,CDM,960,RC,93970,HCPCS,Outpatient,,,66.72,33.36,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
CL US Vein Map Mark Lower Extrem BILAT,3427463,CDM,960,RC,93970,HCPCS,Outpatient,,,66.72,33.36,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
CL US Vein Map Mark Upper Extrem BILAT,3427498,CDM,960,RC,93970,HCPCS,Outpatient,,,66.72,33.36,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
CL US Venous Insuff Lower Extrem BILAT,3427507,CDM,960,RC,93970,HCPCS,Outpatient,,,66.72,33.36,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
CL US Venous Insuff Upper Extrem BILAT,3427510,CDM,960,RC,93970,HCPCS,Outpatient,,,66.72,33.36,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
Read,3575249,CDM,972,RC,93970,HCPCS,Outpatient,,,66.72,33.36,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
Read,4345742,CDM,972,RC,93970,HCPCS,Outpatient,,,325.8,162.9,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
Read,4345744,CDM,972,RC,93970,HCPCS,Outpatient,,,325.8,162.9,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
SCMP US Vein Mapping:Read,3575251,CDM,972,RC,93970,HCPCS,Outpatient,,,66.72,33.36,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
SCSN US Venous Lower Bilat Interp,3575317,CDM,972,RC,93970,HCPCS,Outpatient,,,66.72,33.36,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
SCSN US Venous Upper Bilat Interp,3575323,CDM,972,RC,93970,HCPCS,Outpatient,,,66.72,33.36,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
SCSN Venous Insufficiency Bilat Interp,3575329,CDM,983,RC,93970,HCPCS,Outpatient,,,66.72,33.36,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
WHC US Extremity Vein Complete:Read,2198104,CDM,972,RC,93970,HCPCS,Outpatient,,,66.72,33.36,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
93971 - PB Tech Duplex scan of extremity veins including responses to compression and other maneuver,3641197,CDM,960,RC,93971,HCPCS,Outpatient,,,42.4,21.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
93971- Dup scan/extremity vein/unilat/ltd,3435550,CDM,960,RC,93971,HCPCS,Outpatient,,,42.4,21.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
93971 -Duplex scan of extremity veins including responses to compression and other maneuvers; unilat,3641196,CDM,960,RC,93971,HCPCS,Outpatient,,,42.4,21.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
93971-PF Dup-Scan XTR Veins Unilat/Limited Study,4345295,CDM,983,RC,93971,HCPCS,Outpatient,,,42.4,21.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
CL Periph Venous US Lower LT,3427534,CDM,960,RC,93971,HCPCS,Outpatient,,,42.4,21.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
CL Periph Venous US Lower RT,3427535,CDM,960,RC,93971,HCPCS,Outpatient,,,42.4,21.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
CL Periph Venous US Upper LT,3427538,CDM,960,RC,93971,HCPCS,Outpatient,,,42.4,21.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
CL Periph Venous US Upper RT,3427569,CDM,960,RC,93971,HCPCS,Outpatient,,,42.4,21.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
CL Upper Periph Arterial Duplex LT,3427572,CDM,960,RC,93971,HCPCS,Outpatient,,,42.4,21.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
CL Upper Periph Arterial Duplex RT,3427570,CDM,960,RC,93971,HCPCS,Outpatient,,,42.4,21.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
CL US Vein Map Mark Lower Extrem LT,3427464,CDM,960,RC,93971,HCPCS,Outpatient,,,42.4,21.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
CL US Vein Map Mark Lower Extrem RT,3427497,CDM,960,RC,93971,HCPCS,Outpatient,,,42.4,21.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
CL US Vein Map Mark Upper Extrem LT,3427499,CDM,960,RC,93971,HCPCS,Outpatient,,,42.4,21.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
CL US Vein Map Mark Upper Extrem RT,3427500,CDM,960,RC,93971,HCPCS,Outpatient,,,42.4,21.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
CL US Venous Insuff Lower Extrem LT,3427508,CDM,960,RC,93971,HCPCS,Outpatient,,,42.4,21.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
CL US Venous Insuff Lower Extrem RT,3427509,CDM,960,RC,93971,HCPCS,Outpatient,,,42.4,21.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
CL US Venous Insuff Upper Extrem LT,3427511,CDM,960,RC,93971,HCPCS,Outpatient,,,42.4,21.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
CL US Venous Insuff Upper Extrem RT,3427512,CDM,960,RC,93971,HCPCS,Outpatient,,,42.4,21.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
Read,3569778,CDM,972,RC,93971,HCPCS,Outpatient,,,42.4,21.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
Read,3569780,CDM,972,RC,93971,HCPCS,Outpatient,,,42.4,21.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
Read,3569784,CDM,972,RC,93971,HCPCS,Outpatient,,,42.4,21.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
Read,3569786,CDM,972,RC,93971,HCPCS,Outpatient,,,42.4,21.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
Read,3569790,CDM,972,RC,93971,HCPCS,Outpatient,,,42.4,21.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
Read,3569792,CDM,972,RC,93971,HCPCS,Outpatient,,,42.4,21.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
SCSN US Venous Lower LT Interp,3575319,CDM,972,RC,93971,HCPCS,Outpatient,,,42.4,21.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
SCSN US Venous Lower RT Interp,3575321,CDM,972,RC,93971,HCPCS,Outpatient,,,42.4,21.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
SCSN US Venous Upper LT,3575325,CDM,972,RC,93971,HCPCS,Outpatient,,,42.4,21.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
SCSN US Venous Upper RT Interp,3575327,CDM,972,RC,93971,HCPCS,Outpatient,,,42.4,21.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
SCSN Venous Insuff LT Interp,3575331,CDM,972,RC,93971,HCPCS,Outpatient,,,42.4,21.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
SCSN Venous Insuff RT Interp,3575333,CDM,972,RC,93971,HCPCS,Outpatient,,,42.4,21.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
WHC US Extremity Vein Rt:Read,2198108,CDM,972,RC,93971,HCPCS,Outpatient,,,42.4,21.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
CL Renal Artery Ultrasound BILAT,3427575,CDM,960,RC,93975,HCPCS,Outpatient,,,111,55.5,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
Clinic Abdominal Aortic Ultrasound,3347684,CDM,960,RC,93978,HCPCS,Outpatient,,,77.95,38.98,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
93990- Dup scan/hemodialysis access,3435559,CDM,960,RC,93990,HCPCS,Outpatient,,,64.62,32.31,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
94060- Spirometry/pre/post bronchodilator,3435316,CDM,960,RC,94060,HCPCS,Outpatient,,,20.39,10.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
Clinic Spirometry w/ Diffusion Capacity,3435733,CDM,960,RC,94060,HCPCS,Outpatient,,,20.39,10.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
Clinic Spirometry with and without,3435734,CDM,960,RC,94060,HCPCS,Outpatient,,,20.39,10.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
PFT,617666,CDM,960,RC,94060,HCPCS,Outpatient,,,20.39,10.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
6 Minute Walk,658839,CDM,960,RC,94618,HCPCS,Outpatient,,,44.14,22.07,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
Clinic 6 min walk,3435728,CDM,960,RC,94618,HCPCS,Outpatient,,,44.14,22.07,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
Clinic 6 min walk with Oxygen titration,3435729,CDM,960,RC,94618,HCPCS,Outpatient,,,44.14,22.07,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
Six Minute Walk Test,634111,CDM,983,RC,94618,HCPCS,Outpatient,,,44.14,22.07,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
94726 - (TC) Plethysmography Lung Volumes w/wo airway resist,3896962,CDM,983,RC,94726,HCPCS,Outpatient,,,23.77,11.89,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
94726 - PF Plethysmography/lung volume,3715330,CDM,960,RC,94726,HCPCS,Outpatient,,,23.77,11.89,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
94726 - Plethysmography Lung Volumes w/wo airway resist,3896968,CDM,983,RC,94726,HCPCS,Outpatient,,,23.77,11.89,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
94726- Plethysmography/lung volume,3435709,CDM,960,RC,94726,HCPCS,Outpatient,,,23.77,11.89,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
Clinic Lung Volumes,3435732,CDM,960,RC,94726,HCPCS,Outpatient,,,23.77,11.89,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
Lung Vol & Capacity,617686,CDM,960,RC,94726,HCPCS,Outpatient,,,23.77,11.89,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
94729- Diffusing capacity/CO2/add on,3435712,CDM,960,RC,94729,HCPCS,Outpatient,,,17.7,8.85,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
Carbon Monoxide Diffusing Capacity,625084,CDM,960,RC,94729,HCPCS,Outpatient,,,17.7,8.85,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
Clinic Diffusion Capacity,3435730,CDM,960,RC,94729,HCPCS,Outpatient,,,17.7,8.85,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
DLCO,617682,CDM,960,RC,94729,HCPCS,Outpatient,,,17.7,8.85,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
94762- Noninv ear/pulse ox/cont/overnight,3435716,CDM,960,RC,94762,HCPCS,Outpatient,,,45.81,22.91,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
95800- Stdy Unatnd w/Hrt Rt/O2 Sat/Resp/Slp Time,4347083,CDM,983,RC,95800,HCPCS,Outpatient,,,78.55,39.28,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
95801- Slp Stdy Unatnd w/Min Hrt Rt/O2 Sat/Resp Analys,4347084,CDM,983,RC,95801,HCPCS,Outpatient,,,80.92,40.46,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
Sleep Study - In Lab MSLT 95805,3575514,CDM,960,RC,95805,HCPCS,Outpatient,,,113.34,56.67,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
Sleep Study - Home Study 95806,3575513,CDM,960,RC,95806,HCPCS,Outpatient,,,87.09,43.55,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
95807 - Sleep Study - Attended,4347085,CDM,983,RC,95807,HCPCS,Outpatient,,,753.51,376.76,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
95808- Polysomnography/any age/tech,3430545,CDM,960,RC,95808,HCPCS,Outpatient,,,164.64,82.32,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
Sleep Study - In Lab PSG 95810,3575515,CDM,960,RC,95810,HCPCS,Outpatient,,,234.54,117.27,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
Sleep Study - In Lab Titration 95811,3575516,CDM,960,RC,95811,HCPCS,Outpatient,,,244.18,122.09,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
Clinic EEG,3435538,CDM,960,RC,95812,HCPCS,Outpatient,,,613.96,306.98,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
"EEG, ROUTINE 41-60 MINS",3435541,CDM,960,RC,95812,HCPCS,Outpatient,,,613.96,306.98,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
95813- EEG Routine 61 - 199 Minutes,3435464,CDM,960,RC,95813,HCPCS,Outpatient,,,765.72,382.86,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
CL EEG Routine 61- 199 Minutes 95813,4339185,CDM,960,RC,95813,HCPCS,Outpatient,,,765.72,382.86,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
95816- EEG w/recording/awake/drowsy,3435465,CDM,960,RC,95816,HCPCS,Outpatient,,,113.76,56.88,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
95860 - Needle electromyography; 1 extremity with or without related paraspinal areas,3715346,CDM,960,RC,95860,HCPCS,Outpatient,,,131.45,65.73,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
95861 - Needle electromyography; 2 extremities with or without related paraspinal areas,3715353,CDM,960,RC,95861,HCPCS,Outpatient,,,211.33,105.67,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
95863 - Needle electromyography; 3 extremities with or without related paraspinal areas,3715354,CDM,960,RC,95863,HCPCS,Outpatient,,,255.94,127.97,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
95864 - Needle electromyography; 4 extremities with or without related paraspinal areas,3715360,CDM,960,RC,95864,HCPCS,Outpatient,,,273.91,136.96,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
95869- Needle electromyograp/thor/paraspi,3435479,CDM,960,RC,95869,HCPCS,Outpatient,,,171.62,85.81,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
95870- Needle electromyography/lmt/1 ext,3435480,CDM,960,RC,95870,HCPCS,Outpatient,,,149.46,74.73,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
95873- Electric stim/w chemodenervation,3435482,CDM,960,RC,95873,HCPCS,Outpatient,,,129.1,64.55,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
95874- Needle EMG/chemodenervation,3435483,CDM,960,RC,95874,HCPCS,Outpatient,,,138.42,69.21,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
Clinic EMG,3435539,CDM,960,RC,95874,HCPCS,Outpatient,,,138.42,69.21,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
95885- Needle electromyography/ea ext/lmt,3435485,CDM,960,RC,95885,HCPCS,Outpatient,,,111.42,55.71,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
95886- Needle electromyography/ea ext/com,3435486,CDM,960,RC,95886,HCPCS,Outpatient,,,178.88,89.44,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
95887- Needle electromyography/non-ext,3435487,CDM,960,RC,95887,HCPCS,Outpatient,,,153.56,76.78,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
95905- Motor/sensory nerve conduction/I&R,3435490,CDM,960,RC,95905,HCPCS,Outpatient,,,61.06,30.53,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
95907- Nerve conduction study/1-2 study,3435491,CDM,960,RC,95907,HCPCS,Outpatient,,,166.48,83.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
95908- Nerve conduction study/3-4 study,3435492,CDM,960,RC,95908,HCPCS,Outpatient,,,206.74,103.37,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
95909- Nerve conduction study/5-6 study,3435493,CDM,960,RC,95909,HCPCS,Outpatient,,,248.72,124.36,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
95910- Nerve conduction study/7-8 study,3435494,CDM,960,RC,95910,HCPCS,Outpatient,,,325.7,162.85,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
95911- Nerve conduction study/9-10 study,3435495,CDM,960,RC,95911,HCPCS,Outpatient,,,393.94,196.97,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
95912- Nerve conduction study/11-12 study,3435496,CDM,960,RC,95912,HCPCS,Outpatient,,,461.88,230.94,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
95913- Nerve conduction studies/13 >,3435497,CDM,960,RC,95913,HCPCS,Outpatient,,,534.2,267.1,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
95937- Neuromuscular junc test/ea nerve,3435504,CDM,960,RC,95937,HCPCS,Outpatient,,,191.14,95.57,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
95970- VNS evaluation,3435519,CDM,960,RC,95970,HCPCS,Outpatient,,,36.48,18.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
95972- Elec Anlys Implt Npgt Cplx Sp/Pn Prgrmg,4327334,CDM,983,RC,95972,HCPCS,Outpatient,,,76.88,38.44,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
"95976 - (PF) Electronic analysis of implanted neurostimulator pulse generator/transmitter (eg, conta",3635243,CDM,960,RC,95976,HCPCS,Outpatient,,,104.43,52.22,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
"95976- Electronic analysis of implanted neurostimulator pulse generator/transmitter (eg, contact gro",3692914,CDM,960,RC,95976,HCPCS,Outpatient,,,75.88,37.94,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
"95977 - Electronic analysis of implanted neurostimulator pulse generator/transmitter (eg, contact gr",3715361,CDM,960,RC,95977,HCPCS,Outpatient,,,137.41,68.71,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
"95977-  Electronic analysis of implanted neurostimulator pulse generator/transmitter (eg, contact gr",3692915,CDM,960,RC,95977,HCPCS,Outpatient,,,101.72,50.86,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
95983 - Elec Anlys Implnt Brn Npgt Prgrmg 1st 15 Min,4315922,CDM,960,RC,95983,HCPCS,Outpatient,,,96.48,48.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
95984 - Elec Anlys Implnt Brn Npgt Prgrmg Ea Addl 15 Min,4315923,CDM,960,RC,95984,HCPCS,Outpatient,,,84.4,42.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
95992 - Epley Maneuver,3575063,CDM,960,RC,95992,HCPCS,Outpatient,,,70.58,35.29,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
96156 - Health Coach Assessment,3635244,CDM,983,RC,96156,HCPCS,Outpatient,,,180.73,90.37,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
96158 - Health Coach Initial 30 Mins,3635247,CDM,983,RC,96158,HCPCS,Outpatient,,,121.18,60.59,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
96160 - Pt Focused Hlth Risk Assmt Score Doc Stnd Instrm,4315552,CDM,960,RC,96160,HCPCS,Outpatient,,,4.94,2.47,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
96372-PF Injection of drug/substance under skin or into muscle,4345296,CDM,983,RC,96372,HCPCS,Outpatient,,,27.69,13.85,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
96401- Chemo admin/SQ/IM/anti-neo,3431073,CDM,960,RC,96401,HCPCS,Outpatient,,,153.84,76.92,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
"96402 - Chemotherapy administration, subcutaneous or intramu",3918947,CDM,960,RC,96402,HCPCS,Outpatient,,,80.5,40.25,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
INJ Nonhormonal A/Neo 96402,4297300,CDM,331,RC,96402,HCPCS,Outpatient,,,80.5,40.25,,60.38,75,,,percent of total billed charges,75% of total billed charges,60.38,75,,,percent of total billed charges,75% of total billed charges,63.43,100,,,Fee Schedule,100% of CMS OPPS Rate,21.38,100,,,Fee Schedule,100% of WV Medicaid Rate,104.66,165,,,Fee Schedule,165% of CMS OPPS Rate,65.74,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,182.2,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,249.87,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,312.99,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,21.38,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,63.43,100,,,Fee Schedule,100% of CMS OPPS Rate,65.74,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,11.27,14,,,percent of total billed charges,14% of total billed charges,11.27,312.99,
96920 Excimer lsr psriasis<250sqcm,3431074,CDM,983,RC,96920,HCPCS,Outpatient,,,125.14,62.57,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
96921- Excimer lsr psriasis 250-500,3431095,CDM,983,RC,96921,HCPCS,Outpatient,,,141.87,70.94,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
97010-HOT/COLD PACKS,3430549,CDM,960,RC,97010,HCPCS,Outpatient,,,12.27,6.14,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
97010-PF Application Modality 1/> Areas Hot/Cold Packs,4345297,CDM,983,RC,97010,HCPCS,Outpatient,,,12.27,6.14,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
97014-PF Appl Modality 1/> Areas Elec Stimj Unattended,4345298,CDM,983,RC,97014,HCPCS,Outpatient,,,24.19,12.1,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
97014-PT E-STIM UNATTENDED(WOUND),3430550,CDM,960,RC,97014,HCPCS,Outpatient,,,24.19,12.1,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
97016-PF Appl Modality 1/> Areas Vasopneumatic Devices,4345299,CDM,983,RC,97016,HCPCS,Outpatient,,,23,11.5,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
97026-INFRARED,3430551,CDM,960,RC,97026,HCPCS,Outpatient,,,12.87,6.44,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
97026-PF Application Modality 1/> Areas Infrared,4345300,CDM,983,RC,97026,HCPCS,Outpatient,,,12.87,6.44,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
97035-PF Appl Modality 1/> Areas Ultrasound Ea 15 Min,4345301,CDM,983,RC,97035,HCPCS,Outpatient,,,27.48,13.74,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
97035-PT ULTRASOUND(WOUND),3430552,CDM,960,RC,97035,HCPCS,Outpatient,,,27.48,13.74,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
97039-LASER/OTHER,3430553,CDM,960,RC,97039,HCPCS,Outpatient,,,57.3,28.65,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
97039-PF Unlist Modality Spec Type&Time Constant Attend,4345302,CDM,983,RC,97039,HCPCS,Outpatient,,,57.3,28.65,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
97110-PF Therapeutic Px 1/> Areas Each 15 Min Exercises,4345303,CDM,983,RC,97110,HCPCS,Outpatient,,,57.3,28.65,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
97112-PF Therapeutic Px 1/> Areas Each 15 Min Neuromusc ReEd,4345304,CDM,983,RC,97112,HCPCS,Outpatient,,,65.55,32.78,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
97124 Ther Px 1/> Areas Each 15 Min Massage,3436070,CDM,983,RC,97124,HCPCS,Outpatient,,,58.13,29.07,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
97124-PF Ther Px 1/> Areas Each 15 Min Massage,4345305,CDM,983,RC,97124,HCPCS,Outpatient,,,58.13,29.07,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
97140-PF 0 Manual Therapy TQS 1/> Regions Each 15 Minutes - OT,4345306,CDM,983,RC,97140,HCPCS,Outpatient,,,52.92,26.46,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
97165-PF OT Eval Low Complex 30 Minutes,4345307,CDM,983,RC,97165,HCPCS,Outpatient,,,197.7,98.85,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
97166-PF OT Eval Mod Complex 45 Minutes,4345308,CDM,983,RC,97166,HCPCS,Outpatient,,,197.97,98.99,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
97167-PF OT Eval High Complex 60 Minutes,4345309,CDM,983,RC,97167,HCPCS,Outpatient,,,197.97,98.99,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
97168-PF OT Re-Eval Est Plan Care 30 Minutes,4345310,CDM,983,RC,97168,HCPCS,Outpatient,,,135.83,67.92,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
97530-PF Therapeut Activity Direct  Contact Each 15 Min,4345311,CDM,983,RC,97530,HCPCS,Outpatient,,,70.36,35.18,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
97535-PF Self Care Mngment Training,4345312,CDM,983,RC,97535,HCPCS,Outpatient,,,63.28,31.64,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
97537-PF Community or Work Reint Training Ea 15 Min,4345313,CDM,983,RC,97537,HCPCS,Outpatient,,,61.78,30.89,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
97597- Debrid/select/1st 20 sq cm or less,3430558,CDM,960,RC,97597,HCPCS,Outpatient,,,72.16,36.08,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
97597-PF Debrdmnt Open Wound 20 Sq Cm/<,4345314,CDM,983,RC,97597,HCPCS,Outpatient,,,72.16,36.08,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
"97598 - Debridement (eg, high pressure waterjet with/without suction, sharp selective debridement wi",3715362,CDM,960,RC,97598,HCPCS,Outpatient,,,50.43,25.22,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
97598-PF Debrdmnt Open Wound Each Addtl 20 Sq Cm,4345315,CDM,983,RC,97598,HCPCS,Outpatient,,,50.43,25.22,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
"97602 -Removal of devitalized tissue from wound(s), non-selective debridement, without anesthesia (e",3641199,CDM,960,RC,97602,HCPCS,Outpatient,,,48.68,24.34,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
97602-PF Rmvl Devital Tiss N-Slctv Dbrdmt W/O Anes 1 Sess,4345316,CDM,983,RC,97602,HCPCS,Outpatient,,,48.68,24.34,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
97605-PF Negative Pressure Wound Therapy DME <=50 Sq Cm,4345317,CDM,983,RC,97605,HCPCS,Outpatient,,,48.68,24.34,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
97606- Neg press wound therapy/>50 sq cm,3430560,CDM,983,RC,97606,HCPCS,Outpatient,,,53.34,26.67,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
97606-PF Negative Pressure Wound Therapy DME >50 Sq Cm,4345318,CDM,983,RC,97606,HCPCS,Outpatient,,,53.34,26.67,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
97607-PF Negative Pressure Wound Therapy Non DME <=50 Sq Cm,4345319,CDM,983,RC,97607,HCPCS,Outpatient,,,43.59,21.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
97608-PF Negative Pressure Wound Therapy Non DME >50 Sq Cm,4345320,CDM,983,RC,97608,HCPCS,Outpatient,,,51.52,25.76,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
97750-PF Physical Perf Test/Meas w/ Reprt Ea 15 Min,4345321,CDM,983,RC,97750,HCPCS,Outpatient,,,65.68,32.84,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
97760-PF Orthotics Mgmt & Traing Initial Enctr Ea 15 Mins,4345322,CDM,983,RC,97760,HCPCS,Outpatient,,,90.69,45.35,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
97763-PF Orthotics/Prosth Mgmt & Traing Sbsq Enctr 15 Min,4345323,CDM,983,RC,97763,HCPCS,Outpatient,,,98.88,49.44,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
98925 Osteopathic Manipulations 1-2 body regions,3438184,CDM,960,RC,98925,HCPCS,Outpatient,,,61.75,30.88,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
98925 Osteopathic manipulative treatment (OMT); 1-2 body regions involved,3620985,CDM,960,RC,98925,HCPCS,Outpatient,,,61.75,30.88,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
98926 Osteopathic Manipulations 3-4 body regions,3438185,CDM,983,RC,98926,HCPCS,Outpatient,,,82.01,41.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
98927 Osteopathic Manipulations 5-6 body regions,3438186,CDM,960,RC,98927,HCPCS,Outpatient,,,121.51,60.76,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
98927 Osteopathic manipulative treatment (OMT); 5-6 body regions involved,3621071,CDM,960,RC,98927,HCPCS,Outpatient,,,121.51,60.76,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
98928 Osteopathic Manipulations  7-8 body regions,3438187,CDM,960,RC,98928,HCPCS,Outpatient,,,153.82,76.91,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
98928 Osteopathic manipulative treatment (OMT); 7-8 body regions involved,3621072,CDM,960,RC,98928,HCPCS,Outpatient,,,153.82,76.91,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
98929 Osteopathic Manipulations 9-10 body regions,3438188,CDM,983,RC,98929,HCPCS,Outpatient,,,185.36,92.68,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
98960-PF Education Training for self-mgmt,4345324,CDM,983,RC,98960,HCPCS,Outpatient,,,23.07,11.54,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
99152 - MOD SED SAME PHYS/QHP 5/>YRS,3997219,CDM,960,RC,99152,HCPCS,Outpatient,,,33.75,16.88,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
99153 - MOD SED SAME PHYS/QHP EA,3997220,CDM,960,RC,99153,HCPCS,Outpatient,,,25.91,12.96,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
99183-PF Phys/QHP Attn&Supvj Hyprbaric Oxygen Tx/Session,4345325,CDM,983,RC,99183,HCPCS,Outpatient,,,216.6,108.3,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
99202 Office Outpt visist new StrFrwd or 15 to 29 mins,3572774,CDM,983,RC,99202,HCPCS,Outpatient,,,95.89,47.95,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
99202-PF Office/OP New SF MDM 15 Minutes,4345326,CDM,983,RC,99202,HCPCS,Outpatient,,,95.89,47.95,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
99203 Office Outpt visit new Low or 30 to 44 mins,3572775,CDM,983,RC,99203,HCPCS,Outpatient,,,166.57,83.29,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
99203-PF Office/OP New SF MDM 30 Minutes,4345327,CDM,983,RC,99203,HCPCS,Outpatient,,,166.57,83.29,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
99204 Office Outpt visit new Mod or 45 to 59 mins,3572776,CDM,983,RC,99204,HCPCS,Outpatient,,,270.32,135.16,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
99204-PF Office/OP New SF MDM 45 Minutes,4345328,CDM,983,RC,99204,HCPCS,Outpatient,,,270.32,135.16,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
99205 Office Outpt visist new High 60 to 74 mins,3572777,CDM,983,RC,99205,HCPCS,Outpatient,,,367.44,183.72,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
99205-PF Office/OP New SF MDM 60 Minutes,4345329,CDM,983,RC,99205,HCPCS,Outpatient,,,367.44,183.72,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
99211 Office outpatient visit est  nursing visit only,3572778,CDM,983,RC,99211,HCPCS,Outpatient,,,17.62,8.81,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
99211-EST PATIENT LEVEL 1 Profee,3438255,CDM,983,RC,99211,HCPCS,Outpatient,,,17.62,8.81,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
99211-PF Office/OP Established  May Not Rqr Phys/QHP,4345330,CDM,983,RC,99211,HCPCS,Outpatient,,,17.62,8.81,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
99212 Office Outpt visit est Strtforward or 10 to 19 mins,3572779,CDM,983,RC,99212,HCPCS,Outpatient,,,71.51,35.76,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
99212-PF Office/OP Est SF MDM 10 Minutes,4345331,CDM,983,RC,99212,HCPCS,Outpatient,,,71.51,35.76,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
99213- Office/OP Est SF 20 Minutes,3572780,CDM,983,RC,99213,HCPCS,Outpatient,,,133.01,66.51,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
99213-PF Office/OP Est SF MDM 20 Minutes,4345332,CDM,983,RC,99213,HCPCS,Outpatient,,,133.01,66.51,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
99214- Office/OP Est Mod 30 Minutes,3572781,CDM,983,RC,99214,HCPCS,Outpatient,,,195.91,97.96,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
99214-Office outpatient visit est Moderate or 30 39 minutes,4223209,CDM,983,RC,99214,HCPCS,Outpatient,,,195.91,97.96,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
99214-PF Office/OP Est Mod MDM 30 Minutes,4345333,CDM,983,RC,99214,HCPCS,Outpatient,,,195.91,97.96,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
99214-PRO FEE ESTABLISHED PATIENT LEVEL 4 (30-39 min),3435840,CDM,983,RC,99214,HCPCS,Outpatient,,,195.91,97.96,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
99215 Office Outpatient visit est High or 40 to 54 minutes,3572782,CDM,983,RC,99215,HCPCS,Outpatient,,,290.72,145.36,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
99215-PF Office/OP Est High MDM 40 Minutes,4345334,CDM,983,RC,99215,HCPCS,Outpatient,,,290.72,145.36,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
99244-PF Office Consult New/Est PT Mod MDM Level 4 (40 min),4355204,CDM,983,RC,99244,HCPCS,Outpatient,,,603.67,301.84,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
99245-PF Office Consult New/Est PT High MDM Level 5 (55 min),4355206,CDM,983,RC,99245,HCPCS,Outpatient,,,848.33,424.17,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
99254- Initl IP/OBV Consult New/Est Pt Mod MDM (60 min),3437948,CDM,983,RC,99254,HCPCS,Outpatient,,,612.98,306.49,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
99395- Periodic Comp Preventive Med 18 to 39 years Est,3438040,CDM,983,RC,99395,HCPCS,Outpatient,,,297.85,148.93,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
99396- Periodic Comp Preventive Med 40 to 64 years Est,3438041,CDM,983,RC,99396,HCPCS,Outpatient,,,317.79,158.9,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
99397- Periodic Comp Preventive Med 65+ years Est,3438042,CDM,983,RC,99397,HCPCS,Outpatient,,,315.8,157.9,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
99406-BEHAV CHNG SMOKING 3-10 MIN,3400474,CDM,983,RC,99406,HCPCS,Outpatient,,,23.89,11.95,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
99407-BEHAV CHNG SMOKING > 10 MIN,3537585,CDM,983,RC,99407,HCPCS,Outpatient,,,66.22,33.11,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
99415 - Prolonged Clinical Staff SVC Ofice/O/P 1st HR,3897052,CDM,983,RC,99415,HCPCS,Outpatient,,,24.02,12.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
99416 - Prolonged Clinical Staff SVC Office/O/P Ea Addl 30Mi,3897058,CDM,983,RC,99416,HCPCS,Outpatient,,,13.43,6.72,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
99417-PF Prolonged OP E/M Service ? ea addl 15 min,4355202,CDM,983,RC,99417,HCPCS,Outpatient,,,60.5,30.25,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
ONLINE E/M PHYS CULM 7 DAYS 5-10MIN,3527888,CDM,960,RC,99421,HCPCS,Outpatient,,,38.65,19.33,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
ONLINE E/M PHYS CULM 7 DAYS11-20MIN,3527889,CDM,960,RC,99422,HCPCS,Outpatient,,,75.68,37.84,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
99423- ONLINE E/M PHYS CULM 7 DAYS 21+MIN,3514699,CDM,983,RC,99423,HCPCS,Outpatient,,,123.18,61.59,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
99441-PF Phone E/M Phys/QHP 5-10 Min,4345335,CDM,983,RC,99441,HCPCS,Outpatient,,,70.57,35.29,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
99442-PF Phone E/M Phys/QHP 11-20 Min,4345336,CDM,983,RC,99442,HCPCS,Outpatient,,,132.08,66.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
99443-PF Phone E/M Phys/QHP 21-30 Min,4345337,CDM,983,RC,99443,HCPCS,Outpatient,,,195.91,97.96,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
99495- Trans care mgmt 14 day disch,3438135,CDM,983,RC,99495,HCPCS,Outpatient,,,372.33,186.17,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
99496- Trans care mgmt 7 day disch,3438136,CDM,983,RC,99496,HCPCS,Outpatient,,,503.97,251.99,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
99498 - Advanced care plan addl 30 min,3678905,CDM,983,RC,99498,HCPCS,Outpatient,,,188.51,94.26,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
0001A - ADM SARSCOV2 30MCG/0.3ML 1ST,3999148,CDM,983,RC,0001A,HCPCS,Outpatient,,,96.62,48.31,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
0002A - ADM SARSCOV2 30MCG/0.3ML 2ND,3997221,CDM,983,RC,0002A,HCPCS,Outpatient,,,96.62,48.31,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
0003A - ADM SARSCOV2 30MCG/0.3ML 3RD,3997222,CDM,983,RC,0003A,HCPCS,Outpatient,,,96.62,48.31,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
0004A - ADM SARSCOV2 30MCG/0.3ML BST,3999149,CDM,983,RC,0004A,HCPCS,Outpatient,,,96.62,48.31,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
0011A - ADM SARSCOV2 100MCG/0.5ML1ST,3997223,CDM,983,RC,0011A,HCPCS,Outpatient,,,96.62,48.31,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
0012A - ADM SARSCOV2 100MCG/0.5ML2ND,3997224,CDM,983,RC,0012A,HCPCS,Outpatient,,,96.62,48.31,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
0013A - ADM SARSCOV2 100MCG/0.5ML3RD,3997225,CDM,983,RC,0013A,HCPCS,Outpatient,,,96.62,48.31,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
0031A - ADM SARSCOV2 VAC AD26 .5ML,3999150,CDM,983,RC,0031A,HCPCS,Outpatient,,,96.62,48.31,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
0034A - ADM SARSCOV2 VAC AD26 .5ML B,3999151,CDM,983,RC,0034A,HCPCS,Outpatient,,,96.62,48.31,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
0041A - IMM ADMN SARSCOV2 5 MCG/0.5 ML 1ST DOSE,4037470,CDM,960,RC,0041A,HCPCS,Outpatient,,,96.62,48.31,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
0064A - ADM SARSCOV2 50MCG/0.25MLBST,3997226,CDM,983,RC,0064A,HCPCS,Outpatient,,,96.62,48.31,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
0071A - ADM SARSCV2 10MCG TRS-SUCR 1,3997227,CDM,983,RC,0071A,HCPCS,Outpatient,,,96.62,48.31,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
0072A - ADM SARSCV2 10MCG TRS-SUCR 2,3997228,CDM,983,RC,0072A,HCPCS,Outpatient,,,96.62,48.31,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
0094A - ADM SARSCOV2 50MCG/0.5 MLBST,4113121,CDM,983,RC,0094A,HCPCS,Outpatient,,,96.62,48.31,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
3354F - CLIN SIGN DEP SYMP BY STAND DEP ASSESS TOOL,3999152,CDM,983,RC,3354F,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
Sacral Nerve Stim Test Lead,3966950,CDM,278,RC,A4290,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
G0101- Cervical Or Vaginal Cancer Screening,3431440,CDM,960,RC,G0101,HCPCS,Outpatient,,,35.4,17.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
"G0179- Home health re-certification, physician",3435919,CDM,960,RC,G0179,HCPCS,Outpatient,,,101.88,50.94,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
G0270 - MNT subs tx for change dx,4037466,CDM,983,RC,G0270,HCPCS,Outpatient,,,70.47,35.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
"G0277-PF HBOT, Full Body Chamber, 30 Minutes",4345338,CDM,983,RC,G0277,HCPCS,Outpatient,,,382.62,191.31,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
G0399- Home Sleep Test 3,3430575,CDM,960,RC,G0399,HCPCS,Outpatient,,,250,125,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
G0400 - Home Sleep Test/Type 4 Portable-Unattended,4347086,CDM,983,RC,G0400,HCPCS,Outpatient,,,109.83,54.92,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
G0500 - MOD SEDAT ENDO SERVICE >5YRS,3999154,CDM,960,RC,G0500,HCPCS,Outpatient,,,14.58,7.29,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
G2212 - Prolonged OP E/M Service-beyond the maximum (ea addl 15 min),3623709,CDM,983,RC,G2212,HCPCS,Outpatient,,,99.72,49.86,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
"Q0091- Screening Pap Smear,Specimen Prep",3431441,CDM,960,RC,Q0091,HCPCS,Outpatient,,,60,30,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
Q0111 Wet mounts w preparations,3428512,CDM,983,RC,Q0111,HCPCS,Outpatient,,,15.48,7.74,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
S0610 Annual gynecological examina,3428517,CDM,983,RC,S0610,HCPCS,Outpatient,,,327.11,163.56,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
Esophageal Manometry,3359090,CDM,750,RC,91010,HCPCS,Outpatient,,,1279.13,639.57,,959.35,75,,,percent of total billed charges,75% of total billed charges,959.35,75,,,percent of total billed charges,75% of total billed charges,454.5,100,,,Fee Schedule,100% of CMS OPPS Rate,147.97,100,,,Fee Schedule,100% of WV Medicaid Rate,749.91,165,,,Fee Schedule,165% of CMS OPPS Rate,471.04,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1305.49,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1790.39,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,2242.64,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,147.97,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,454.5,100,,,Fee Schedule,100% of CMS OPPS Rate,471.04,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,179.08,14,,,percent of total billed charges,14% of total billed charges,147.97,2242.64,
24 Hour pH-Impedance Monitoring,3361239,CDM,750,RC,91038,HCPCS,Outpatient,,,1279.13,639.57,,959.35,75,,,percent of total billed charges,75% of total billed charges,959.35,75,,,percent of total billed charges,75% of total billed charges,454.5,100,,,Fee Schedule,100% of CMS OPPS Rate,272.35,100,,,Fee Schedule,100% of WV Medicaid Rate,749.91,165,,,Fee Schedule,165% of CMS OPPS Rate,471.04,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1305.49,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1790.39,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,2242.64,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,272.35,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,454.5,100,,,Fee Schedule,100% of CMS OPPS Rate,471.04,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,179.08,14,,,percent of total billed charges,14% of total billed charges,179.08,2242.64,
Impedance > 1 Hour,3361274,CDM,750,RC,91038,HCPCS,Outpatient,,,1077.44,538.72,,808.08,75,,,percent of total billed charges,75% of total billed charges,808.08,75,,,percent of total billed charges,75% of total billed charges,454.5,100,,,Fee Schedule,100% of CMS OPPS Rate,272.35,100,,,Fee Schedule,100% of WV Medicaid Rate,749.91,165,,,Fee Schedule,165% of CMS OPPS Rate,471.04,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1305.49,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1790.39,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,2242.64,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,272.35,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,454.5,100,,,Fee Schedule,100% of CMS OPPS Rate,471.04,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,150.84,14,,,percent of total billed charges,14% of total billed charges,150.84,2242.64,
Capsule Endoscopy Intestine (Pill-Cam),3359595,CDM,750,RC,91110,HCPCS,Outpatient,,,3493.03,1746.52,,2619.77,75,,,percent of total billed charges,75% of total billed charges,2619.77,75,,,percent of total billed charges,75% of total billed charges,776.11,100,,,Fee Schedule,100% of CMS OPPS Rate,500.45,100,,,Fee Schedule,100% of WV Medicaid Rate,1280.58,165,,,Fee Schedule,165% of CMS OPPS Rate,804.37,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,2229.28,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,3057.28,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,3829.56,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,500.45,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,776.11,100,,,Fee Schedule,100% of CMS OPPS Rate,804.37,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,489.02,14,,,percent of total billed charges,14% of total billed charges,489.02,3829.56,
Smart Pill,3361237,CDM,750,RC,91112,HCPCS,Outpatient,,,852.94,426.47,,639.71,75,,,percent of total billed charges,75% of total billed charges,639.71,75,,,percent of total billed charges,75% of total billed charges,776.11,100,,,Fee Schedule,100% of CMS OPPS Rate,852.94,100,,,Fee Schedule,100% of WV Medicaid Rate,1280.58,165,,,Fee Schedule,165% of CMS OPPS Rate,804.37,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,2229.28,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,3057.28,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,3829.56,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,852.94,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,776.11,100,,,Fee Schedule,100% of CMS OPPS Rate,804.37,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,119.41,14,,,percent of total billed charges,14% of total billed charges,119.41,3829.56,
Anorectal Manometry,3370860,CDM,750,RC,91122,HCPCS,Outpatient,,,700,350,,525,75,,,percent of total billed charges,75% of total billed charges,525,75,,,percent of total billed charges,75% of total billed charges,263.29,100,,,Fee Schedule,100% of CMS OPPS Rate,180.66,100,,,Fee Schedule,100% of WV Medicaid Rate,434.44,165,,,Fee Schedule,165% of CMS OPPS Rate,272.88,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,756.29,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1037.2,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1299.2,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,180.66,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,263.29,100,,,Fee Schedule,100% of CMS OPPS Rate,272.88,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,98,14,,,percent of total billed charges,14% of total billed charges,98,1299.2,
Aquablation,4041222,CDM,360,RC,0421T,HCPCS,Outpatient,,,36354.44,18177.22,,27265.83,75,,,percent of total billed charges,75% of total billed charges,27265.83,75,,,percent of total billed charges,75% of total billed charges,8045.5,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,13275.07,165,,,Fee Schedule,165% of CMS OPPS Rate,8338.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,23109.59,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,31692.97,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,39698.66,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,8045.5,100,,,Fee Schedule,100% of CMS OPPS Rate,8338.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,5089.62,14,,,percent of total billed charges,14% of total billed charges,5089.62,39698.66,
O/R SUP/IMPLANT/BRACHY/NEEDLES,1221027,CDM,278,RC,C1715,HCPCS,Outpatient,,,3862.88,1931.44,,2897.16,75,,,percent of total billed charges,75% of total billed charges,2897.16,75,,,percent of total billed charges,75% of total billed charges,1236.12,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,540.8,14,,,percent of total billed charges,14% of total billed charges,540.8,2897.16,
10007-MSA FNA BIOPSY W/ FLUORO GD 1ST LES,3428648,CDM,361,RC,10007,HCPCS,Outpatient,,,3736.01,1868.01,,2802.01,75,,,percent of total billed charges,75% of total billed charges,2802.01,75,,,percent of total billed charges,75% of total billed charges,610.13,100,,,Fee Schedule,100% of CMS OPPS Rate,191.36,102,,,Fee Schedule,102% of WV Medicaid Rate,1006.72,165,,,Fee Schedule,165% of CMS OPPS Rate,632.35,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1752.53,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2403.46,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,3010.58,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,187.61,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,610.13,100,,,Fee Schedule,100% of CMS OPPS Rate,632.35,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,523.04,14,,,percent of total billed charges,14% of total billed charges,187.61,3010.58,
10008-MSA FNA BIOPSY W/ FLUORO GD ADD LES,3428649,CDM,361,RC,10008,HCPCS,Outpatient,,,525.17,262.59,,393.88,75,,,percent of total billed charges,75% of total billed charges,393.88,75,,,percent of total billed charges,75% of total billed charges,168.05,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,73.52,14,,,percent of total billed charges,14% of total billed charges,73.52,393.88,
10021- Fine needle asp w/o image guide,3431472,CDM,761,RC,10021,HCPCS,Outpatient,,,2125.56,1062.78,,1594.17,75,,,percent of total billed charges,75% of total billed charges,1594.17,75,,,percent of total billed charges,75% of total billed charges,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,51.05,102,,,Fee Schedule,102% of WV Medicaid Rate,578.72,165,,,Fee Schedule,165% of CMS OPPS Rate,363.51,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1007.47,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1381.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1730.67,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,50.05,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,363.51,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,297.58,14,,,percent of total billed charges,14% of total billed charges,50.05,1730.67,
SCMP US Guided Fine Needle Asp. Abdomen,3370904,CDM,510,RC,10021,HCPCS,Outpatient,,,2125.56,1062.78,,1594.17,75,,,percent of total billed charges,75% of total billed charges,1594.17,75,,,percent of total billed charges,75% of total billed charges,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,51.05,102,,,Fee Schedule,102% of WV Medicaid Rate,578.72,165,,,Fee Schedule,165% of CMS OPPS Rate,363.51,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1007.47,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1381.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1730.67,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,50.05,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,363.51,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,297.58,14,,,percent of total billed charges,14% of total billed charges,50.05,1730.67,
SCMP US Guided Fine Needle Asp. Breast,3370906,CDM,510,RC,10021,HCPCS,Outpatient,,,2125.56,1062.78,,1594.17,75,,,percent of total billed charges,75% of total billed charges,1594.17,75,,,percent of total billed charges,75% of total billed charges,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,51.05,102,,,Fee Schedule,102% of WV Medicaid Rate,578.72,165,,,Fee Schedule,165% of CMS OPPS Rate,363.51,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1007.47,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1381.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1730.67,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,50.05,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,363.51,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,297.58,14,,,percent of total billed charges,14% of total billed charges,50.05,1730.67,
10040- Acne surgery,3431474,CDM,761,RC,10040,HCPCS,Outpatient,,,1173.1,586.55,,879.83,75,,,percent of total billed charges,75% of total billed charges,879.83,75,,,percent of total billed charges,75% of total billed charges,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,280.12,165,,,Fee Schedule,165% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,487.65,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,668.78,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,837.71,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,164.23,14,,,percent of total billed charges,14% of total billed charges,164.23,879.83,
10060- Abscess/simple/single/I  & D,3431475,CDM,761,RC,10060,HCPCS,Outpatient,,,1219.59,609.8,,914.69,75,,,percent of total billed charges,75% of total billed charges,914.69,75,,,percent of total billed charges,75% of total billed charges,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,64.15,102,,,Fee Schedule,102% of WV Medicaid Rate,280.12,165,,,Fee Schedule,165% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,487.65,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,668.77,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,837.71,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,62.89,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,170.74,14,,,percent of total billed charges,14% of total billed charges,62.89,914.69,
"10060- Incision and Drainage, Simple",3428468,CDM,761,RC,10060,HCPCS,Outpatient,,,208.61,104.31,,156.46,75,,,percent of total billed charges,75% of total billed charges,156.46,75,,,percent of total billed charges,75% of total billed charges,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,64.15,102,,,Fee Schedule,102% of WV Medicaid Rate,280.12,165,,,Fee Schedule,165% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,487.65,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,668.77,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,837.71,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,62.89,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,29.21,14,,,percent of total billed charges,14% of total billed charges,29.21,837.71,
"10061- I&D ,Abscess, Complex or S",3428656,CDM,761,RC,10061,HCPCS,Outpatient,,,2380.21,1190.11,,1785.16,75,,,percent of total billed charges,75% of total billed charges,1785.16,75,,,percent of total billed charges,75% of total billed charges,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,96.91,102,,,Fee Schedule,102% of WV Medicaid Rate,578.72,165,,,Fee Schedule,165% of CMS OPPS Rate,363.51,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1007.47,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1381.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1730.67,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,95.01,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,363.51,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,333.23,14,,,percent of total billed charges,14% of total billed charges,95.01,1785.16,
"10061- Incision and Drainage, Complex",3428467,CDM,510,RC,10061,HCPCS,Outpatient,,,528.33,264.17,,396.25,75,,,percent of total billed charges,75% of total billed charges,396.25,75,,,percent of total billed charges,75% of total billed charges,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,96.91,102,,,Fee Schedule,102% of WV Medicaid Rate,578.72,165,,,Fee Schedule,165% of CMS OPPS Rate,363.51,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1007.47,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1381.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1730.67,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,95.01,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,363.51,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,73.97,14,,,percent of total billed charges,14% of total billed charges,73.97,1730.67,
"10080- Incision and Drainage( IND) Pilonidal Cyst, Simple",3428657,CDM,510,RC,10080,HCPCS,Outpatient,,,3761.41,1880.71,,2821.06,75,,,percent of total billed charges,75% of total billed charges,2821.06,75,,,percent of total billed charges,75% of total billed charges,610.13,100,,,Fee Schedule,100% of CMS OPPS Rate,171.71,102,,,Fee Schedule,102% of WV Medicaid Rate,1006.72,165,,,Fee Schedule,165% of CMS OPPS Rate,632.35,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1752.53,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2403.46,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,3010.58,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,168.34,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,610.13,100,,,Fee Schedule,100% of CMS OPPS Rate,632.35,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,526.6,14,,,percent of total billed charges,14% of total billed charges,168.34,3010.58,
10081- I & D/pilonidal cyst/complicated,3431476,CDM,761,RC,10081,HCPCS,Outpatient,,,3900.4,1950.2,,2925.3,75,,,percent of total billed charges,75% of total billed charges,2925.3,75,,,percent of total billed charges,75% of total billed charges,610.13,100,,,Fee Schedule,100% of CMS OPPS Rate,206.38,102,,,Fee Schedule,102% of WV Medicaid Rate,1006.72,165,,,Fee Schedule,165% of CMS OPPS Rate,632.35,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1752.53,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2403.46,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,3010.58,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,202.33,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,610.13,100,,,Fee Schedule,100% of CMS OPPS Rate,632.35,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,546.06,14,,,percent of total billed charges,14% of total billed charges,202.33,3010.58,
10120- Incision/rmv FB/SQ tis/simple,3431477,CDM,761,RC,10120,HCPCS,Outpatient,,,2221.06,1110.53,,1665.8,75,,,percent of total billed charges,75% of total billed charges,1665.8,75,,,percent of total billed charges,75% of total billed charges,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,85.17,102,,,Fee Schedule,102% of WV Medicaid Rate,578.72,165,,,Fee Schedule,165% of CMS OPPS Rate,363.51,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1007.47,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1381.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1730.67,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,83.5,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,363.51,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,310.95,14,,,percent of total billed charges,14% of total billed charges,83.5,1730.67,
10121- Incision/rmv FB/SQ tis/complicat,3431478,CDM,761,RC,10121,HCPCS,Outpatient,,,8556.82,4278.41,,6417.62,75,,,percent of total billed charges,75% of total billed charges,6417.62,75,,,percent of total billed charges,75% of total billed charges,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,479.67,102,,,Fee Schedule,102% of WV Medicaid Rate,2326.19,165,,,Fee Schedule,165% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4049.52,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5553.61,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6956.46,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,470.26,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1197.95,14,,,percent of total billed charges,14% of total billed charges,470.26,6956.46,
"10140- Incision and Drainage of hematoma, seroma or fluid collection",4346598,CDM,510,RC,10140,HCPCS,Outpatient,,,8422.8,4211.4,,6317.1,75,,,percent of total billed charges,75% of total billed charges,6317.1,75,,,percent of total billed charges,75% of total billed charges,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,89.55,102,,,Fee Schedule,102% of WV Medicaid Rate,2326.19,165,,,Fee Schedule,165% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4049.52,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5553.61,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6956.46,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,87.79,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1179.19,14,,,percent of total billed charges,14% of total billed charges,87.79,6956.46,
10160- Punc asp/abscess/hema/bulla/cyst,3428658,CDM,761,RC,10160,HCPCS,Outpatient,,,2204.91,1102.46,,1653.68,75,,,percent of total billed charges,75% of total billed charges,1653.68,75,,,percent of total billed charges,75% of total billed charges,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,66.88,102,,,Fee Schedule,102% of WV Medicaid Rate,578.72,165,,,Fee Schedule,165% of CMS OPPS Rate,363.51,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1007.47,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1381.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1730.67,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,65.57,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,363.51,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,308.69,14,,,percent of total billed charges,14% of total billed charges,65.57,1730.67,
"10180- Incision and Drainage, Compex post-op wound infection",4346593,CDM,510,RC,10180,HCPCS,Outpatient,,,14710.19,7355.1,,11032.64,75,,,percent of total billed charges,75% of total billed charges,11032.64,75,,,percent of total billed charges,75% of total billed charges,2428.67,100,,,Fee Schedule,100% of CMS OPPS Rate,803.83,102,,,Fee Schedule,102% of WV Medicaid Rate,4007.32,165,,,Fee Schedule,165% of CMS OPPS Rate,2517.11,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,6976.06,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,9567.11,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,11983.78,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,788.07,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2428.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2517.11,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,2059.43,14,,,percent of total billed charges,14% of total billed charges,788.07,11983.78,
10180- Postop wound infection/complex/I&D,3431479,CDM,761,RC,10180,HCPCS,Outpatient,,,14710.19,7355.1,,11032.64,75,,,percent of total billed charges,75% of total billed charges,11032.64,75,,,percent of total billed charges,75% of total billed charges,2428.67,100,,,Fee Schedule,100% of CMS OPPS Rate,803.83,102,,,Fee Schedule,102% of WV Medicaid Rate,4007.32,165,,,Fee Schedule,165% of CMS OPPS Rate,2517.11,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,6976.06,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,9567.11,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,11983.78,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,788.07,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2428.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2517.11,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,2059.43,14,,,percent of total billed charges,14% of total billed charges,788.07,11983.78,
11000- Debrid ecz/inf skin up tp 10% body,3428659,CDM,510,RC,11000,HCPCS,Outpatient,,,3227.98,1613.99,,2420.99,75,,,percent of total billed charges,75% of total billed charges,2420.99,75,,,percent of total billed charges,75% of total billed charges,546.17,100,,,Fee Schedule,100% of CMS OPPS Rate,29.48,102,,,Fee Schedule,102% of WV Medicaid Rate,901.2,165,,,Fee Schedule,165% of CMS OPPS Rate,566.07,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1568.84,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2151.55,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,2695.04,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,28.9,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,546.17,100,,,Fee Schedule,100% of CMS OPPS Rate,566.07,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,451.92,14,,,percent of total billed charges,14% of total billed charges,28.9,2695.04,
11001 - DBRDMT EXTNSVE ECZEMA/INFECT SKN EA 10% BDY SURF,4037472,CDM,510,RC,11001,HCPCS,Outpatient,,,1810.99,905.5,,1358.24,75,,,percent of total billed charges,75% of total billed charges,1358.24,75,,,percent of total billed charges,75% of total billed charges,579.52,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,253.54,14,,,percent of total billed charges,14% of total billed charges,253.54,1358.24,
11011- Debride/rmv FB/open fx/skin/sq/mus,3431484,CDM,510,RC,11011,HCPCS,Outpatient,,,7163.3,3581.65,,5372.48,75,,,percent of total billed charges,75% of total billed charges,5372.48,75,,,percent of total billed charges,75% of total billed charges,610.13,100,,,Fee Schedule,100% of CMS OPPS Rate,254,102,,,Fee Schedule,102% of WV Medicaid Rate,1006.72,165,,,Fee Schedule,165% of CMS OPPS Rate,632.35,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1752.53,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2403.46,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,3010.58,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,249.02,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,610.13,100,,,Fee Schedule,100% of CMS OPPS Rate,632.35,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1002.86,14,,,percent of total billed charges,14% of total billed charges,249.02,5372.48,
11042 Debridement Subcutaneous Tissue 20 Sq Cm/<,3436013,CDM,761,RC,11042,HCPCS,Outpatient,,,322.53,161.27,,241.9,75,,,percent of total billed charges,75% of total billed charges,241.9,75,,,percent of total billed charges,75% of total billed charges,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,141.09,102,,,Fee Schedule,102% of WV Medicaid Rate,578.72,165,,,Fee Schedule,165% of CMS OPPS Rate,363.51,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1007.47,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1381.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1730.67,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,138.32,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,363.51,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,45.15,14,,,percent of total billed charges,14% of total billed charges,45.15,1730.67,
11042-DEB SUBQ Tissue 20 SQ CM/<,3574980,CDM,510,RC,11042,HCPCS,Outpatient,,,2135.82,1067.91,,1601.87,75,,,percent of total billed charges,75% of total billed charges,1601.87,75,,,percent of total billed charges,75% of total billed charges,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,141.09,102,,,Fee Schedule,102% of WV Medicaid Rate,578.72,165,,,Fee Schedule,165% of CMS OPPS Rate,363.51,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1007.47,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1381.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1730.67,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,138.32,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,363.51,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,299.01,14,,,percent of total billed charges,14% of total billed charges,138.32,1730.67,
11043 Deb Musc Fascia 20 Sq Cm less than,3572727,CDM,510,RC,11043,HCPCS,Outpatient,,,3484.52,1742.26,,2613.39,75,,,percent of total billed charges,75% of total billed charges,2613.39,75,,,percent of total billed charges,75% of total billed charges,546.17,100,,,Fee Schedule,100% of CMS OPPS Rate,213.77,102,,,Fee Schedule,102% of WV Medicaid Rate,901.2,165,,,Fee Schedule,165% of CMS OPPS Rate,566.07,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1568.84,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2151.55,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,2695.04,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,209.58,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,546.17,100,,,Fee Schedule,100% of CMS OPPS Rate,566.07,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,487.83,14,,,percent of total billed charges,14% of total billed charges,209.58,2695.04,
11043 Debridement Muscle & Fascia 20 Sq Cm/<,3436016,CDM,761,RC,11043,HCPCS,Outpatient,,,594.51,297.26,,445.88,75,,,percent of total billed charges,75% of total billed charges,445.88,75,,,percent of total billed charges,75% of total billed charges,546.17,100,,,Fee Schedule,100% of CMS OPPS Rate,213.77,102,,,Fee Schedule,102% of WV Medicaid Rate,901.2,165,,,Fee Schedule,165% of CMS OPPS Rate,566.07,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1568.84,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2151.55,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,2695.04,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,209.58,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,546.17,100,,,Fee Schedule,100% of CMS OPPS Rate,566.07,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,83.23,14,,,percent of total billed charges,14% of total billed charges,83.23,2695.04,
11044 Debridement Bone Muscle & Fascia 20 Sq Cm/<,3436020,CDM,761,RC,11044,HCPCS,Outpatient,,,799.58,399.79,,599.69,75,,,percent of total billed charges,75% of total billed charges,599.69,75,,,percent of total billed charges,75% of total billed charges,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,479.67,102,,,Fee Schedule,102% of WV Medicaid Rate,2326.19,165,,,Fee Schedule,165% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4049.52,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5553.61,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6956.46,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,470.26,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,111.94,14,,,percent of total billed charges,14% of total billed charges,111.94,6956.46,
"11044 Debridement, bone (includes epidermis, dermis, subcutaneous tissue, muscle and/or fascia, if p",3621458,CDM,510,RC,11044,HCPCS,Outpatient,,,8650.14,4325.07,,6487.61,75,,,percent of total billed charges,75% of total billed charges,6487.61,75,,,percent of total billed charges,75% of total billed charges,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,479.67,102,,,Fee Schedule,102% of WV Medicaid Rate,2326.19,165,,,Fee Schedule,165% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4049.52,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5553.61,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6956.46,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,470.26,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1211.02,14,,,percent of total billed charges,14% of total billed charges,470.26,6956.46,
11045 Debride subq tiss ea add 20sq cm,3570187,CDM,510,RC,11045,HCPCS,Outpatient,,,701.37,350.69,,526.03,75,,,percent of total billed charges,75% of total billed charges,526.03,75,,,percent of total billed charges,75% of total billed charges,224.44,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,98.19,14,,,percent of total billed charges,14% of total billed charges,98.19,526.03,
11046 Deb Mus Fasica Add On,3550404,CDM,510,RC,11046,HCPCS,Outpatient,,,866.92,433.46,,650.19,75,,,percent of total billed charges,75% of total billed charges,650.19,75,,,percent of total billed charges,75% of total billed charges,277.41,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,121.37,14,,,percent of total billed charges,14% of total billed charges,121.37,650.19,
11047- Debridement/bone/ea add 20 sq cm,3431488,CDM,761,RC,11047,HCPCS,Outpatient,,,2733.56,1366.78,,2050.17,75,,,percent of total billed charges,75% of total billed charges,2050.17,75,,,percent of total billed charges,75% of total billed charges,874.74,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,382.7,14,,,percent of total billed charges,14% of total billed charges,382.7,2050.17,
11055- Trim hyperkeratotic lesion/sng,3431489,CDM,761,RC,11055,HCPCS,Outpatient,,,1042.84,521.42,,782.13,75,,,percent of total billed charges,75% of total billed charges,782.13,75,,,percent of total billed charges,75% of total billed charges,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,280.12,165,,,Fee Schedule,165% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,487.65,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,668.78,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,837.71,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,146,14,,,percent of total billed charges,14% of total billed charges,146,837.71,
11056- Trim hyperkeratotic lesion/2-4,3431490,CDM,761,RC,11056,HCPCS,Outpatient,,,1055.97,527.99,,791.98,75,,,percent of total billed charges,75% of total billed charges,791.98,75,,,percent of total billed charges,75% of total billed charges,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,280.12,165,,,Fee Schedule,165% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,487.65,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,668.78,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,837.71,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,147.84,14,,,percent of total billed charges,14% of total billed charges,147.84,837.71,
11057- Trim hyperkeratotic lesion/>4,3431491,CDM,761,RC,11057,HCPCS,Outpatient,,,1069.7,534.85,,802.28,75,,,percent of total billed charges,75% of total billed charges,802.28,75,,,percent of total billed charges,75% of total billed charges,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,54.87,102,,,Fee Schedule,102% of WV Medicaid Rate,280.12,165,,,Fee Schedule,165% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,487.65,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,668.77,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,837.71,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,53.79,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,149.76,14,,,percent of total billed charges,14% of total billed charges,53.79,837.71,
11102 Shave Biopsy,3428674,CDM,761,RC,11102,HCPCS,Outpatient,,,1086.6,543.3,,814.95,75,,,percent of total billed charges,75% of total billed charges,814.95,75,,,percent of total billed charges,75% of total billed charges,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,63.33,102,,,Fee Schedule,102% of WV Medicaid Rate,280.12,165,,,Fee Schedule,165% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,487.65,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,668.77,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,837.71,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,62.09,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,152.12,14,,,percent of total billed charges,14% of total billed charges,62.09,837.71,
11103 Additional Shave Biopsy,3428675,CDM,761,RC,11103,HCPCS,Outpatient,,,170.08,85.04,,127.56,75,,,percent of total billed charges,75% of total billed charges,127.56,75,,,percent of total billed charges,75% of total billed charges,54.43,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.81,14,,,percent of total billed charges,14% of total billed charges,23.81,127.56,
11104 Punch Biopsy with Suture,3428676,CDM,761,RC,11104,HCPCS,Outpatient,,,2107.98,1053.99,,1580.99,75,,,percent of total billed charges,75% of total billed charges,1580.99,75,,,percent of total billed charges,75% of total billed charges,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,78.36,102,,,Fee Schedule,102% of WV Medicaid Rate,578.72,165,,,Fee Schedule,165% of CMS OPPS Rate,363.51,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1007.47,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1381.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1730.67,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,76.82,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,363.51,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,295.12,14,,,percent of total billed charges,14% of total billed charges,76.82,1730.67,
11105 Add'l Punch Biospy with suture,3428677,CDM,761,RC,11105,HCPCS,Outpatient,,,481.7,240.85,,361.28,75,,,percent of total billed charges,75% of total billed charges,361.28,75,,,percent of total billed charges,75% of total billed charges,154.14,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.44,14,,,percent of total billed charges,14% of total billed charges,67.44,361.28,
11106 Wedge Biopsy with Suture,3428678,CDM,761,RC,11106,HCPCS,Outpatient,,,3285.68,1642.84,,2464.26,75,,,percent of total billed charges,75% of total billed charges,2464.26,75,,,percent of total billed charges,75% of total billed charges,546.17,100,,,Fee Schedule,100% of CMS OPPS Rate,97.45,102,,,Fee Schedule,102% of WV Medicaid Rate,901.2,165,,,Fee Schedule,165% of CMS OPPS Rate,566.07,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1568.84,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2151.55,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,2695.04,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,95.54,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,546.17,100,,,Fee Schedule,100% of CMS OPPS Rate,566.07,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,460,14,,,percent of total billed charges,14% of total billed charges,95.54,2695.04,
11107 Add'l Wedge Biopsy with suture,3428679,CDM,761,RC,11107,HCPCS,Outpatient,,,237.28,118.64,,177.96,75,,,percent of total billed charges,75% of total billed charges,177.96,75,,,percent of total billed charges,75% of total billed charges,75.93,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.22,14,,,percent of total billed charges,14% of total billed charges,33.22,177.96,
11200- Remove skin tags </= 15,3431493,CDM,761,RC,11200,HCPCS,Outpatient,,,1159.99,580,,869.99,75,,,percent of total billed charges,75% of total billed charges,869.99,75,,,percent of total billed charges,75% of total billed charges,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,280.12,165,,,Fee Schedule,165% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,487.65,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,668.78,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,837.71,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,162.4,14,,,percent of total billed charges,14% of total billed charges,162.4,869.99,
11201- Remove skin tags/ea add 10 lesions,3431494,CDM,761,RC,11201,HCPCS,Outpatient,,,80.16,40.08,,60.12,75,,,percent of total billed charges,75% of total billed charges,60.12,75,,,percent of total billed charges,75% of total billed charges,25.65,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.22,14,,,percent of total billed charges,14% of total billed charges,11.22,60.12,
"11300- Shave Skin Lesion,0.5Cm Or Less",3431495,CDM,761,RC,11300,HCPCS,Outpatient,,,2082.06,1041.03,,1561.55,75,,,percent of total billed charges,75% of total billed charges,1561.55,75,,,percent of total billed charges,75% of total billed charges,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,578.73,165,,,Fee Schedule,165% of CMS OPPS Rate,363.52,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1007.47,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1381.67,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1730.68,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,363.52,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,291.49,14,,,percent of total billed charges,14% of total billed charges,291.49,1730.68,
"11301- Shave Skin Lesion,0.6-1.0Cm",3431496,CDM,761,RC,11301,HCPCS,Outpatient,,,1113.82,556.91,,835.37,75,,,percent of total billed charges,75% of total billed charges,835.37,75,,,percent of total billed charges,75% of total billed charges,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,280.12,165,,,Fee Schedule,165% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,487.65,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,668.78,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,837.71,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,155.93,14,,,percent of total billed charges,14% of total billed charges,155.93,837.71,
"11302- Shave Skin Lesion,1.1-2.0Cm",3431497,CDM,761,RC,11302,HCPCS,Outpatient,,,1130.55,565.28,,847.91,75,,,percent of total billed charges,75% of total billed charges,847.91,75,,,percent of total billed charges,75% of total billed charges,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,280.12,165,,,Fee Schedule,165% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,487.65,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,668.78,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,837.71,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,158.28,14,,,percent of total billed charges,14% of total billed charges,158.28,847.91,
11303- Shave epi/derm sng lesion/trunk/arm/leg/>2.0cm,3431498,CDM,761,RC,11303,HCPCS,Outpatient,,,2156.38,1078.19,,1617.29,75,,,percent of total billed charges,75% of total billed charges,1617.29,75,,,percent of total billed charges,75% of total billed charges,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,578.73,165,,,Fee Schedule,165% of CMS OPPS Rate,363.52,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1007.47,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1381.67,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1730.68,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,363.52,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,301.89,14,,,percent of total billed charges,14% of total billed charges,301.89,1730.68,
"11305- Shave Skin Lesion, .5Cm Or Less",3431499,CDM,761,RC,11305,HCPCS,Outpatient,,,1087.34,543.67,,815.51,75,,,percent of total billed charges,75% of total billed charges,815.51,75,,,percent of total billed charges,75% of total billed charges,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,280.12,165,,,Fee Schedule,165% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,487.65,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,668.78,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,837.71,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,152.23,14,,,percent of total billed charges,14% of total billed charges,152.23,837.71,
"11306- Shave Skin Lesion,0.6-1.0 Cm",3431500,CDM,761,RC,11306,HCPCS,Outpatient,,,1109.88,554.94,,832.41,75,,,percent of total billed charges,75% of total billed charges,832.41,75,,,percent of total billed charges,75% of total billed charges,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,280.12,165,,,Fee Schedule,165% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,487.65,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,668.78,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,837.71,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,155.38,14,,,percent of total billed charges,14% of total billed charges,155.38,837.71,
"11307- Shave Skin Lesion,1.1-2.0 Cm",3431501,CDM,761,RC,11307,HCPCS,Outpatient,,,1137.1,568.55,,852.83,75,,,percent of total billed charges,75% of total billed charges,852.83,75,,,percent of total billed charges,75% of total billed charges,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,73.31,102,,,Fee Schedule,102% of WV Medicaid Rate,280.12,165,,,Fee Schedule,165% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,487.65,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,668.77,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,837.71,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,71.87,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,159.19,14,,,percent of total billed charges,14% of total billed charges,71.87,852.83,
11308- Shave epi/derm sng lesion/scalp/neck/hnd/ft/genit/>2.0cm,3431502,CDM,761,RC,11308,HCPCS,Outpatient,,,2155.68,1077.84,,1616.76,75,,,percent of total billed charges,75% of total billed charges,1616.76,75,,,percent of total billed charges,75% of total billed charges,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,578.73,165,,,Fee Schedule,165% of CMS OPPS Rate,363.52,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1007.47,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1381.67,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1730.68,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,363.52,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,301.8,14,,,percent of total billed charges,14% of total billed charges,301.8,1730.68,
11310- Shave epi/derm sng lesion/face/ear/lid/nose/lip/0.5cm or <,3431503,CDM,761,RC,11310,HCPCS,Outpatient,,,1102.37,551.19,,826.78,75,,,percent of total billed charges,75% of total billed charges,826.78,75,,,percent of total billed charges,75% of total billed charges,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,70.98,102,,,Fee Schedule,102% of WV Medicaid Rate,280.12,165,,,Fee Schedule,165% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,487.65,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,668.77,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,837.71,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,69.59,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,154.33,14,,,percent of total billed charges,14% of total billed charges,69.59,837.71,
11311- Shave epi/derm sng lesion/face/ear/lid/nose/lip/0.6-1.0cm,3431504,CDM,761,RC,11311,HCPCS,Outpatient,,,1136.74,568.37,,852.56,75,,,percent of total billed charges,75% of total billed charges,852.56,75,,,percent of total billed charges,75% of total billed charges,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,73.31,102,,,Fee Schedule,102% of WV Medicaid Rate,280.12,165,,,Fee Schedule,165% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,487.65,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,668.77,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,837.71,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,71.87,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,159.14,14,,,percent of total billed charges,14% of total billed charges,71.87,852.56,
11312- Shave epi/derm sng lesion/face/ear/lid/nose/lip/1.1-2.0cm,3431505,CDM,761,RC,11312,HCPCS,Outpatient,,,2162.26,1081.13,,1621.7,75,,,percent of total billed charges,75% of total billed charges,1621.7,75,,,percent of total billed charges,75% of total billed charges,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,88.18,102,,,Fee Schedule,102% of WV Medicaid Rate,578.72,165,,,Fee Schedule,165% of CMS OPPS Rate,363.51,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1007.47,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1381.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1730.67,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,86.45,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,363.51,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,302.72,14,,,percent of total billed charges,14% of total billed charges,86.45,1730.67,
11313- Shave epi/derm sng lesion/face/ear/lid/nose/lip/>2.0cm,3431506,CDM,761,RC,11313,HCPCS,Outpatient,,,2206.42,1103.21,,1654.82,75,,,percent of total billed charges,75% of total billed charges,1654.82,75,,,percent of total billed charges,75% of total billed charges,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,97.19,102,,,Fee Schedule,102% of WV Medicaid Rate,578.72,165,,,Fee Schedule,165% of CMS OPPS Rate,363.51,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1007.47,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1381.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1730.67,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,95.28,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,363.51,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,308.9,14,,,percent of total billed charges,14% of total billed charges,95.28,1730.67,
11400- Exc Tr-Ext Benign+Marg 0.5 < Cm,3431507,CDM,761,RC,11400,HCPCS,Outpatient,,,3718.04,1859.02,,2788.53,75,,,percent of total billed charges,75% of total billed charges,2788.53,75,,,percent of total billed charges,75% of total billed charges,610.13,100,,,Fee Schedule,100% of CMS OPPS Rate,76.7,102,,,Fee Schedule,102% of WV Medicaid Rate,1006.72,165,,,Fee Schedule,165% of CMS OPPS Rate,632.35,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1752.53,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2403.46,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,3010.58,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,75.2,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,610.13,100,,,Fee Schedule,100% of CMS OPPS Rate,632.35,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,520.53,14,,,percent of total billed charges,14% of total billed charges,75.2,3010.58,
11401- Exc tr-ext benign+marg 0.6-1 cm,3431508,CDM,761,RC,11401,HCPCS,Outpatient,,,2221.95,1110.98,,1666.46,75,,,percent of total billed charges,75% of total billed charges,1666.46,75,,,percent of total billed charges,75% of total billed charges,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,87.9,102,,,Fee Schedule,102% of WV Medicaid Rate,578.72,165,,,Fee Schedule,165% of CMS OPPS Rate,363.51,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1007.47,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1381.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1730.67,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,86.18,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,363.51,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,311.07,14,,,percent of total billed charges,14% of total billed charges,86.18,1730.67,
11402- Exc tr-ext benign+marg 1.1-2 cm,3431509,CDM,761,RC,11402,HCPCS,Outpatient,,,3781.85,1890.93,,2836.39,75,,,percent of total billed charges,75% of total billed charges,2836.39,75,,,percent of total billed charges,75% of total billed charges,610.13,100,,,Fee Schedule,100% of CMS OPPS Rate,95.28,102,,,Fee Schedule,102% of WV Medicaid Rate,1006.72,165,,,Fee Schedule,165% of CMS OPPS Rate,632.35,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1752.53,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2403.46,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,3010.58,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,93.41,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,610.13,100,,,Fee Schedule,100% of CMS OPPS Rate,632.35,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,529.46,14,,,percent of total billed charges,14% of total billed charges,93.41,3010.58,
11403- Exc tr-ext bengin+marg 2.1-3cm,3431510,CDM,761,RC,11403,HCPCS,Outpatient,,,3849.84,1924.92,,2887.38,75,,,percent of total billed charges,75% of total billed charges,2887.38,75,,,percent of total billed charges,75% of total billed charges,610.13,100,,,Fee Schedule,100% of CMS OPPS Rate,103.73,102,,,Fee Schedule,102% of WV Medicaid Rate,1006.72,165,,,Fee Schedule,165% of CMS OPPS Rate,632.35,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1752.53,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2403.46,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,3010.58,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,101.7,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,610.13,100,,,Fee Schedule,100% of CMS OPPS Rate,632.35,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,538.98,14,,,percent of total billed charges,14% of total billed charges,101.7,3010.58,
11404- Exc tr-ext benign+marg 3.1-4 cm,3431511,CDM,761,RC,11404,HCPCS,Outpatient,,,8516.23,4258.12,,6387.17,75,,,percent of total billed charges,75% of total billed charges,6387.17,75,,,percent of total billed charges,75% of total billed charges,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,479.67,102,,,Fee Schedule,102% of WV Medicaid Rate,2326.19,165,,,Fee Schedule,165% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4049.52,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5553.61,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6956.46,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,470.26,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1192.27,14,,,percent of total billed charges,14% of total billed charges,470.26,6956.46,
11406- Exc tr-ext bengin+marg >4.0 cm,3431512,CDM,761,RC,11406,HCPCS,Outpatient,,,8690.66,4345.33,,6518,75,,,percent of total billed charges,75% of total billed charges,6518,75,,,percent of total billed charges,75% of total billed charges,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,479.67,102,,,Fee Schedule,102% of WV Medicaid Rate,2326.19,165,,,Fee Schedule,165% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4049.52,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5553.61,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6956.46,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,470.26,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1216.69,14,,,percent of total billed charges,14% of total billed charges,470.26,6956.46,
11420- Exc h-f-nk-sp benign+marg 0.5/<,3431513,CDM,761,RC,11420,HCPCS,Outpatient,,,8348.72,4174.36,,6261.54,75,,,percent of total billed charges,75% of total billed charges,6261.54,75,,,percent of total billed charges,75% of total billed charges,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,73.15,102,,,Fee Schedule,102% of WV Medicaid Rate,2326.19,165,,,Fee Schedule,165% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4049.52,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5553.61,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6956.46,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,71.72,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1168.82,14,,,percent of total billed charges,14% of total billed charges,71.72,6956.46,
11421- Exc h-f-nk-sp benign+marg 0.6-1,3431514,CDM,761,RC,11421,HCPCS,Outpatient,,,3769.43,1884.72,,2827.07,75,,,percent of total billed charges,75% of total billed charges,2827.07,75,,,percent of total billed charges,75% of total billed charges,610.13,100,,,Fee Schedule,100% of CMS OPPS Rate,85.45,102,,,Fee Schedule,102% of WV Medicaid Rate,1006.72,165,,,Fee Schedule,165% of CMS OPPS Rate,632.35,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1752.53,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2403.46,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,3010.58,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,83.77,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,610.13,100,,,Fee Schedule,100% of CMS OPPS Rate,632.35,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,527.72,14,,,percent of total billed charges,14% of total billed charges,83.77,3010.58,
11422- Exc h-f-nk-sp benign1.1-2,3431515,CDM,761,RC,11422,HCPCS,Outpatient,,,8455.47,4227.74,,6341.6,75,,,percent of total billed charges,75% of total billed charges,6341.6,75,,,percent of total billed charges,75% of total billed charges,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,94.45,102,,,Fee Schedule,102% of WV Medicaid Rate,2326.19,165,,,Fee Schedule,165% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4049.52,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5553.61,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6956.46,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,92.6,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1183.77,14,,,percent of total billed charges,14% of total billed charges,92.6,6956.46,
11423- Exc h-f-nk-sp benign+marg 2.1-3,3431516,CDM,761,RC,11423,HCPCS,Outpatient,,,8499.37,4249.69,,6374.53,75,,,percent of total billed charges,75% of total billed charges,6374.53,75,,,percent of total billed charges,75% of total billed charges,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,102.92,102,,,Fee Schedule,102% of WV Medicaid Rate,2326.19,165,,,Fee Schedule,165% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4049.52,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5553.61,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6956.46,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,100.9,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1189.91,14,,,percent of total billed charges,14% of total billed charges,100.9,6956.46,
11424- Exc benign les/see area/3.1-4.0cm,3431517,CDM,761,RC,11424,HCPCS,Outpatient,,,8549.74,4274.87,,6412.31,75,,,percent of total billed charges,75% of total billed charges,6412.31,75,,,percent of total billed charges,75% of total billed charges,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,479.67,102,,,Fee Schedule,102% of WV Medicaid Rate,2326.19,165,,,Fee Schedule,165% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4049.52,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5553.61,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6956.46,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,470.26,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1196.96,14,,,percent of total billed charges,14% of total billed charges,470.26,6956.46,
11426- Exc h-f-nk-sp benign+marg >4 cm,3431518,CDM,761,RC,11426,HCPCS,Outpatient,,,14891.04,7445.52,,11168.28,75,,,percent of total billed charges,75% of total billed charges,11168.28,75,,,percent of total billed charges,75% of total billed charges,2428.67,100,,,Fee Schedule,100% of CMS OPPS Rate,803.83,102,,,Fee Schedule,102% of WV Medicaid Rate,4007.32,165,,,Fee Schedule,165% of CMS OPPS Rate,2517.11,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,6976.06,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,9567.11,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,11983.78,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,788.07,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2428.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2517.11,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,2084.75,14,,,percent of total billed charges,14% of total billed charges,788.07,11983.78,
11440- Exc face-mm benign+marg 0.5 cm/<,3431519,CDM,761,RC,11440,HCPCS,Outpatient,,,3760.44,1880.22,,2820.33,75,,,percent of total billed charges,75% of total billed charges,2820.33,75,,,percent of total billed charges,75% of total billed charges,610.13,100,,,Fee Schedule,100% of CMS OPPS Rate,85.17,102,,,Fee Schedule,102% of WV Medicaid Rate,1006.72,165,,,Fee Schedule,165% of CMS OPPS Rate,632.35,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1752.53,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2403.46,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,3010.58,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,83.5,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,610.13,100,,,Fee Schedule,100% of CMS OPPS Rate,632.35,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,526.46,14,,,percent of total billed charges,14% of total billed charges,83.5,3010.58,
11441- Exc face-mm benign+marg 0.6-1 cm,3431520,CDM,761,RC,11441,HCPCS,Outpatient,,,3815.26,1907.63,,2861.45,75,,,percent of total billed charges,75% of total billed charges,2861.45,75,,,percent of total billed charges,75% of total billed charges,610.13,100,,,Fee Schedule,100% of CMS OPPS Rate,94.72,102,,,Fee Schedule,102% of WV Medicaid Rate,1006.72,165,,,Fee Schedule,165% of CMS OPPS Rate,632.35,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1752.53,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2403.46,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,3010.58,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,92.86,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,610.13,100,,,Fee Schedule,100% of CMS OPPS Rate,632.35,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,534.14,14,,,percent of total billed charges,14% of total billed charges,92.86,3010.58,
11442- Exc face-mm benign+marg 1.1-2 cm,3431521,CDM,761,RC,11442,HCPCS,Outpatient,,,3843.39,1921.7,,2882.54,75,,,percent of total billed charges,75% of total billed charges,2882.54,75,,,percent of total billed charges,75% of total billed charges,610.13,100,,,Fee Schedule,100% of CMS OPPS Rate,102.37,102,,,Fee Schedule,102% of WV Medicaid Rate,1006.72,165,,,Fee Schedule,165% of CMS OPPS Rate,632.35,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1752.53,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2403.46,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,3010.58,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,100.36,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,610.13,100,,,Fee Schedule,100% of CMS OPPS Rate,632.35,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,538.07,14,,,percent of total billed charges,14% of total billed charges,100.36,3010.58,
11443- Exc face-mm benign+marg 2.1-3 cm,3431522,CDM,761,RC,11443,HCPCS,Outpatient,,,8543.19,4271.6,,6407.39,75,,,percent of total billed charges,75% of total billed charges,6407.39,75,,,percent of total billed charges,75% of total billed charges,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,112.74,102,,,Fee Schedule,102% of WV Medicaid Rate,2326.19,165,,,Fee Schedule,165% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4049.52,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5553.61,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6956.46,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,110.53,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1196.05,14,,,percent of total billed charges,14% of total billed charges,110.53,6956.46,
11444- Exc/benign les/see area/3.1-4.0cm,3431523,CDM,761,RC,11444,HCPCS,Outpatient,,,8638.42,4319.21,,6478.82,75,,,percent of total billed charges,75% of total billed charges,6478.82,75,,,percent of total billed charges,75% of total billed charges,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,479.67,102,,,Fee Schedule,102% of WV Medicaid Rate,2326.19,165,,,Fee Schedule,165% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4049.52,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5553.61,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6956.46,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,470.26,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1209.38,14,,,percent of total billed charges,14% of total billed charges,470.26,6956.46,
11446- Exc benign lesion/see area/>4.0cm,3431524,CDM,761,RC,11446,HCPCS,Outpatient,,,14987.44,7493.72,,11240.58,75,,,percent of total billed charges,75% of total billed charges,11240.58,75,,,percent of total billed charges,75% of total billed charges,2428.67,100,,,Fee Schedule,100% of CMS OPPS Rate,803.83,102,,,Fee Schedule,102% of WV Medicaid Rate,4007.32,165,,,Fee Schedule,165% of CMS OPPS Rate,2517.11,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,6976.06,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,9567.11,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,11983.78,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,788.07,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2428.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2517.11,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,2098.24,14,,,percent of total billed charges,14% of total billed charges,788.07,11983.78,
11450- Exc/hidradenitis/axilla/smp/im rpr,3431525,CDM,761,RC,11450,HCPCS,Outpatient,,,14879.1,7439.55,,11159.33,75,,,percent of total billed charges,75% of total billed charges,11159.33,75,,,percent of total billed charges,75% of total billed charges,2428.67,100,,,Fee Schedule,100% of CMS OPPS Rate,803.83,102,,,Fee Schedule,102% of WV Medicaid Rate,4007.32,165,,,Fee Schedule,165% of CMS OPPS Rate,2517.11,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,6976.06,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,9567.11,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,11983.78,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,788.07,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2428.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2517.11,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,2083.07,14,,,percent of total billed charges,14% of total billed charges,788.07,11983.78,
11451- Exc/hidradenitis/axilla/comp rpr,3431526,CDM,761,RC,11451,HCPCS,Outpatient,,,15022.03,7511.02,,11266.52,75,,,percent of total billed charges,75% of total billed charges,11266.52,75,,,percent of total billed charges,75% of total billed charges,2428.67,100,,,Fee Schedule,100% of CMS OPPS Rate,803.83,102,,,Fee Schedule,102% of WV Medicaid Rate,4007.32,165,,,Fee Schedule,165% of CMS OPPS Rate,2517.11,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,6976.06,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,9567.11,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,11983.78,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,788.07,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2428.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2517.11,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,2103.08,14,,,percent of total billed charges,14% of total billed charges,788.07,11983.78,
11462- Exc/hidradenitis/ingun/smp/imt rpr,3431527,CDM,761,RC,11462,HCPCS,Outpatient,,,14852.31,7426.16,,11139.23,75,,,percent of total billed charges,75% of total billed charges,11139.23,75,,,percent of total billed charges,75% of total billed charges,2428.67,100,,,Fee Schedule,100% of CMS OPPS Rate,803.83,102,,,Fee Schedule,102% of WV Medicaid Rate,4007.32,165,,,Fee Schedule,165% of CMS OPPS Rate,2517.11,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,6976.06,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,9567.11,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,11983.78,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,788.07,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2428.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2517.11,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,2079.32,14,,,percent of total billed charges,14% of total billed charges,788.07,11983.78,
11463- Exc/hidradenitis/inguinal/comp rpr,3431528,CDM,761,RC,11463,HCPCS,Outpatient,,,15023.71,7511.86,,11267.78,75,,,percent of total billed charges,75% of total billed charges,11267.78,75,,,percent of total billed charges,75% of total billed charges,2428.67,100,,,Fee Schedule,100% of CMS OPPS Rate,803.83,102,,,Fee Schedule,102% of WV Medicaid Rate,4007.32,165,,,Fee Schedule,165% of CMS OPPS Rate,2517.11,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,6976.06,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,9567.11,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,11983.78,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,788.07,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2428.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2517.11,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,2103.32,14,,,percent of total billed charges,14% of total billed charges,788.07,11983.78,
11470- Exc hidradenit/perianal/neal/sp/in,3431529,CDM,761,RC,11470,HCPCS,Outpatient,,,14929.69,7464.85,,11197.27,75,,,percent of total billed charges,75% of total billed charges,11197.27,75,,,percent of total billed charges,75% of total billed charges,2428.67,100,,,Fee Schedule,100% of CMS OPPS Rate,803.83,102,,,Fee Schedule,102% of WV Medicaid Rate,4007.32,165,,,Fee Schedule,165% of CMS OPPS Rate,2517.11,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,6976.06,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,9567.11,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,11983.78,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,788.07,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2428.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2517.11,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,2090.16,14,,,percent of total billed charges,14% of total billed charges,788.07,11983.78,
11471- Exc hidradenitis/perianal/neal/com,3431530,CDM,761,RC,11471,HCPCS,Outpatient,,,15061.04,7530.52,,11295.78,75,,,percent of total billed charges,75% of total billed charges,11295.78,75,,,percent of total billed charges,75% of total billed charges,2428.67,100,,,Fee Schedule,100% of CMS OPPS Rate,803.83,102,,,Fee Schedule,102% of WV Medicaid Rate,4007.32,165,,,Fee Schedule,165% of CMS OPPS Rate,2517.11,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,6976.06,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,9567.11,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,11983.78,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,788.07,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2428.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2517.11,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,2108.55,14,,,percent of total billed charges,14% of total billed charges,788.07,11983.78,
11600- Exc/malig/trunk/arms/legs <0.5cm,3431531,CDM,761,RC,11600,HCPCS,Outpatient,,,3795.92,1897.96,,2846.94,75,,,percent of total billed charges,75% of total billed charges,2846.94,75,,,percent of total billed charges,75% of total billed charges,610.13,100,,,Fee Schedule,100% of CMS OPPS Rate,111.11,102,,,Fee Schedule,102% of WV Medicaid Rate,1006.72,165,,,Fee Schedule,165% of CMS OPPS Rate,632.35,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1752.53,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2403.46,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,3010.58,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,108.93,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,610.13,100,,,Fee Schedule,100% of CMS OPPS Rate,632.35,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,531.43,14,,,percent of total billed charges,14% of total billed charges,108.93,3010.58,
11601- Exc malig/trunk/arm/leg 0.6-1.0cm,3431532,CDM,761,RC,11601,HCPCS,Outpatient,,,3847.19,1923.6,,2885.39,75,,,percent of total billed charges,75% of total billed charges,2885.39,75,,,percent of total billed charges,75% of total billed charges,610.13,100,,,Fee Schedule,100% of CMS OPPS Rate,122.57,102,,,Fee Schedule,102% of WV Medicaid Rate,1006.72,165,,,Fee Schedule,165% of CMS OPPS Rate,632.35,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1752.53,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2403.46,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,3010.58,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,120.17,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,610.13,100,,,Fee Schedule,100% of CMS OPPS Rate,632.35,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,538.61,14,,,percent of total billed charges,14% of total billed charges,120.17,3010.58,
11602- Exc tr-ext mal+marg 1.1-2 cm,3431533,CDM,761,RC,11602,HCPCS,Outpatient,,,2332.51,1166.26,,1749.38,75,,,percent of total billed charges,75% of total billed charges,1749.38,75,,,percent of total billed charges,75% of total billed charges,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,129.4,102,,,Fee Schedule,102% of WV Medicaid Rate,578.72,165,,,Fee Schedule,165% of CMS OPPS Rate,363.51,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1007.47,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1381.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1730.67,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,126.86,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,363.51,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,326.55,14,,,percent of total billed charges,14% of total billed charges,126.86,1749.38,
11603- Exc tr-ext mal+marg 2.1-3 cm,3431534,CDM,761,RC,11603,HCPCS,Outpatient,,,3936.31,1968.16,,2952.23,75,,,percent of total billed charges,75% of total billed charges,2952.23,75,,,percent of total billed charges,75% of total billed charges,610.13,100,,,Fee Schedule,100% of CMS OPPS Rate,139.5,102,,,Fee Schedule,102% of WV Medicaid Rate,1006.72,165,,,Fee Schedule,165% of CMS OPPS Rate,632.35,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1752.53,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2403.46,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,3010.58,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,136.76,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,610.13,100,,,Fee Schedule,100% of CMS OPPS Rate,632.35,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,551.08,14,,,percent of total billed charges,14% of total billed charges,136.76,3010.58,
11604- Exc tr-ext mal+marg 3.1-4 cm,3431535,CDM,761,RC,11604,HCPCS,Outpatient,,,3976.97,1988.49,,2982.73,75,,,percent of total billed charges,75% of total billed charges,2982.73,75,,,percent of total billed charges,75% of total billed charges,610.13,100,,,Fee Schedule,100% of CMS OPPS Rate,254,102,,,Fee Schedule,102% of WV Medicaid Rate,1006.72,165,,,Fee Schedule,165% of CMS OPPS Rate,632.35,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1752.53,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2403.46,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,3010.58,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,249.02,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,610.13,100,,,Fee Schedule,100% of CMS OPPS Rate,632.35,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,556.78,14,,,percent of total billed charges,14% of total billed charges,249.02,3010.58,
11606- Exc tr-ext mal+marg >4 cm,3431536,CDM,761,RC,11606,HCPCS,Outpatient,,,8829.77,4414.89,,6622.33,75,,,percent of total billed charges,75% of total billed charges,6622.33,75,,,percent of total billed charges,75% of total billed charges,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,479.67,102,,,Fee Schedule,102% of WV Medicaid Rate,2326.19,165,,,Fee Schedule,165% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4049.52,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5553.61,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6956.46,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,470.26,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1236.17,14,,,percent of total billed charges,14% of total billed charges,470.26,6956.46,
11620- Exc/malig/see area/0.5cm or less,3431537,CDM,761,RC,11620,HCPCS,Outpatient,,,8432.4,4216.2,,6324.3,75,,,percent of total billed charges,75% of total billed charges,6324.3,75,,,percent of total billed charges,75% of total billed charges,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,111.37,102,,,Fee Schedule,102% of WV Medicaid Rate,2326.19,165,,,Fee Schedule,165% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4049.52,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5553.61,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6956.46,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,109.19,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1180.54,14,,,percent of total billed charges,14% of total billed charges,109.19,6956.46,
11621- Exc H-F-Nk-Sp Mlg+Marg 0.6-1.0 Cm,3431538,CDM,761,RC,11621,HCPCS,Outpatient,,,3848.82,1924.41,,2886.62,75,,,percent of total billed charges,75% of total billed charges,2886.62,75,,,percent of total billed charges,75% of total billed charges,610.13,100,,,Fee Schedule,100% of CMS OPPS Rate,122.85,102,,,Fee Schedule,102% of WV Medicaid Rate,1006.72,165,,,Fee Schedule,165% of CMS OPPS Rate,632.35,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1752.53,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2403.46,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,3010.58,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,120.44,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,610.13,100,,,Fee Schedule,100% of CMS OPPS Rate,632.35,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,538.83,14,,,percent of total billed charges,14% of total billed charges,120.44,3010.58,
11622- Exc s/n/h/f/g mal+mrg 1.1-2,3431539,CDM,761,RC,11622,HCPCS,Outpatient,,,3888.86,1944.43,,2916.65,75,,,percent of total billed charges,75% of total billed charges,2916.65,75,,,percent of total billed charges,75% of total billed charges,610.13,100,,,Fee Schedule,100% of CMS OPPS Rate,131.58,102,,,Fee Schedule,102% of WV Medicaid Rate,1006.72,165,,,Fee Schedule,165% of CMS OPPS Rate,632.35,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1752.53,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2403.46,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,3010.58,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,129,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,610.13,100,,,Fee Schedule,100% of CMS OPPS Rate,632.35,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,544.44,14,,,percent of total billed charges,14% of total billed charges,129,3010.58,
11623- Exc H-F-Nk-Sp Mlg+Marg 2.1-3 Cm,3431540,CDM,761,RC,11623,HCPCS,Outpatient,,,8604.03,4302.02,,6453.02,75,,,percent of total billed charges,75% of total billed charges,6453.02,75,,,percent of total billed charges,75% of total billed charges,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,144.41,102,,,Fee Schedule,102% of WV Medicaid Rate,2326.19,165,,,Fee Schedule,165% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4049.52,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5553.61,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6956.46,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,141.58,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1204.56,14,,,percent of total billed charges,14% of total billed charges,141.58,6956.46,
11624- Exc s/n/h/f/g mal+mrg 3.1-4,3431541,CDM,761,RC,11624,HCPCS,Outpatient,,,8664.3,4332.15,,6498.23,75,,,percent of total billed charges,75% of total billed charges,6498.23,75,,,percent of total billed charges,75% of total billed charges,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,479.67,102,,,Fee Schedule,102% of WV Medicaid Rate,2326.19,165,,,Fee Schedule,165% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4049.52,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5553.61,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6956.46,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,470.26,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1213,14,,,percent of total billed charges,14% of total billed charges,470.26,6956.46,
11626- Exc s/n/h/f/g mal+mrg >4 cm,3431542,CDM,761,RC,11626,HCPCS,Outpatient,,,14938.29,7469.15,,11203.72,75,,,percent of total billed charges,75% of total billed charges,11203.72,75,,,percent of total billed charges,75% of total billed charges,2428.67,100,,,Fee Schedule,100% of CMS OPPS Rate,803.83,102,,,Fee Schedule,102% of WV Medicaid Rate,4007.32,165,,,Fee Schedule,165% of CMS OPPS Rate,2517.11,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,6976.06,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,9567.11,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,11983.78,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,788.07,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2428.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2517.11,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,2091.36,14,,,percent of total billed charges,14% of total billed charges,788.07,11983.78,
11640- Exc/malg/fac/ear/lid/nos/lip<0.5cm,3431543,CDM,761,RC,11640,HCPCS,Outpatient,,,3803.75,1901.88,,2852.81,75,,,percent of total billed charges,75% of total billed charges,2852.81,75,,,percent of total billed charges,75% of total billed charges,610.13,100,,,Fee Schedule,100% of CMS OPPS Rate,114.38,102,,,Fee Schedule,102% of WV Medicaid Rate,1006.72,165,,,Fee Schedule,165% of CMS OPPS Rate,632.35,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1752.53,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2403.46,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,3010.58,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,112.14,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,610.13,100,,,Fee Schedule,100% of CMS OPPS Rate,632.35,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,532.53,14,,,percent of total billed charges,14% of total billed charges,112.14,3010.58,
11641- Exc f/e/e/n/l mal+mrg 0.6-1,3431544,CDM,761,RC,11641,HCPCS,Outpatient,,,3861.37,1930.69,,2896.03,75,,,percent of total billed charges,75% of total billed charges,2896.03,75,,,percent of total billed charges,75% of total billed charges,610.13,100,,,Fee Schedule,100% of CMS OPPS Rate,126.11,102,,,Fee Schedule,102% of WV Medicaid Rate,1006.72,165,,,Fee Schedule,165% of CMS OPPS Rate,632.35,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1752.53,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2403.46,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,3010.58,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,123.64,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,610.13,100,,,Fee Schedule,100% of CMS OPPS Rate,632.35,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,540.59,14,,,percent of total billed charges,14% of total billed charges,123.64,3010.58,
11642- Exc Face-Mm Malig+Marg 1.1-2,3431545,CDM,761,RC,11642,HCPCS,Outpatient,,,3915.24,1957.62,,2936.43,75,,,percent of total billed charges,75% of total billed charges,2936.43,75,,,percent of total billed charges,75% of total billed charges,610.13,100,,,Fee Schedule,100% of CMS OPPS Rate,137.04,102,,,Fee Schedule,102% of WV Medicaid Rate,1006.72,165,,,Fee Schedule,165% of CMS OPPS Rate,632.35,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1752.53,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2403.46,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,3010.58,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,134.35,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,610.13,100,,,Fee Schedule,100% of CMS OPPS Rate,632.35,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,548.13,14,,,percent of total billed charges,14% of total billed charges,134.35,3010.58,
11643- Exc f/e/e/n/l mal+mrg 2.1-3,3431546,CDM,761,RC,11643,HCPCS,Outpatient,,,8641.28,4320.64,,6480.96,75,,,percent of total billed charges,75% of total billed charges,6480.96,75,,,percent of total billed charges,75% of total billed charges,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,150.14,102,,,Fee Schedule,102% of WV Medicaid Rate,2326.19,165,,,Fee Schedule,165% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4049.52,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5553.61,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6956.46,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,147.2,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1209.78,14,,,percent of total billed charges,14% of total billed charges,147.2,6956.46,
11644- Exc Face-Mm Malig+Marg 3.1-4.0,3431547,CDM,761,RC,11644,HCPCS,Outpatient,,,8752.26,4376.13,,6564.2,75,,,percent of total billed charges,75% of total billed charges,6564.2,75,,,percent of total billed charges,75% of total billed charges,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,479.67,102,,,Fee Schedule,102% of WV Medicaid Rate,2326.19,165,,,Fee Schedule,165% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4049.52,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5553.61,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6956.46,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,470.26,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1225.32,14,,,percent of total billed charges,14% of total billed charges,470.26,6956.46,
11646- Exc/malig/fac/ear/lid/nose/lip>4cm,3431548,CDM,761,RC,11646,HCPCS,Outpatient,,,15136.01,7568.01,,11352.01,75,,,percent of total billed charges,75% of total billed charges,11352.01,75,,,percent of total billed charges,75% of total billed charges,2428.67,100,,,Fee Schedule,100% of CMS OPPS Rate,803.83,102,,,Fee Schedule,102% of WV Medicaid Rate,4007.32,165,,,Fee Schedule,165% of CMS OPPS Rate,2517.11,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,6976.06,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,9567.11,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,11983.78,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,788.07,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2428.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2517.11,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,2119.04,14,,,percent of total billed charges,14% of total billed charges,788.07,11983.78,
11721- Debride/nails/any method/6 or more,3431551,CDM,761,RC,11721,HCPCS,Outpatient,,,357.24,178.62,,267.93,75,,,percent of total billed charges,75% of total billed charges,267.93,75,,,percent of total billed charges,75% of total billed charges,54.04,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,89.16,165,,,Fee Schedule,165% of CMS OPPS Rate,56,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,155.22,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,212.87,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,266.65,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,54.04,100,,,Fee Schedule,100% of CMS OPPS Rate,56,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,50.01,14,,,percent of total billed charges,14% of total billed charges,50.01,267.93,
11730- Avulsion/nail plate/simple/single,3431552,CDM,761,RC,11730,HCPCS,Outpatient,,,1119.71,559.86,,839.78,75,,,percent of total billed charges,75% of total billed charges,839.78,75,,,percent of total billed charges,75% of total billed charges,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,280.12,165,,,Fee Schedule,165% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,487.65,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,668.78,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,837.71,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,156.76,14,,,percent of total billed charges,14% of total billed charges,156.76,839.78,
11732- Avulsion/nail plate/simple/ea add,3431553,CDM,761,RC,11732,HCPCS,Outpatient,,,429.87,214.94,,322.4,75,,,percent of total billed charges,75% of total billed charges,322.4,75,,,percent of total billed charges,75% of total billed charges,137.56,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.18,14,,,percent of total billed charges,14% of total billed charges,60.18,322.4,
11900- Intralesional injection/</=7,3431563,CDM,761,RC,11900,HCPCS,Outpatient,,,1071.18,535.59,,803.39,75,,,percent of total billed charges,75% of total billed charges,803.39,75,,,percent of total billed charges,75% of total billed charges,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,280.12,165,,,Fee Schedule,165% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,487.65,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,668.78,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,837.71,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,149.97,14,,,percent of total billed charges,14% of total billed charges,149.97,837.71,
11901- Inj/intralesional/> 7 lesions,3431564,CDM,761,RC,11901,HCPCS,Outpatient,,,1102.03,551.02,,826.52,75,,,percent of total billed charges,75% of total billed charges,826.52,75,,,percent of total billed charges,75% of total billed charges,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,280.12,165,,,Fee Schedule,165% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,487.65,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,668.78,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,837.71,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,154.28,14,,,percent of total billed charges,14% of total billed charges,154.28,837.71,
11950 - Subcutaneous injection filling material,3572729,CDM,983,RC,11950,HCPCS,Outpatient,,,1117,558.5,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
11950- Subq inj/fill material/1cc or <,3431566,CDM,761,RC,11950,HCPCS,Outpatient,,,1117,558.5,,837.75,75,,,percent of total billed charges,75% of total billed charges,837.75,75,,,percent of total billed charges,75% of total billed charges,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,37.94,102,,,Fee Schedule,102% of WV Medicaid Rate,280.12,165,,,Fee Schedule,165% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,487.65,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,668.77,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,837.71,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,37.2,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,156.38,14,,,percent of total billed charges,14% of total billed charges,37.2,837.75,
11951- Subq inj/fill material/1.1-5.0 cc,3431567,CDM,761,RC,11951,HCPCS,Outpatient,,,3319.96,1659.98,,2489.97,75,,,percent of total billed charges,75% of total billed charges,2489.97,75,,,percent of total billed charges,75% of total billed charges,546.17,100,,,Fee Schedule,100% of CMS OPPS Rate,48.32,102,,,Fee Schedule,102% of WV Medicaid Rate,901.2,165,,,Fee Schedule,165% of CMS OPPS Rate,566.07,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1568.84,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2151.55,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,2695.04,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,47.37,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,546.17,100,,,Fee Schedule,100% of CMS OPPS Rate,566.07,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,464.79,14,,,percent of total billed charges,14% of total billed charges,47.37,2695.04,
11982- Remove/drug delivery implant,3431572,CDM,510,RC,11982,HCPCS,Outpatient,,,1975.91,987.96,,1481.93,75,,,percent of total billed charges,75% of total billed charges,1481.93,75,,,percent of total billed charges,75% of total billed charges,354.97,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,585.71,165,,,Fee Schedule,165% of CMS OPPS Rate,367.9,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1019.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1398.33,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1751.55,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,354.97,100,,,Fee Schedule,100% of CMS OPPS Rate,367.9,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,276.63,14,,,percent of total billed charges,14% of total billed charges,276.63,1751.55,
12001 - SIMPLE REPAIR SCALP/NECK/AX/GENIT/TRUNK 2.5CM/<,4037467,CDM,510,RC,12001,HCPCS,Outpatient,,,1104.45,552.23,,828.34,75,,,percent of total billed charges,75% of total billed charges,828.34,75,,,percent of total billed charges,75% of total billed charges,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,280.12,165,,,Fee Schedule,165% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,487.65,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,668.78,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,837.71,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,154.62,14,,,percent of total billed charges,14% of total billed charges,154.62,837.71,
12001- Rep Superfic Wound 2.5Cm Less,3431574,CDM,761,RC,12001,HCPCS,Outpatient,,,966.27,483.14,,724.7,75,,,percent of total billed charges,75% of total billed charges,724.7,75,,,percent of total billed charges,75% of total billed charges,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,280.12,165,,,Fee Schedule,165% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,487.65,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,668.78,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,837.71,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,135.28,14,,,percent of total billed charges,14% of total billed charges,135.28,837.71,
12002- Rep Superfic Wound 2.6-7.5Cm,3431575,CDM,761,RC,12002,HCPCS,Outpatient,,,1134.4,567.2,,850.8,75,,,percent of total billed charges,75% of total billed charges,850.8,75,,,percent of total billed charges,75% of total billed charges,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,280.12,165,,,Fee Schedule,165% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,487.65,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,668.78,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,837.71,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,158.82,14,,,percent of total billed charges,14% of total billed charges,158.82,850.8,
12004- Rep Superific Wound 7.6-12.5 cm,3431576,CDM,761,RC,12004,HCPCS,Outpatient,,,1165.9,582.95,,874.43,75,,,percent of total billed charges,75% of total billed charges,874.43,75,,,percent of total billed charges,75% of total billed charges,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,280.12,165,,,Fee Schedule,165% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,487.65,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,668.78,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,837.71,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,163.23,14,,,percent of total billed charges,14% of total billed charges,163.23,874.43,
12005- Rep Superfic Wound 12.6-20.0Cm,3431577,CDM,761,RC,12005,HCPCS,Outpatient,,,2214.87,1107.44,,1661.15,75,,,percent of total billed charges,75% of total billed charges,1661.15,75,,,percent of total billed charges,75% of total billed charges,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,141.09,102,,,Fee Schedule,102% of WV Medicaid Rate,578.73,165,,,Fee Schedule,165% of CMS OPPS Rate,363.52,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1007.47,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1381.67,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1730.68,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,138.32,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,363.52,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,310.08,14,,,percent of total billed charges,14% of total billed charges,138.32,1730.68,
"12006- Simple Repair, scalp/neck/axillae/trunk/genital/extrem, 2.5 - 7.5 cm",3428737,CDM,510,RC,12006,HCPCS,Outpatient,,,2258.88,1129.44,,1694.16,75,,,percent of total billed charges,75% of total billed charges,1694.16,75,,,percent of total billed charges,75% of total billed charges,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,141.09,102,,,Fee Schedule,102% of WV Medicaid Rate,578.73,165,,,Fee Schedule,165% of CMS OPPS Rate,363.52,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1007.47,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1381.67,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1730.68,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,138.32,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,363.52,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,316.24,14,,,percent of total billed charges,14% of total billed charges,138.32,1730.68,
12007- Smpl rpr/scalp/neck/ax/ext genit/trnk/extrem/inc hnd/ft/>30cm,3431578,CDM,761,RC,12007,HCPCS,Outpatient,,,1315.03,657.52,,986.27,75,,,percent of total billed charges,75% of total billed charges,986.27,75,,,percent of total billed charges,75% of total billed charges,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,73.31,102,,,Fee Schedule,102% of WV Medicaid Rate,280.12,165,,,Fee Schedule,165% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,487.65,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,668.77,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,837.71,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,71.87,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,184.1,14,,,percent of total billed charges,14% of total billed charges,71.87,986.27,
12011- Rep Superfic Wounds 2.5Cm Less,3431579,CDM,761,RC,12011,HCPCS,Outpatient,,,119.35,59.68,,89.51,75,,,percent of total billed charges,75% of total billed charges,89.51,75,,,percent of total billed charges,75% of total billed charges,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,280.12,165,,,Fee Schedule,165% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,487.65,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,668.78,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,837.71,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,16.71,14,,,percent of total billed charges,14% of total billed charges,16.71,837.71,
12011-EYE RPR SPR WND FACE <2.5CM,3428738,CDM,510,RC,12011,HCPCS,Outpatient,,,1127.43,563.72,,845.57,75,,,percent of total billed charges,75% of total billed charges,845.57,75,,,percent of total billed charges,75% of total billed charges,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,280.12,165,,,Fee Schedule,165% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,487.65,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,668.78,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,837.71,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,157.84,14,,,percent of total billed charges,14% of total billed charges,157.84,845.57,
12011-OCC EYE RPR SPR WND FACE <2.5CM,3536972,CDM,983,RC,12011,HCPCS,Outpatient,,,1127.43,563.72,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
12013- Rep Superfic Wounds 2.6-5.0Cm,3431580,CDM,761,RC,12013,HCPCS,Outpatient,,,1134.02,567.01,,850.52,75,,,percent of total billed charges,75% of total billed charges,850.52,75,,,percent of total billed charges,75% of total billed charges,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,280.12,165,,,Fee Schedule,165% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,487.65,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,668.78,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,837.71,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,158.76,14,,,percent of total billed charges,14% of total billed charges,158.76,850.52,
12014 - Simple repair of superficial wound of eyelid,3428739,CDM,983,RC,12014,HCPCS,Outpatient,,,1170.51,585.26,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
12015- Rep Superfic Wounds 7.6-12.5Cm,3431581,CDM,761,RC,12015,HCPCS,Outpatient,,,1211.17,605.59,,908.38,75,,,percent of total billed charges,75% of total billed charges,908.38,75,,,percent of total billed charges,75% of total billed charges,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,73.31,102,,,Fee Schedule,102% of WV Medicaid Rate,280.12,165,,,Fee Schedule,165% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,487.65,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,668.78,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,837.71,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,71.87,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,169.56,14,,,percent of total billed charges,14% of total billed charges,71.87,908.38,
12016- Smp rp fac/ear/no/lip/lid 12.6-20,3428740,CDM,510,RC,12016,HCPCS,Outpatient,,,2284.89,1142.45,,1713.67,75,,,percent of total billed charges,75% of total billed charges,1713.67,75,,,percent of total billed charges,75% of total billed charges,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,141.09,102,,,Fee Schedule,102% of WV Medicaid Rate,578.73,165,,,Fee Schedule,165% of CMS OPPS Rate,363.52,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1007.47,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1381.67,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1730.68,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,138.32,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,363.52,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,319.88,14,,,percent of total billed charges,14% of total billed charges,138.32,1730.68,
12018- Smpl rpr/face/ear/lid/nose/lip/>30.0cm,3431582,CDM,761,RC,12018,HCPCS,Outpatient,,,1380.7,690.35,,1035.53,75,,,percent of total billed charges,75% of total billed charges,1035.53,75,,,percent of total billed charges,75% of total billed charges,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,73.31,102,,,Fee Schedule,102% of WV Medicaid Rate,280.12,165,,,Fee Schedule,165% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,487.65,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,668.78,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,837.71,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,71.87,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,193.3,14,,,percent of total billed charges,14% of total billed charges,71.87,1035.53,
12020 - Treatment of superficial wound dehiscence; simple cl,4231108,CDM,510,RC,12020,HCPCS,Outpatient,,,3549.52,1774.76,,2662.14,75,,,percent of total billed charges,75% of total billed charges,2662.14,75,,,percent of total billed charges,75% of total billed charges,546.17,100,,,Fee Schedule,100% of CMS OPPS Rate,213.77,102,,,Fee Schedule,102% of WV Medicaid Rate,901.2,165,,,Fee Schedule,165% of CMS OPPS Rate,566.07,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1568.84,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2151.55,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,2695.04,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,209.58,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,546.17,100,,,Fee Schedule,100% of CMS OPPS Rate,566.07,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,496.93,14,,,percent of total billed charges,14% of total billed charges,209.58,2695.04,
12020 -OCC CLOSURE OF SPLIT WOUND,3568838,CDM,983,RC,12020,HCPCS,Outpatient,,,2549.52,1274.76,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
12020- Tx superfic wnd dehise/smp close,3431583,CDM,761,RC,12020,HCPCS,Outpatient,,,3549.52,1774.76,,2662.14,75,,,percent of total billed charges,75% of total billed charges,2662.14,75,,,percent of total billed charges,75% of total billed charges,546.17,100,,,Fee Schedule,100% of CMS OPPS Rate,213.77,102,,,Fee Schedule,102% of WV Medicaid Rate,901.2,165,,,Fee Schedule,165% of CMS OPPS Rate,566.07,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1568.84,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2151.55,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,2695.04,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,209.58,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,546.17,100,,,Fee Schedule,100% of CMS OPPS Rate,566.07,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,496.93,14,,,percent of total billed charges,14% of total billed charges,209.58,2695.04,
12021- Tx superficial wnd dehise/smp/pack,3431584,CDM,761,RC,12021,HCPCS,Outpatient,,,2296.13,1148.07,,1722.1,75,,,percent of total billed charges,75% of total billed charges,1722.1,75,,,percent of total billed charges,75% of total billed charges,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,141.09,102,,,Fee Schedule,102% of WV Medicaid Rate,578.72,165,,,Fee Schedule,165% of CMS OPPS Rate,363.51,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1007.47,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1381.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1730.67,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,138.32,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,363.51,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,321.46,14,,,percent of total billed charges,14% of total billed charges,138.32,1730.67,
12031- Int rp scalp/ax/trunk/ext 2.5 or <,3428743,CDM,761,RC,12031,HCPCS,Outpatient,,,2312.58,1156.29,,1734.44,75,,,percent of total billed charges,75% of total billed charges,1734.44,75,,,percent of total billed charges,75% of total billed charges,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,141.09,102,,,Fee Schedule,102% of WV Medicaid Rate,578.72,165,,,Fee Schedule,165% of CMS OPPS Rate,363.51,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1007.47,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1381.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1730.67,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,138.32,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,363.51,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,323.76,14,,,percent of total billed charges,14% of total billed charges,138.32,1734.44,
"12032- Intermed Rpr, Scalp, Axillae, Trunk, Extremities 2.6-7.5cm",3431585,CDM,761,RC,12032,HCPCS,Outpatient,,,2388.29,1194.15,,1791.22,75,,,percent of total billed charges,75% of total billed charges,1791.22,75,,,percent of total billed charges,75% of total billed charges,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,141.09,102,,,Fee Schedule,102% of WV Medicaid Rate,578.72,165,,,Fee Schedule,165% of CMS OPPS Rate,363.51,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1007.47,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1381.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1730.67,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,138.32,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,363.51,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,334.36,14,,,percent of total billed charges,14% of total billed charges,138.32,1791.22,
12034- Itmed rpr/scalp/ax/trnk/extrem/exclu hnd/ft/7.6-12.5c,3431586,CDM,761,RC,12034,HCPCS,Outpatient,,,2423.12,1211.56,,1817.34,75,,,percent of total billed charges,75% of total billed charges,1817.34,75,,,percent of total billed charges,75% of total billed charges,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,141.09,102,,,Fee Schedule,102% of WV Medicaid Rate,578.72,165,,,Fee Schedule,165% of CMS OPPS Rate,363.51,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1007.47,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1381.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1730.67,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,138.32,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,363.51,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,339.24,14,,,percent of total billed charges,14% of total billed charges,138.32,1817.34,
12035- Int rp scalp/ax/trunk/ext 12.6-20,3428744,CDM,510,RC,12035,HCPCS,Outpatient,,,2500.92,1250.46,,1875.69,75,,,percent of total billed charges,75% of total billed charges,1875.69,75,,,percent of total billed charges,75% of total billed charges,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,141.09,102,,,Fee Schedule,102% of WV Medicaid Rate,578.72,165,,,Fee Schedule,165% of CMS OPPS Rate,363.51,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1007.47,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1381.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1730.67,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,138.32,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,363.51,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,350.13,14,,,percent of total billed charges,14% of total billed charges,138.32,1875.69,
"12037 - Repair, intermediate, wounds of scalp, axillae, trunk and/or extremities (excluding hands an",3715279,CDM,510,RC,12037,HCPCS,Outpatient,,,9880.27,4940.14,,7410.2,75,,,percent of total billed charges,75% of total billed charges,7410.2,75,,,percent of total billed charges,75% of total billed charges,1622.59,100,,,Fee Schedule,100% of CMS OPPS Rate,699.11,102,,,Fee Schedule,102% of WV Medicaid Rate,2677.27,165,,,Fee Schedule,165% of CMS OPPS Rate,1681.67,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4660.68,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,6391.75,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,8006.31,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,685.4,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1622.59,100,,,Fee Schedule,100% of CMS OPPS Rate,1681.67,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1383.24,14,,,percent of total billed charges,14% of total billed charges,685.4,8006.31,
12041- Itmed rpr/neck/hand/ft/ext genit/2.5 cm or <,3431587,CDM,761,RC,12041,HCPCS,Outpatient,,,2302.49,1151.25,,1726.87,75,,,percent of total billed charges,75% of total billed charges,1726.87,75,,,percent of total billed charges,75% of total billed charges,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,141.09,102,,,Fee Schedule,102% of WV Medicaid Rate,578.73,165,,,Fee Schedule,165% of CMS OPPS Rate,363.52,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1007.47,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1381.67,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1730.68,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,138.32,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,363.52,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,322.35,14,,,percent of total billed charges,14% of total billed charges,138.32,1730.68,
12042- Itmed rpr/neck/hand/ft/ext genit/2.6-7.5 cm,3431588,CDM,761,RC,12042,HCPCS,Outpatient,,,2401.75,1200.88,,1801.31,75,,,percent of total billed charges,75% of total billed charges,1801.31,75,,,percent of total billed charges,75% of total billed charges,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,141.09,102,,,Fee Schedule,102% of WV Medicaid Rate,578.72,165,,,Fee Schedule,165% of CMS OPPS Rate,363.51,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1007.47,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1381.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1730.67,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,138.32,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,363.51,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,336.25,14,,,percent of total billed charges,14% of total billed charges,138.32,1801.31,
12044- Int rp neck/hand/feet/gen 7.6-12.5,3428745,CDM,510,RC,12044,HCPCS,Outpatient,,,3600.95,1800.48,,2700.71,75,,,percent of total billed charges,75% of total billed charges,2700.71,75,,,percent of total billed charges,75% of total billed charges,546.17,100,,,Fee Schedule,100% of CMS OPPS Rate,213.77,102,,,Fee Schedule,102% of WV Medicaid Rate,901.2,165,,,Fee Schedule,165% of CMS OPPS Rate,566.07,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1568.84,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2151.55,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,2695.04,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,209.58,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,546.17,100,,,Fee Schedule,100% of CMS OPPS Rate,566.07,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,504.13,14,,,percent of total billed charges,14% of total billed charges,209.58,2700.71,
12045- Itmed rpr/neck/hnd/ft/ext genit/12.6-20.0cm,3431589,CDM,761,RC,12045,HCPCS,Outpatient,,,3721.87,1860.94,,2791.4,75,,,percent of total billed charges,75% of total billed charges,2791.4,75,,,percent of total billed charges,75% of total billed charges,546.17,100,,,Fee Schedule,100% of CMS OPPS Rate,213.77,102,,,Fee Schedule,102% of WV Medicaid Rate,901.2,165,,,Fee Schedule,165% of CMS OPPS Rate,566.07,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1568.84,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2151.55,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,2695.04,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,209.58,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,546.17,100,,,Fee Schedule,100% of CMS OPPS Rate,566.07,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,521.06,14,,,percent of total billed charges,14% of total billed charges,209.58,2791.4,
12046- Itmed rpr/neck/hnd/ft/ext genit/20.1-30.0cm,3431590,CDM,761,RC,12046,HCPCS,Outpatient,,,3822.57,1911.29,,2866.93,75,,,percent of total billed charges,75% of total billed charges,2866.93,75,,,percent of total billed charges,75% of total billed charges,546.17,100,,,Fee Schedule,100% of CMS OPPS Rate,213.77,102,,,Fee Schedule,102% of WV Medicaid Rate,901.2,165,,,Fee Schedule,165% of CMS OPPS Rate,566.07,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1568.84,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2151.55,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,2695.04,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,209.58,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,546.17,100,,,Fee Schedule,100% of CMS OPPS Rate,566.07,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,535.16,14,,,percent of total billed charges,14% of total billed charges,209.58,2866.93,
12047- Itmed rpr/neck/hnd/ft/ext genit/> 30.0 cm,3431591,CDM,761,RC,12047,HCPCS,Outpatient,,,9933.33,4966.67,,7450,75,,,percent of total billed charges,75% of total billed charges,7450,75,,,percent of total billed charges,75% of total billed charges,1622.59,100,,,Fee Schedule,100% of CMS OPPS Rate,699.11,102,,,Fee Schedule,102% of WV Medicaid Rate,2677.27,165,,,Fee Schedule,165% of CMS OPPS Rate,1681.67,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4660.68,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,6391.75,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,8006.31,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,685.4,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1622.59,100,,,Fee Schedule,100% of CMS OPPS Rate,1681.67,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1390.67,14,,,percent of total billed charges,14% of total billed charges,685.4,8006.31,
12051- Itmed rpr/face/ear/lid/nose/lip/2.5 cm or<,3431592,CDM,761,RC,12051,HCPCS,Outpatient,,,2350.02,1175.01,,1762.52,75,,,percent of total billed charges,75% of total billed charges,1762.52,75,,,percent of total billed charges,75% of total billed charges,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,141.09,102,,,Fee Schedule,102% of WV Medicaid Rate,578.72,165,,,Fee Schedule,165% of CMS OPPS Rate,363.51,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1007.47,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1381.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1730.67,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,138.32,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,363.51,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,329,14,,,percent of total billed charges,14% of total billed charges,138.32,1762.52,
12052- Itmed rpr/face/ear/lid/nose/lip/2.6-5.0 cm,3431593,CDM,761,RC,12052,HCPCS,Outpatient,,,2409.74,1204.87,,1807.31,75,,,percent of total billed charges,75% of total billed charges,1807.31,75,,,percent of total billed charges,75% of total billed charges,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,141.09,102,,,Fee Schedule,102% of WV Medicaid Rate,578.72,165,,,Fee Schedule,165% of CMS OPPS Rate,363.51,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1007.47,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1381.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1730.67,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,138.32,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,363.51,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,337.36,14,,,percent of total billed charges,14% of total billed charges,138.32,1807.31,
12053- Int rp fac/ear/lid/nos/lip 5.1-7.5,3428750,CDM,761,RC,12053,HCPCS,Outpatient,,,2442.39,1221.2,,1831.79,75,,,percent of total billed charges,75% of total billed charges,1831.79,75,,,percent of total billed charges,75% of total billed charges,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,141.09,102,,,Fee Schedule,102% of WV Medicaid Rate,578.72,165,,,Fee Schedule,165% of CMS OPPS Rate,363.51,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1007.47,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1381.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1730.67,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,138.32,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,363.51,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,341.93,14,,,percent of total billed charges,14% of total billed charges,138.32,1831.79,
12054- In rp fac/ear/lid/nos/lip 7.6-12.5,3428751,CDM,510,RC,12054,HCPCS,Outpatient,,,2458.44,1229.22,,1843.83,75,,,percent of total billed charges,75% of total billed charges,1843.83,75,,,percent of total billed charges,75% of total billed charges,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,141.09,102,,,Fee Schedule,102% of WV Medicaid Rate,578.73,165,,,Fee Schedule,165% of CMS OPPS Rate,363.52,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1007.47,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1381.67,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1730.68,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,138.32,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,363.52,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,344.18,14,,,percent of total billed charges,14% of total billed charges,138.32,1843.83,
12055- Itmed rpr/face 2.6-20.0cm,3428752,CDM,510,RC,12055,HCPCS,Outpatient,,,2624.71,1312.36,,1968.53,75,,,percent of total billed charges,75% of total billed charges,1968.53,75,,,percent of total billed charges,75% of total billed charges,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,141.09,102,,,Fee Schedule,102% of WV Medicaid Rate,578.72,165,,,Fee Schedule,165% of CMS OPPS Rate,363.51,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1007.47,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1381.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1730.67,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,138.32,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,363.51,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,367.46,14,,,percent of total billed charges,14% of total billed charges,138.32,1968.53,
12056- Int rp fac/ear/lid/nos/lip 20.1-30,3428755,CDM,510,RC,12056,HCPCS,Outpatient,,,2785.72,1392.86,,2089.29,75,,,percent of total billed charges,75% of total billed charges,2089.29,75,,,percent of total billed charges,75% of total billed charges,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,141.09,102,,,Fee Schedule,102% of WV Medicaid Rate,578.73,165,,,Fee Schedule,165% of CMS OPPS Rate,363.52,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1007.47,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1381.67,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1730.68,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,138.32,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,363.52,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,390,14,,,percent of total billed charges,14% of total billed charges,138.32,2089.29,
12057- Itmed rpr/face/ear/lid/nose/lip/>30.0cm,3431594,CDM,761,RC,12057,HCPCS,Outpatient,,,2859.84,1429.92,,2144.88,75,,,percent of total billed charges,75% of total billed charges,2144.88,75,,,percent of total billed charges,75% of total billed charges,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,141.09,102,,,Fee Schedule,102% of WV Medicaid Rate,578.72,165,,,Fee Schedule,165% of CMS OPPS Rate,363.51,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1007.47,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1381.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1730.67,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,138.32,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,363.51,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,400.38,14,,,percent of total billed charges,14% of total billed charges,138.32,2144.88,
13101- Complex repair/trunk/2.6-7.5 cm,3431595,CDM,761,RC,13101,HCPCS,Outpatient,,,3659.18,1829.59,,2744.39,75,,,percent of total billed charges,75% of total billed charges,2744.39,75,,,percent of total billed charges,75% of total billed charges,546.17,100,,,Fee Schedule,100% of CMS OPPS Rate,213.77,102,,,Fee Schedule,102% of WV Medicaid Rate,901.2,165,,,Fee Schedule,165% of CMS OPPS Rate,566.07,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1568.84,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2151.55,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,2695.04,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,209.58,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,546.17,100,,,Fee Schedule,100% of CMS OPPS Rate,566.07,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,512.29,14,,,percent of total billed charges,14% of total billed charges,209.58,2744.39,
"13102 - Repair, complex, trunk; each additional 5 cm or less",4037473,CDM,510,RC,13102,HCPCS,Outpatient,,,1926.68,963.34,,1445.01,75,,,percent of total billed charges,75% of total billed charges,1445.01,75,,,percent of total billed charges,75% of total billed charges,616.54,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,269.74,14,,,percent of total billed charges,14% of total billed charges,269.74,1445.01,
13120- Repair/comp/scalp/arm/leg/1.1-2.5c,3431596,CDM,761,RC,13120,HCPCS,Outpatient,,,3629.02,1814.51,,2721.77,75,,,percent of total billed charges,75% of total billed charges,2721.77,75,,,percent of total billed charges,75% of total billed charges,546.17,100,,,Fee Schedule,100% of CMS OPPS Rate,213.77,102,,,Fee Schedule,102% of WV Medicaid Rate,901.2,165,,,Fee Schedule,165% of CMS OPPS Rate,566.07,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1568.84,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2151.55,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,2695.04,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,209.58,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,546.17,100,,,Fee Schedule,100% of CMS OPPS Rate,566.07,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,508.06,14,,,percent of total billed charges,14% of total billed charges,209.58,2721.77,
13121- Cmplx rpr s/a/l 2.6-7.5 cm,3431597,CDM,761,RC,13121,HCPCS,Outpatient,,,3684.77,1842.39,,2763.58,75,,,percent of total billed charges,75% of total billed charges,2763.58,75,,,percent of total billed charges,75% of total billed charges,546.17,100,,,Fee Schedule,100% of CMS OPPS Rate,213.77,102,,,Fee Schedule,102% of WV Medicaid Rate,901.2,165,,,Fee Schedule,165% of CMS OPPS Rate,566.07,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1568.84,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2151.55,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,2695.04,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,209.58,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,546.17,100,,,Fee Schedule,100% of CMS OPPS Rate,566.07,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,515.87,14,,,percent of total billed charges,14% of total billed charges,209.58,2763.58,
"13122 - Repair, complex, scalp, arms, and/or legs; each additional 5 cm or less (List separately in",3715283,CDM,510,RC,13122,HCPCS,Outpatient,,,1948.39,974.2,,1461.29,75,,,percent of total billed charges,75% of total billed charges,1461.29,75,,,percent of total billed charges,75% of total billed charges,623.48,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,272.77,14,,,percent of total billed charges,14% of total billed charges,272.77,1461.29,
13131- Cmplx rpr f/c/c/m/n/ax/g/h/f; 1.1 cm to 2.5 cm,3431598,CDM,761,RC,13131,HCPCS,Outpatient,,,2495.77,1247.89,,1871.83,75,,,percent of total billed charges,75% of total billed charges,1871.83,75,,,percent of total billed charges,75% of total billed charges,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,141.09,102,,,Fee Schedule,102% of WV Medicaid Rate,578.72,165,,,Fee Schedule,165% of CMS OPPS Rate,363.51,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1007.47,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1381.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1730.67,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,138.32,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,363.51,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,349.41,14,,,percent of total billed charges,14% of total billed charges,138.32,1871.83,
13132- Cmplx rpr f/c/c/m/n/ax/g/h/f; 2.6 cm to 7.5 cm,3431599,CDM,761,RC,13132,HCPCS,Outpatient,,,3773.83,1886.92,,2830.37,75,,,percent of total billed charges,75% of total billed charges,2830.37,75,,,percent of total billed charges,75% of total billed charges,546.17,100,,,Fee Schedule,100% of CMS OPPS Rate,213.77,102,,,Fee Schedule,102% of WV Medicaid Rate,901.2,165,,,Fee Schedule,165% of CMS OPPS Rate,566.07,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1568.84,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2151.55,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,2695.04,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,209.58,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,546.17,100,,,Fee Schedule,100% of CMS OPPS Rate,566.07,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,528.34,14,,,percent of total billed charges,14% of total billed charges,209.58,2830.37,
13151- Cmplx rpr e/n/e/l; 1.1-2.5 cm,3431601,CDM,761,RC,13151,HCPCS,Outpatient,,,3726.22,1863.11,,2794.67,75,,,percent of total billed charges,75% of total billed charges,2794.67,75,,,percent of total billed charges,75% of total billed charges,546.17,100,,,Fee Schedule,100% of CMS OPPS Rate,213.77,102,,,Fee Schedule,102% of WV Medicaid Rate,901.2,165,,,Fee Schedule,165% of CMS OPPS Rate,566.07,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1568.84,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2151.55,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,2695.04,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,209.58,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,546.17,100,,,Fee Schedule,100% of CMS OPPS Rate,566.07,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,521.67,14,,,percent of total billed charges,14% of total billed charges,209.58,2794.67,
13152- Cmplx rpr e/n/e/l; 2.6-7.5 cm,3431602,CDM,761,RC,13152,HCPCS,Outpatient,,,3841.44,1920.72,,2881.08,75,,,percent of total billed charges,75% of total billed charges,2881.08,75,,,percent of total billed charges,75% of total billed charges,546.17,100,,,Fee Schedule,100% of CMS OPPS Rate,213.77,102,,,Fee Schedule,102% of WV Medicaid Rate,901.2,165,,,Fee Schedule,165% of CMS OPPS Rate,566.07,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1568.84,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2151.55,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,2695.04,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,209.58,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,546.17,100,,,Fee Schedule,100% of CMS OPPS Rate,566.07,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,537.8,14,,,percent of total billed charges,14% of total billed charges,209.58,2881.08,
13160- Secondary clos/surg wound/ext/comp,3431603,CDM,761,RC,13160,HCPCS,Outpatient,,,10821.47,5410.74,,8116.1,75,,,percent of total billed charges,75% of total billed charges,8116.1,75,,,percent of total billed charges,75% of total billed charges,1622.59,100,,,Fee Schedule,100% of CMS OPPS Rate,699.11,102,,,Fee Schedule,102% of WV Medicaid Rate,2677.27,165,,,Fee Schedule,165% of CMS OPPS Rate,1681.67,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4660.68,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,6391.75,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,8006.31,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,685.4,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1622.59,100,,,Fee Schedule,100% of CMS OPPS Rate,1681.67,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1515.01,14,,,percent of total billed charges,14% of total billed charges,685.4,8116.1,
14001- Skin Tiss Transfer 10.1-30Sq Cm,3431604,CDM,761,RC,14001,HCPCS,Outpatient,,,10523.37,5261.69,,7892.53,75,,,percent of total billed charges,75% of total billed charges,7892.53,75,,,percent of total billed charges,75% of total billed charges,1622.59,100,,,Fee Schedule,100% of CMS OPPS Rate,699.11,102,,,Fee Schedule,102% of WV Medicaid Rate,2677.27,165,,,Fee Schedule,165% of CMS OPPS Rate,1681.67,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4660.68,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,6391.75,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,8006.31,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,685.4,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1622.59,100,,,Fee Schedule,100% of CMS OPPS Rate,1681.67,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1473.27,14,,,percent of total billed charges,14% of total billed charges,685.4,8006.31,
14020- Skin Tissue Trnfr 10Sq Cm Less,3431605,CDM,761,RC,14020,HCPCS,Outpatient,,,10333.25,5166.63,,7749.94,75,,,percent of total billed charges,75% of total billed charges,7749.94,75,,,percent of total billed charges,75% of total billed charges,1622.59,100,,,Fee Schedule,100% of CMS OPPS Rate,699.11,102,,,Fee Schedule,102% of WV Medicaid Rate,2677.27,165,,,Fee Schedule,165% of CMS OPPS Rate,1681.67,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4660.68,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,6391.75,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,8006.31,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,685.4,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1622.59,100,,,Fee Schedule,100% of CMS OPPS Rate,1681.67,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1446.66,14,,,percent of total billed charges,14% of total billed charges,685.4,8006.31,
14021- Skin Tissue Trnfr 10.1-30Sq Cm,3431606,CDM,761,RC,14021,HCPCS,Outpatient,,,10619.24,5309.62,,7964.43,75,,,percent of total billed charges,75% of total billed charges,7964.43,75,,,percent of total billed charges,75% of total billed charges,1622.59,100,,,Fee Schedule,100% of CMS OPPS Rate,699.11,102,,,Fee Schedule,102% of WV Medicaid Rate,2677.27,165,,,Fee Schedule,165% of CMS OPPS Rate,1681.67,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4660.68,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,6391.75,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,8006.31,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,685.4,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1622.59,100,,,Fee Schedule,100% of CMS OPPS Rate,1681.67,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1486.69,14,,,percent of total billed charges,14% of total billed charges,685.4,8006.31,
14040- Tis trnfr f/c/c/m/n/a/g/h/f; defect 10 sq cm or less,3431607,CDM,761,RC,14040,HCPCS,Outpatient,,,10448.69,5224.35,,7836.52,75,,,percent of total billed charges,75% of total billed charges,7836.52,75,,,percent of total billed charges,75% of total billed charges,1622.59,100,,,Fee Schedule,100% of CMS OPPS Rate,699.11,102,,,Fee Schedule,102% of WV Medicaid Rate,2677.27,165,,,Fee Schedule,165% of CMS OPPS Rate,1681.67,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4660.68,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,6391.75,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,8006.31,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,685.4,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1622.59,100,,,Fee Schedule,100% of CMS OPPS Rate,1681.67,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1462.82,14,,,percent of total billed charges,14% of total billed charges,685.4,8006.31,
14041- Adj tis trans/see area/10.1-30sqcm,3431608,CDM,761,RC,14041,HCPCS,Outpatient,,,10723.16,5361.58,,8042.37,75,,,percent of total billed charges,75% of total billed charges,8042.37,75,,,percent of total billed charges,75% of total billed charges,1622.59,100,,,Fee Schedule,100% of CMS OPPS Rate,699.11,102,,,Fee Schedule,102% of WV Medicaid Rate,2677.27,165,,,Fee Schedule,165% of CMS OPPS Rate,1681.67,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4660.68,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,6391.75,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,8006.31,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,685.4,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1622.59,100,,,Fee Schedule,100% of CMS OPPS Rate,1681.67,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1501.24,14,,,percent of total billed charges,14% of total billed charges,685.4,8042.37,
14060- Tis trnfr e/n/e/l 10 sq cm/<,3431609,CDM,761,RC,14060,HCPCS,Outpatient,,,10723.16,5361.58,,8042.37,75,,,percent of total billed charges,75% of total billed charges,8042.37,75,,,percent of total billed charges,75% of total billed charges,1622.59,100,,,Fee Schedule,100% of CMS OPPS Rate,699.11,102,,,Fee Schedule,102% of WV Medicaid Rate,2677.27,165,,,Fee Schedule,165% of CMS OPPS Rate,1681.67,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4660.68,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,6391.75,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,8006.31,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,685.4,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1622.59,100,,,Fee Schedule,100% of CMS OPPS Rate,1681.67,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1501.24,14,,,percent of total billed charges,14% of total billed charges,685.4,8042.37,
"15040 - Harvest of skin for tissue cultured skin autograft, 100 sq cm or less",3715286,CDM,510,RC,15040,HCPCS,Outpatient,,,9464.62,4732.31,,7098.47,75,,,percent of total billed charges,75% of total billed charges,7098.47,75,,,percent of total billed charges,75% of total billed charges,1622.59,100,,,Fee Schedule,100% of CMS OPPS Rate,699.11,102,,,Fee Schedule,102% of WV Medicaid Rate,2677.27,165,,,Fee Schedule,165% of CMS OPPS Rate,1681.67,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4660.68,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,6391.75,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,8006.31,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,685.4,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1622.59,100,,,Fee Schedule,100% of CMS OPPS Rate,1681.67,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1325.05,14,,,percent of total billed charges,14% of total billed charges,685.4,8006.31,
15101- Skin Split Graft Addl 100Sq Cm,3431614,CDM,761,RC,15101,HCPCS,Outpatient,,,4830.83,2415.42,,3623.12,75,,,percent of total billed charges,75% of total billed charges,3623.12,75,,,percent of total billed charges,75% of total billed charges,1545.87,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,676.32,14,,,percent of total billed charges,14% of total billed charges,676.32,3623.12,
15110- Epidrm Autogrft Trnk/Arm/Leg,3431615,CDM,761,RC,15110,HCPCS,Outpatient,,,10667.98,5333.99,,8000.99,75,,,percent of total billed charges,75% of total billed charges,8000.99,75,,,percent of total billed charges,75% of total billed charges,1622.59,100,,,Fee Schedule,100% of CMS OPPS Rate,699.11,102,,,Fee Schedule,102% of WV Medicaid Rate,2677.27,165,,,Fee Schedule,165% of CMS OPPS Rate,1681.67,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4660.68,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,6391.75,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,8006.31,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,685.4,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1622.59,100,,,Fee Schedule,100% of CMS OPPS Rate,1681.67,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1493.52,14,,,percent of total billed charges,14% of total billed charges,685.4,8006.31,
15111- Epiderm autograft/specified areas/ea add 100sq cm/ea add 1% body area infant/child,3431616,CDM,761,RC,15111,HCPCS,Outpatient,,,4816.63,2408.32,,3612.47,75,,,percent of total billed charges,75% of total billed charges,3612.47,75,,,percent of total billed charges,75% of total billed charges,1541.32,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,674.33,14,,,percent of total billed charges,14% of total billed charges,674.33,3612.47,
15115- Epiderm autograft/specified areas/first 100sq cm or </1% body area/infant/child,3431617,CDM,761,RC,15115,HCPCS,Outpatient,,,10624.48,5312.24,,7968.36,75,,,percent of total billed charges,75% of total billed charges,7968.36,75,,,percent of total billed charges,75% of total billed charges,1622.59,100,,,Fee Schedule,100% of CMS OPPS Rate,699.11,102,,,Fee Schedule,102% of WV Medicaid Rate,2677.27,165,,,Fee Schedule,165% of CMS OPPS Rate,1681.67,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4660.68,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,6391.75,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,8006.31,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,685.4,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1622.59,100,,,Fee Schedule,100% of CMS OPPS Rate,1681.67,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1487.43,14,,,percent of total billed charges,14% of total billed charges,685.4,8006.31,
15120 - SPLIT AGRFT F/S/N/H/F/G/M/D GT 1ST 100 CM/,4037474,CDM,510,RC,15120,HCPCS,Outpatient,,,19509.07,9754.54,,14631.8,75,,,percent of total billed charges,75% of total billed charges,14631.8,75,,,percent of total billed charges,75% of total billed charges,3058.39,100,,,Fee Schedule,100% of CMS OPPS Rate,1437.27,102,,,Fee Schedule,102% of WV Medicaid Rate,5046.34,165,,,Fee Schedule,165% of CMS OPPS Rate,3169.76,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8784.82,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,12047.69,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,15090.95,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1409.09,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,3058.39,100,,,Fee Schedule,100% of CMS OPPS Rate,3169.76,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,2731.27,14,,,percent of total billed charges,14% of total billed charges,1409.09,15090.95,
15200- Full thick graft/trunk/</=20 sq cm,3431619,CDM,761,RC,15200,HCPCS,Outpatient,,,10562.23,5281.12,,7921.67,75,,,percent of total billed charges,75% of total billed charges,7921.67,75,,,percent of total billed charges,75% of total billed charges,1622.59,100,,,Fee Schedule,100% of CMS OPPS Rate,699.11,102,,,Fee Schedule,102% of WV Medicaid Rate,2677.27,165,,,Fee Schedule,165% of CMS OPPS Rate,1681.67,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4660.68,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,6391.75,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,8006.31,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,685.4,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1622.59,100,,,Fee Schedule,100% of CMS OPPS Rate,1681.67,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1478.71,14,,,percent of total billed charges,14% of total billed charges,685.4,8006.31,
15220- Full thick gft/scalp/arm/leg/20sqcm or<,3431620,CDM,761,RC,15220,HCPCS,Outpatient,,,10422.74,5211.37,,7817.06,75,,,percent of total billed charges,75% of total billed charges,7817.06,75,,,percent of total billed charges,75% of total billed charges,1622.59,100,,,Fee Schedule,100% of CMS OPPS Rate,699.11,102,,,Fee Schedule,102% of WV Medicaid Rate,2677.27,165,,,Fee Schedule,165% of CMS OPPS Rate,1681.67,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4660.68,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,6391.75,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,8006.31,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,685.4,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1622.59,100,,,Fee Schedule,100% of CMS OPPS Rate,1681.67,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1459.18,14,,,percent of total billed charges,14% of total billed charges,685.4,8006.31,
15221- Full thick gft/scalp/arm/leg/add 20sqcm,3431621,CDM,761,RC,15221,HCPCS,Outpatient,,,4745.4,2372.7,,3559.05,75,,,percent of total billed charges,75% of total billed charges,3559.05,75,,,percent of total billed charges,75% of total billed charges,1518.53,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,664.36,14,,,percent of total billed charges,14% of total billed charges,664.36,3559.05,
15240- Full Thick Graft w/close donor site face/neck/ax/genit/hnd/ft <=20sqcm,3431622,CDM,761,RC,15240,HCPCS,Outpatient,,,10787.04,5393.52,,8090.28,75,,,percent of total billed charges,75% of total billed charges,8090.28,75,,,percent of total billed charges,75% of total billed charges,1622.59,100,,,Fee Schedule,100% of CMS OPPS Rate,699.11,102,,,Fee Schedule,102% of WV Medicaid Rate,2677.27,165,,,Fee Schedule,165% of CMS OPPS Rate,1681.67,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4660.68,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,6391.75,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,8006.31,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,685.4,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1622.59,100,,,Fee Schedule,100% of CMS OPPS Rate,1681.67,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1510.19,14,,,percent of total billed charges,14% of total billed charges,685.4,8090.28,
15241- Skin Full Graft Add 20Sq Cm,3431623,CDM,761,RC,15241,HCPCS,Outpatient,,,4822.69,2411.35,,3617.02,75,,,percent of total billed charges,75% of total billed charges,3617.02,75,,,percent of total billed charges,75% of total billed charges,1543.26,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,675.18,14,,,percent of total billed charges,14% of total billed charges,675.18,3617.02,
15260- Full thick gft/nose/ear/lid/lip/20sqcm or<,3431624,CDM,761,RC,15260,HCPCS,Outpatient,,,10882.76,5441.38,,8162.07,75,,,percent of total billed charges,75% of total billed charges,8162.07,75,,,percent of total billed charges,75% of total billed charges,1622.59,100,,,Fee Schedule,100% of CMS OPPS Rate,699.11,102,,,Fee Schedule,102% of WV Medicaid Rate,2677.27,165,,,Fee Schedule,165% of CMS OPPS Rate,1681.67,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4660.68,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,6391.75,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,8006.31,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,685.4,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1622.59,100,,,Fee Schedule,100% of CMS OPPS Rate,1681.67,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1523.59,14,,,percent of total billed charges,14% of total billed charges,685.4,8162.07,
15261- Skin Full Graft Add 20 Sq Cm,3431625,CDM,761,RC,15261,HCPCS,Outpatient,,,4877.16,2438.58,,3657.87,75,,,percent of total billed charges,75% of total billed charges,3657.87,75,,,percent of total billed charges,75% of total billed charges,1560.69,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,682.8,14,,,percent of total billed charges,14% of total billed charges,682.8,3657.87,
15273- Skin Sub Grft Trnk Arm Lg Child,3431626,CDM,761,RC,15273,HCPCS,Outpatient,,,18518.28,9259.14,,13888.71,75,,,percent of total billed charges,75% of total billed charges,13888.71,75,,,percent of total billed charges,75% of total billed charges,3058.39,100,,,Fee Schedule,100% of CMS OPPS Rate,1437.27,102,,,Fee Schedule,102% of WV Medicaid Rate,5046.34,165,,,Fee Schedule,165% of CMS OPPS Rate,3169.76,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8784.82,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,12047.69,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,15090.95,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1409.09,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,3058.39,100,,,Fee Schedule,100% of CMS OPPS Rate,3169.76,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,2592.56,14,,,percent of total billed charges,14% of total billed charges,1409.09,15090.95,
15274 App Skn Sub Grft T/A/L Area>=100sqc Adl 100sqc,3549034,CDM,761,RC,15274,HCPCS,Outpatient,,,214.29,107.15,,160.72,75,,,percent of total billed charges,75% of total billed charges,160.72,75,,,percent of total billed charges,75% of total billed charges,68.57,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30,14,,,percent of total billed charges,14% of total billed charges,30,160.72,
"15275 Application of skin substitute graft to face, scalp, eyelids, mouth, neck, ears, orbits, genit",3621205,CDM,510,RC,15275,HCPCS,Outpatient,,,9398.39,4699.2,,7048.79,75,,,percent of total billed charges,75% of total billed charges,7048.79,75,,,percent of total billed charges,75% of total billed charges,1622.59,100,,,Fee Schedule,100% of CMS OPPS Rate,699.11,102,,,Fee Schedule,102% of WV Medicaid Rate,2677.27,165,,,Fee Schedule,165% of CMS OPPS Rate,1681.67,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4660.68,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,6391.75,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,8006.31,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,685.4,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1622.59,100,,,Fee Schedule,100% of CMS OPPS Rate,1681.67,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1315.77,14,,,percent of total billed charges,14% of total billed charges,685.4,8006.31,
15275 Sub Grft F/S/N/H/F/G/M/D <100 Sq Cm 1st 25 Sq Cm,3436032,CDM,761,RC,15275,HCPCS,Outpatient,,,405.23,202.62,,303.92,75,,,percent of total billed charges,75% of total billed charges,303.92,75,,,percent of total billed charges,75% of total billed charges,1622.59,100,,,Fee Schedule,100% of CMS OPPS Rate,699.11,102,,,Fee Schedule,102% of WV Medicaid Rate,2677.27,165,,,Fee Schedule,165% of CMS OPPS Rate,1681.67,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4660.68,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,6391.75,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,8006.31,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,685.4,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1622.59,100,,,Fee Schedule,100% of CMS OPPS Rate,1681.67,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,56.73,14,,,percent of total billed charges,14% of total billed charges,56.73,8006.31,
15275-OCC Skin sub graft face/nk/hf/g,3536971,CDM,983,RC,15275,HCPCS,Outpatient,,,9398.39,4699.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
15276 Sub Grft F/S/N/H/F/G/M/D<100 Sq Cm Ea Addl 25sqc,3436033,CDM,761,RC,15276,HCPCS,Outpatient,,,85.64,42.82,,64.23,75,,,percent of total billed charges,75% of total billed charges,64.23,75,,,percent of total billed charges,75% of total billed charges,27.4,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.99,14,,,percent of total billed charges,14% of total billed charges,11.99,64.23,
15760- Composite graft/pri close/don area,3431628,CDM,761,RC,15760,HCPCS,Outpatient,,,10602.96,5301.48,,7952.22,75,,,percent of total billed charges,75% of total billed charges,7952.22,75,,,percent of total billed charges,75% of total billed charges,1622.59,100,,,Fee Schedule,100% of CMS OPPS Rate,699.11,102,,,Fee Schedule,102% of WV Medicaid Rate,2677.27,165,,,Fee Schedule,165% of CMS OPPS Rate,1681.67,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4660.68,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,6391.75,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,8006.31,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,685.4,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1622.59,100,,,Fee Schedule,100% of CMS OPPS Rate,1681.67,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1484.41,14,,,percent of total billed charges,14% of total billed charges,685.4,8006.31,
"15788 - Chemical peel, facial; epidermal",3715288,CDM,510,RC,15788,HCPCS,Outpatient,,,2432.78,1216.39,,1824.59,75,,,percent of total billed charges,75% of total billed charges,1824.59,75,,,percent of total billed charges,75% of total billed charges,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,578.73,165,,,Fee Schedule,165% of CMS OPPS Rate,363.52,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1007.47,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1381.67,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1730.68,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,363.52,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,340.59,14,,,percent of total billed charges,14% of total billed charges,340.59,1824.59,
"15789 - Chemical peel, facial; dermal",3715293,CDM,510,RC,15789,HCPCS,Outpatient,,,3976.78,1988.39,,2982.59,75,,,percent of total billed charges,75% of total billed charges,2982.59,75,,,percent of total billed charges,75% of total billed charges,546.17,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,901.2,165,,,Fee Schedule,165% of CMS OPPS Rate,566.07,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1568.84,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2151.55,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,2695.04,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,546.17,100,,,Fee Schedule,100% of CMS OPPS Rate,566.07,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,556.75,14,,,percent of total billed charges,14% of total billed charges,546.17,2982.59,
"15792 -Chemical peel, nonfacial; epidermal",3715294,CDM,510,RC,15792,HCPCS,Outpatient,,,3577.75,1788.88,,2683.31,75,,,percent of total billed charges,75% of total billed charges,2683.31,75,,,percent of total billed charges,75% of total billed charges,546.17,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,901.21,165,,,Fee Schedule,165% of CMS OPPS Rate,566.07,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1568.85,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2151.55,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,2695.04,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,546.17,100,,,Fee Schedule,100% of CMS OPPS Rate,566.07,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,500.89,14,,,percent of total billed charges,14% of total billed charges,500.89,2695.04,
"15793 - Chemical peel, nonfacial; dermal",3715296,CDM,510,RC,15793,HCPCS,Outpatient,,,2712.65,1356.33,,2034.49,75,,,percent of total billed charges,75% of total billed charges,2034.49,75,,,percent of total billed charges,75% of total billed charges,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,578.73,165,,,Fee Schedule,165% of CMS OPPS Rate,363.52,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1007.47,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1381.67,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1730.68,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,363.52,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,379.77,14,,,percent of total billed charges,14% of total billed charges,350.74,2034.49,
"15820 - Blepharoplasty, lower eyelid;",3712914,CDM,510,RC,15820,HCPCS,Outpatient,,,10211.29,5105.65,,7658.47,75,,,percent of total billed charges,75% of total billed charges,7658.47,75,,,percent of total billed charges,75% of total billed charges,1622.59,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,2677.27,165,,,Fee Schedule,165% of CMS OPPS Rate,1681.67,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4660.68,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,6391.75,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,8006.31,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,1622.59,100,,,Fee Schedule,100% of CMS OPPS Rate,1681.67,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1429.58,14,,,percent of total billed charges,14% of total billed charges,1429.58,8006.31,
"15851 - Removal of sutures under anesthesia (other than local), other surgeon",3715463,CDM,510,RC,15851,HCPCS,Outpatient,,,9340.05,4670.03,,7005.04,75,,,percent of total billed charges,75% of total billed charges,7005.04,75,,,percent of total billed charges,75% of total billed charges,1622.59,100,,,Fee Schedule,100% of CMS OPPS Rate,61.42,102,,,Fee Schedule,102% of WV Medicaid Rate,2677.27,165,,,Fee Schedule,165% of CMS OPPS Rate,1681.67,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4660.68,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,6391.75,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,8006.31,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,60.22,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1622.59,100,,,Fee Schedule,100% of CMS OPPS Rate,1681.67,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1307.61,14,,,percent of total billed charges,14% of total billed charges,60.22,8006.31,
16020- Dress/debride pt-thick burn/<5% BS,3431631,CDM,761,RC,16020,HCPCS,Outpatient,,,1122.23,561.12,,841.67,75,,,percent of total billed charges,75% of total billed charges,841.67,75,,,percent of total billed charges,75% of total billed charges,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,280.12,165,,,Fee Schedule,165% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,487.65,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,668.78,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,837.71,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,157.11,14,,,percent of total billed charges,14% of total billed charges,157.11,841.67,
16025- Dress/debride pt-tck burn/5-10% BS,3431632,CDM,761,RC,16025,HCPCS,Outpatient,,,1236.99,618.5,,927.74,75,,,percent of total billed charges,75% of total billed charges,927.74,75,,,percent of total billed charges,75% of total billed charges,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,73.31,102,,,Fee Schedule,102% of WV Medicaid Rate,280.12,165,,,Fee Schedule,165% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,487.65,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,668.77,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,837.71,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,71.87,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,173.18,14,,,percent of total billed charges,14% of total billed charges,71.87,927.74,
17000- Destruct premalig lesion/1st les,3431633,CDM,761,RC,17000,HCPCS,Outpatient,,,1118.12,559.06,,838.59,75,,,percent of total billed charges,75% of total billed charges,838.59,75,,,percent of total billed charges,75% of total billed charges,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,280.12,165,,,Fee Schedule,165% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,487.65,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,668.78,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,837.71,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,156.54,14,,,percent of total billed charges,14% of total billed charges,156.54,838.59,
17003- DERM DESTRUCT PREMALG LES 2-14,3514645,CDM,761,RC,17003,HCPCS,Outpatient,,,509.45,254.73,,382.09,75,,,percent of total billed charges,75% of total billed charges,382.09,75,,,percent of total billed charges,75% of total billed charges,163.02,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,71.32,14,,,percent of total billed charges,14% of total billed charges,71.32,382.09,
17004- Destroy premal lesions 15/>,3428770,CDM,510,RC,17004,HCPCS,Outpatient,,,2208.13,1104.07,,1656.1,75,,,percent of total billed charges,75% of total billed charges,1656.1,75,,,percent of total billed charges,75% of total billed charges,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,95.82,102,,,Fee Schedule,102% of WV Medicaid Rate,578.72,165,,,Fee Schedule,165% of CMS OPPS Rate,363.51,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1007.47,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1381.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1730.67,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,93.94,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,363.51,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,309.14,14,,,percent of total billed charges,14% of total billed charges,93.94,1730.67,
17110- Destruct benign lesion 1-14,3431075,CDM,761,RC,17110,HCPCS,Outpatient,,,1143.84,571.92,,857.88,75,,,percent of total billed charges,75% of total billed charges,857.88,75,,,percent of total billed charges,75% of total billed charges,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,280.12,165,,,Fee Schedule,165% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,487.65,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,668.78,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,837.71,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,160.14,14,,,percent of total billed charges,14% of total billed charges,160.14,857.88,
17111- Destruct lesion 15 or more,3431076,CDM,761,RC,17111,HCPCS,Outpatient,,,1173.73,586.87,,880.3,75,,,percent of total billed charges,75% of total billed charges,880.3,75,,,percent of total billed charges,75% of total billed charges,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,280.12,165,,,Fee Schedule,165% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,487.65,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,668.78,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,837.71,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,164.32,14,,,percent of total billed charges,14% of total billed charges,164.32,880.3,
17250 Chemical Cauterization if Granulation Tissue,3436034,CDM,761,RC,17250,HCPCS,Outpatient,,,220.96,110.48,,165.72,75,,,percent of total billed charges,75% of total billed charges,165.72,75,,,percent of total billed charges,75% of total billed charges,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,280.12,165,,,Fee Schedule,165% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,487.65,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,668.78,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,837.71,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,30.93,14,,,percent of total billed charges,14% of total billed charges,30.93,837.71,
17250- Chemical cautery of granulated tissue,3431077,CDM,761,RC,17250,HCPCS,Outpatient,,,1086,543,,814.5,75,,,percent of total billed charges,75% of total billed charges,814.5,75,,,percent of total billed charges,75% of total billed charges,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,280.12,165,,,Fee Schedule,165% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,487.65,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,668.78,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,837.71,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,152.04,14,,,percent of total billed charges,14% of total billed charges,152.04,837.71,
17260- Destruction of skin lesions,3431078,CDM,761,RC,17260,HCPCS,Outpatient,,,1150.3,575.15,,862.73,75,,,percent of total billed charges,75% of total billed charges,862.73,75,,,percent of total billed charges,75% of total billed charges,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,280.12,165,,,Fee Schedule,165% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,487.65,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,668.78,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,837.71,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,161.04,14,,,percent of total billed charges,14% of total billed charges,161.04,862.73,
17261- Destruction of skin lesions,3431079,CDM,761,RC,17261,HCPCS,Outpatient,,,1183.69,591.85,,887.77,75,,,percent of total billed charges,75% of total billed charges,887.77,75,,,percent of total billed charges,75% of total billed charges,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,280.12,165,,,Fee Schedule,165% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,487.65,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,668.78,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,837.71,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,165.72,14,,,percent of total billed charges,14% of total billed charges,165.72,887.77,
17262- Destruction of skin lesions,3431080,CDM,761,RC,17262,HCPCS,Outpatient,,,1230.2,615.1,,922.65,75,,,percent of total billed charges,75% of total billed charges,922.65,75,,,percent of total billed charges,75% of total billed charges,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,280.12,165,,,Fee Schedule,165% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,487.65,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,668.78,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,837.71,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,172.23,14,,,percent of total billed charges,14% of total billed charges,169.77,922.65,
17263- Destruction of skin lesions,3431081,CDM,761,RC,17263,HCPCS,Outpatient,,,1253.82,626.91,,940.37,75,,,percent of total billed charges,75% of total billed charges,940.37,75,,,percent of total billed charges,75% of total billed charges,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,280.12,165,,,Fee Schedule,165% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,487.65,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,668.78,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,837.71,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,175.53,14,,,percent of total billed charges,14% of total billed charges,169.77,940.37,
17264- Destruction of skin lesions,3431082,CDM,761,RC,17264,HCPCS,Outpatient,,,2273.47,1136.74,,1705.1,75,,,percent of total billed charges,75% of total billed charges,1705.1,75,,,percent of total billed charges,75% of total billed charges,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,107.56,102,,,Fee Schedule,102% of WV Medicaid Rate,578.72,165,,,Fee Schedule,165% of CMS OPPS Rate,363.51,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1007.47,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1381.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1730.67,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,105.45,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,363.51,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,318.29,14,,,percent of total billed charges,14% of total billed charges,105.45,1730.67,
17266- Destruction of skin lesions,3431083,CDM,761,RC,17266,HCPCS,Outpatient,,,2318.71,1159.36,,1739.03,75,,,percent of total billed charges,75% of total billed charges,1739.03,75,,,percent of total billed charges,75% of total billed charges,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,118.47,102,,,Fee Schedule,102% of WV Medicaid Rate,578.72,165,,,Fee Schedule,165% of CMS OPPS Rate,363.51,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1007.47,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1381.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1730.67,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,116.15,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,363.51,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,324.62,14,,,percent of total billed charges,14% of total billed charges,116.15,1739.03,
17270- Destruction of skin lesions,3431084,CDM,761,RC,17270,HCPCS,Outpatient,,,1200.74,600.37,,900.56,75,,,percent of total billed charges,75% of total billed charges,900.56,75,,,percent of total billed charges,75% of total billed charges,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,73.31,102,,,Fee Schedule,102% of WV Medicaid Rate,280.12,165,,,Fee Schedule,165% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,487.65,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,668.77,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,837.71,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,71.87,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,168.1,14,,,percent of total billed charges,14% of total billed charges,71.87,900.56,
17271- Destruction of skin lesions,3431085,CDM,761,RC,17271,HCPCS,Outpatient,,,1219.46,609.73,,914.6,75,,,percent of total billed charges,75% of total billed charges,914.6,75,,,percent of total billed charges,75% of total billed charges,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,73.31,102,,,Fee Schedule,102% of WV Medicaid Rate,280.12,165,,,Fee Schedule,165% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,487.65,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,668.77,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,837.71,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,71.87,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,170.72,14,,,percent of total billed charges,14% of total billed charges,71.87,914.6,
17272- Destruction of skin lesions,3431086,CDM,761,RC,17272,HCPCS,Outpatient,,,1251.83,625.92,,938.87,75,,,percent of total billed charges,75% of total billed charges,938.87,75,,,percent of total billed charges,75% of total billed charges,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,280.12,165,,,Fee Schedule,165% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,487.65,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,668.78,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,837.71,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,175.26,14,,,percent of total billed charges,14% of total billed charges,169.77,938.87,
17273- Destruction of skin lesions,3431087,CDM,761,RC,17273,HCPCS,Outpatient,,,2286.23,1143.12,,1714.67,75,,,percent of total billed charges,75% of total billed charges,1714.67,75,,,percent of total billed charges,75% of total billed charges,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,105.92,102,,,Fee Schedule,102% of WV Medicaid Rate,578.72,165,,,Fee Schedule,165% of CMS OPPS Rate,363.51,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1007.47,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1381.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1730.67,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,103.84,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,363.51,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,320.07,14,,,percent of total billed charges,14% of total billed charges,103.84,1730.67,
17274- Destruction of skin lesions,3431088,CDM,761,RC,17274,HCPCS,Outpatient,,,2346.88,1173.44,,1760.16,75,,,percent of total billed charges,75% of total billed charges,1760.16,75,,,percent of total billed charges,75% of total billed charges,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,118.47,102,,,Fee Schedule,102% of WV Medicaid Rate,578.72,165,,,Fee Schedule,165% of CMS OPPS Rate,363.51,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1007.47,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1381.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1730.67,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,116.15,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,363.51,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,328.56,14,,,percent of total billed charges,14% of total billed charges,116.15,1760.16,
17276- Destruction of skin lesions,3431089,CDM,761,RC,17276,HCPCS,Outpatient,,,2416.97,1208.49,,1812.73,75,,,percent of total billed charges,75% of total billed charges,1812.73,75,,,percent of total billed charges,75% of total billed charges,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,131.86,102,,,Fee Schedule,102% of WV Medicaid Rate,578.72,165,,,Fee Schedule,165% of CMS OPPS Rate,363.51,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1007.47,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1381.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1730.67,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,129.27,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,363.51,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,338.38,14,,,percent of total billed charges,14% of total billed charges,129.27,1812.73,
17280- Destruction of skin lesions,3431090,CDM,761,RC,17280,HCPCS,Outpatient,,,1183.1,591.55,,887.33,75,,,percent of total billed charges,75% of total billed charges,887.33,75,,,percent of total billed charges,75% of total billed charges,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,280.12,165,,,Fee Schedule,165% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,487.65,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,668.78,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,837.71,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,165.63,14,,,percent of total billed charges,14% of total billed charges,165.63,887.33,
17281- Destruction of skin lesions,3431091,CDM,761,RC,17281,HCPCS,Outpatient,,,2248.58,1124.29,,1686.44,75,,,percent of total billed charges,75% of total billed charges,1686.44,75,,,percent of total billed charges,75% of total billed charges,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,92.27,102,,,Fee Schedule,102% of WV Medicaid Rate,578.72,165,,,Fee Schedule,165% of CMS OPPS Rate,363.51,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1007.47,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1381.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1730.67,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,90.46,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,363.51,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,314.8,14,,,percent of total billed charges,14% of total billed charges,90.46,1730.67,
17282- Destruction of skin lesions,3431092,CDM,761,RC,17282,HCPCS,Outpatient,,,2284.94,1142.47,,1713.71,75,,,percent of total billed charges,75% of total billed charges,1713.71,75,,,percent of total billed charges,75% of total billed charges,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,103.47,102,,,Fee Schedule,102% of WV Medicaid Rate,578.72,165,,,Fee Schedule,165% of CMS OPPS Rate,363.51,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1007.47,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1381.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1730.67,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,101.44,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,363.51,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,319.89,14,,,percent of total billed charges,14% of total billed charges,101.44,1730.67,
"17283- Destruct Skin Lesions,2.1-3.0 cm",3431634,CDM,761,RC,17283,HCPCS,Outpatient,,,2354.01,1177.01,,1765.51,75,,,percent of total billed charges,75% of total billed charges,1765.51,75,,,percent of total billed charges,75% of total billed charges,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,115.46,102,,,Fee Schedule,102% of WV Medicaid Rate,578.72,165,,,Fee Schedule,165% of CMS OPPS Rate,363.51,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1007.47,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1381.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1730.67,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,113.2,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,363.51,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,329.56,14,,,percent of total billed charges,14% of total billed charges,113.2,1765.51,
17284- Destruction of skin lesions,3431093,CDM,761,RC,17284,HCPCS,Outpatient,,,3568.13,1784.07,,2676.1,75,,,percent of total billed charges,75% of total billed charges,2676.1,75,,,percent of total billed charges,75% of total billed charges,546.17,100,,,Fee Schedule,100% of CMS OPPS Rate,126.94,102,,,Fee Schedule,102% of WV Medicaid Rate,901.2,165,,,Fee Schedule,165% of CMS OPPS Rate,566.07,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1568.84,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2151.55,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,2695.04,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,124.45,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,546.17,100,,,Fee Schedule,100% of CMS OPPS Rate,566.07,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,499.54,14,,,percent of total billed charges,14% of total billed charges,124.45,2695.04,
17286- Destruction of skin lesions,3431094,CDM,761,RC,17286,HCPCS,Outpatient,,,3711.51,1855.76,,2783.63,75,,,percent of total billed charges,75% of total billed charges,2783.63,75,,,percent of total billed charges,75% of total billed charges,546.17,100,,,Fee Schedule,100% of CMS OPPS Rate,151.24,102,,,Fee Schedule,102% of WV Medicaid Rate,901.2,165,,,Fee Schedule,165% of CMS OPPS Rate,566.07,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1568.84,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2151.55,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,2695.04,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,148.27,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,546.17,100,,,Fee Schedule,100% of CMS OPPS Rate,566.07,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,519.61,14,,,percent of total billed charges,14% of total billed charges,148.27,2783.63,
"17999 Unlisted procedure, skin, mucous membrane and subcutan",3623321,CDM,510,RC,17999,HCPCS,Outpatient,,,1350.98,675.49,,1013.24,75,,,percent of total billed charges,75% of total billed charges,1013.24,75,,,percent of total billed charges,75% of total billed charges,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,280.12,165,,,Fee Schedule,165% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,487.65,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,668.78,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,837.71,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,189.14,14,,,percent of total billed charges,14% of total billed charges,169.77,1013.24,
MA Stereotactic Lt Breast Biopsy:Read,603846,CDM,972,RC,19081,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
Aspiration/Inj/Arthrcntsis,3428392,CDM,981,RC,20600,HCPCS,Outpatient,,,135.42,67.71,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
20604- Arthrocen/asp/inj/sm jt/bursa/w US,3434657,CDM,510,RC,20604,HCPCS,Outpatient,,,206.64,103.32,,154.98,75,,,percent of total billed charges,75% of total billed charges,154.98,75,,,percent of total billed charges,75% of total billed charges,255.61,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,421.75,165,,,Fee Schedule,165% of CMS OPPS Rate,264.92,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,734.23,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1006.94,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1261.29,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,255.61,100,,,Fee Schedule,100% of CMS OPPS Rate,264.92,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,28.93,14,,,percent of total billed charges,14% of total billed charges,28.93,1261.29,
20606- Arthrocen/asp/inj/int jt/burs/w US,3434659,CDM,510,RC,20606,HCPCS,Outpatient,,,224.97,112.49,,168.73,75,,,percent of total billed charges,75% of total billed charges,168.73,75,,,percent of total billed charges,75% of total billed charges,605.77,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,999.54,165,,,Fee Schedule,165% of CMS OPPS Rate,627.84,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1740.03,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2386.32,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,2989.1,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,605.77,100,,,Fee Schedule,100% of CMS OPPS Rate,627.84,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,31.5,14,,,percent of total billed charges,14% of total billed charges,31.5,2989.1,
"Joint Aspiration, Injection",3428473,CDM,981,RC,20610,HCPCS,Outpatient,,,165.68,82.84,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
20660- App/rmv cranial tong/cali/ST frame,3434662,CDM,510,RC,20660,HCPCS,Outpatient,,,652.65,326.33,,489.49,75,,,percent of total billed charges,75% of total billed charges,489.49,75,,,percent of total billed charges,75% of total billed charges,1348.68,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,2225.33,165,,,Fee Schedule,165% of CMS OPPS Rate,1397.79,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,3873.92,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5312.77,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6654.78,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,1348.68,100,,,Fee Schedule,100% of CMS OPPS Rate,1397.79,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,91.37,14,,,percent of total billed charges,14% of total billed charges,91.37,6654.78,
20665- Rmv tongs/halo/app by other indiv,3434663,CDM,510,RC,20665,HCPCS,Outpatient,,,290.96,145.48,,218.22,75,,,percent of total billed charges,75% of total billed charges,218.22,75,,,percent of total billed charges,75% of total billed charges,354.97,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,585.71,165,,,Fee Schedule,165% of CMS OPPS Rate,367.9,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1019.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1398.33,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1751.55,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,354.97,100,,,Fee Schedule,100% of CMS OPPS Rate,367.9,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,40.73,14,,,percent of total billed charges,14% of total billed charges,40.73,1751.55,
20690- App uniplane/unilat/ext fixation,3434666,CDM,510,RC,20690,HCPCS,Outpatient,,,1563.98,781.99,,1172.99,75,,,percent of total billed charges,75% of total billed charges,1172.99,75,,,percent of total billed charges,75% of total billed charges,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,3374.44,102,,,Fee Schedule,102% of WV Medicaid Rate,10261.1,165,,,Fee Schedule,165% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,17862.79,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,24497.4,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,30685.48,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,3308.27,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,218.96,14,,,percent of total billed charges,14% of total billed charges,218.96,30685.48,
20692- App multiplane/unilat/ext fixation,3434667,CDM,510,RC,20692,HCPCS,Outpatient,,,2917.8,1458.9,,2188.35,75,,,percent of total billed charges,75% of total billed charges,2188.35,75,,,percent of total billed charges,75% of total billed charges,12267.36,100,,,Fee Schedule,100% of CMS OPPS Rate,7344.6,102,,,Fee Schedule,102% of WV Medicaid Rate,20241.15,165,,,Fee Schedule,165% of CMS OPPS Rate,12714.07,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,35236.32,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,48323.81,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,60530.47,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,7200.59,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,12267.36,100,,,Fee Schedule,100% of CMS OPPS Rate,12714.07,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,408.49,14,,,percent of total billed charges,14% of total billed charges,408.49,60530.47,
20694- Rmv ext fixation system/anesthesia,3434668,CDM,510,RC,20694,HCPCS,Outpatient,,,1089.92,544.96,,817.44,75,,,percent of total billed charges,75% of total billed charges,817.44,75,,,percent of total billed charges,75% of total billed charges,1348.68,100,,,Fee Schedule,100% of CMS OPPS Rate,584.77,102,,,Fee Schedule,102% of WV Medicaid Rate,2225.33,165,,,Fee Schedule,165% of CMS OPPS Rate,1397.79,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,3873.92,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5312.77,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6654.78,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,573.3,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1348.68,100,,,Fee Schedule,100% of CMS OPPS Rate,1397.79,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,152.59,14,,,percent of total billed charges,14% of total billed charges,152.59,6654.78,
20822- Replant/digit/not thumb/comp amp,3434669,CDM,510,RC,20822,HCPCS,Outpatient,,,4660.43,2330.22,,3495.32,75,,,percent of total billed charges,75% of total billed charges,3495.32,75,,,percent of total billed charges,75% of total billed charges,1348.67,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,2225.32,165,,,Fee Schedule,165% of CMS OPPS Rate,1397.79,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,3873.91,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5312.76,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6654.78,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,1348.67,100,,,Fee Schedule,100% of CMS OPPS Rate,1397.79,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,652.46,14,,,percent of total billed charges,14% of total billed charges,652.46,6654.78,
20900- Bone graft/any donor area/minor/sm,3434670,CDM,510,RC,20900,HCPCS,Outpatient,,,986.43,493.22,,739.82,75,,,percent of total billed charges,75% of total billed charges,739.82,75,,,percent of total billed charges,75% of total billed charges,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,3078.97,102,,,Fee Schedule,102% of WV Medicaid Rate,10261.1,165,,,Fee Schedule,165% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,17862.79,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,24497.4,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,30685.48,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,3018.6,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,138.1,14,,,percent of total billed charges,14% of total billed charges,138.1,30685.48,
20902- Bone graft/any donor area/large,3434671,CDM,510,RC,20902,HCPCS,Outpatient,,,732.2,366.1,,549.15,75,,,percent of total billed charges,75% of total billed charges,549.15,75,,,percent of total billed charges,75% of total billed charges,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,2365.05,102,,,Fee Schedule,102% of WV Medicaid Rate,10261.1,165,,,Fee Schedule,165% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,17862.79,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,24497.4,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,30685.48,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,2318.68,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,102.51,14,,,percent of total billed charges,14% of total billed charges,102.51,30685.48,
20912- Cartilage graft/nasal septum,3434672,CDM,510,RC,20912,HCPCS,Outpatient,,,1242.44,621.22,,931.83,75,,,percent of total billed charges,75% of total billed charges,931.83,75,,,percent of total billed charges,75% of total billed charges,3058.39,100,,,Fee Schedule,100% of CMS OPPS Rate,1437.27,102,,,Fee Schedule,102% of WV Medicaid Rate,5046.34,165,,,Fee Schedule,165% of CMS OPPS Rate,3169.76,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8784.82,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,12047.69,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,15090.95,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1409.09,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,3058.39,100,,,Fee Schedule,100% of CMS OPPS Rate,3169.76,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,173.94,14,,,percent of total billed charges,14% of total billed charges,173.94,15090.95,
20930 - PF Allograft for Spine Surgery Only Morselized,4363311,CDM,960,RC,20930,HCPCS,Outpatient,,,300,150,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
20931- Allograft/structural/spine surg,3434675,CDM,510,RC,20931,HCPCS,Outpatient,,,298.59,149.3,,223.94,75,,,percent of total billed charges,75% of total billed charges,223.94,75,,,percent of total billed charges,75% of total billed charges,95.55,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.8,14,,,percent of total billed charges,14% of total billed charges,41.8,223.94,
20936-  PF Autograft Spine Surgery Local From Same Incision PF,4363312,CDM,960,RC,20936,HCPCS,Outpatient,,,325,162.5,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
20937- Autograft/spine surg/morselized,3434677,CDM,510,RC,20937,HCPCS,Outpatient,,,448.42,224.21,,336.32,75,,,percent of total billed charges,75% of total billed charges,336.32,75,,,percent of total billed charges,75% of total billed charges,143.49,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62.78,14,,,percent of total billed charges,14% of total billed charges,62.78,336.32,
20938- Autograft/spine surg/struct/bi/tricortical,3434678,CDM,510,RC,20938,HCPCS,Outpatient,,,497.32,248.66,,372.99,75,,,percent of total billed charges,75% of total billed charges,372.99,75,,,percent of total billed charges,75% of total billed charges,159.14,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,69.62,14,,,percent of total billed charges,14% of total billed charges,69.62,372.99,
20950- Muscle compart syn monitor/device,3434679,CDM,510,RC,20950,HCPCS,Outpatient,,,658.03,329.02,,493.52,75,,,percent of total billed charges,75% of total billed charges,493.52,75,,,percent of total billed charges,75% of total billed charges,610.13,100,,,Fee Schedule,100% of CMS OPPS Rate,254,102,,,Fee Schedule,102% of WV Medicaid Rate,1006.72,165,,,Fee Schedule,165% of CMS OPPS Rate,632.35,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1752.53,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2403.46,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,3010.58,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,249.02,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,610.13,100,,,Fee Schedule,100% of CMS OPPS Rate,632.35,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,92.12,14,,,percent of total billed charges,14% of total billed charges,92.12,3010.58,
20985- Computer assist/surg nav/musc/skel,3434680,CDM,510,RC,20985,HCPCS,Outpatient,,,386.59,193.3,,289.94,75,,,percent of total billed charges,75% of total billed charges,289.94,75,,,percent of total billed charges,75% of total billed charges,123.71,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,54.12,14,,,percent of total billed charges,14% of total billed charges,54.12,289.94,
21011- Ex SQ tumor/face or scalp < 2 cm,3434682,CDM,510,RC,21011,HCPCS,Outpatient,,,8705.82,4352.91,,6529.37,75,,,percent of total billed charges,75% of total billed charges,6529.37,75,,,percent of total billed charges,75% of total billed charges,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,208.83,102,,,Fee Schedule,102% of WV Medicaid Rate,2326.19,165,,,Fee Schedule,165% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4049.52,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5553.61,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6956.46,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,204.74,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1218.81,14,,,percent of total billed charges,14% of total billed charges,204.74,6956.46,
21012- Ex SQ tumor/face or scalp 2 cm/>,3434683,CDM,510,RC,21012,HCPCS,Outpatient,,,8875.29,4437.65,,6656.47,75,,,percent of total billed charges,75% of total billed charges,6656.47,75,,,percent of total billed charges,75% of total billed charges,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,479.67,102,,,Fee Schedule,102% of WV Medicaid Rate,2326.19,165,,,Fee Schedule,165% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4049.52,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5553.61,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6956.46,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,470.26,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1242.54,14,,,percent of total billed charges,14% of total billed charges,470.26,6956.46,
21013- Exc IM tumor/face & scalp < 2 cm,3434684,CDM,510,RC,21013,HCPCS,Outpatient,,,8998.72,4499.36,,6749.04,75,,,percent of total billed charges,75% of total billed charges,6749.04,75,,,percent of total billed charges,75% of total billed charges,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,263.15,102,,,Fee Schedule,102% of WV Medicaid Rate,2326.19,165,,,Fee Schedule,165% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4049.52,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5553.61,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6956.46,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,257.99,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1259.82,14,,,percent of total billed charges,14% of total billed charges,257.99,6956.46,
21026- Exc of facial bones/osteomy/abscess,3434687,CDM,510,RC,21026,HCPCS,Outpatient,,,1342.74,671.37,,1007.06,75,,,percent of total billed charges,75% of total billed charges,1007.06,75,,,percent of total billed charges,75% of total billed charges,5020.17,100,,,Fee Schedule,100% of CMS OPPS Rate,1926.95,102,,,Fee Schedule,102% of WV Medicaid Rate,8283.28,165,,,Fee Schedule,165% of CMS OPPS Rate,5202.97,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,14419.76,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,19775.56,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,24770.9,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1889.17,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,5020.17,100,,,Fee Schedule,100% of CMS OPPS Rate,5202.97,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,187.98,14,,,percent of total billed charges,14% of total billed charges,187.98,24770.9,
21029- Benign tumor/fac bone/rmv/contour,3434688,CDM,510,RC,21029,HCPCS,Outpatient,,,1936.31,968.16,,1452.23,75,,,percent of total billed charges,75% of total billed charges,1452.23,75,,,percent of total billed charges,75% of total billed charges,2674.8,100,,,Fee Schedule,100% of CMS OPPS Rate,874.26,102,,,Fee Schedule,102% of WV Medicaid Rate,4413.39,165,,,Fee Schedule,165% of CMS OPPS Rate,2772.2,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,7682.99,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,10536.61,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13198.18,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,857.12,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2674.8,100,,,Fee Schedule,100% of CMS OPPS Rate,2772.2,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,271.08,14,,,percent of total billed charges,14% of total billed charges,271.08,13198.18,
21030- Exc bgn tum/maxilla/zygo/enuc/cure,3434689,CDM,510,RC,21030,HCPCS,Outpatient,,,1161.27,580.64,,870.95,75,,,percent of total billed charges,75% of total billed charges,870.95,75,,,percent of total billed charges,75% of total billed charges,5020.17,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,8283.28,165,,,Fee Schedule,165% of CMS OPPS Rate,5202.97,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,14419.76,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,19775.56,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,24770.9,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,5020.17,100,,,Fee Schedule,100% of CMS OPPS Rate,5202.97,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,162.58,14,,,percent of total billed charges,14% of total billed charges,162.58,24770.9,
21040- Exc bgn tum/cyst/mandib/enuc/curet,3434690,CDM,510,RC,21040,HCPCS,Outpatient,,,1177.08,588.54,,882.81,75,,,percent of total billed charges,75% of total billed charges,882.81,75,,,percent of total billed charges,75% of total billed charges,2674.8,100,,,Fee Schedule,100% of CMS OPPS Rate,874.26,102,,,Fee Schedule,102% of WV Medicaid Rate,4413.39,165,,,Fee Schedule,165% of CMS OPPS Rate,2772.2,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,7682.99,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,10536.61,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13198.18,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,857.12,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2674.8,100,,,Fee Schedule,100% of CMS OPPS Rate,2772.2,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,164.79,14,,,percent of total billed charges,14% of total billed charges,164.79,13198.18,
21085- Impress/cust prep/oral surg splint,3434691,CDM,510,RC,21085,HCPCS,Outpatient,,,1709.86,854.93,,1282.4,75,,,percent of total billed charges,75% of total billed charges,1282.4,75,,,percent of total billed charges,75% of total billed charges,195.39,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,322.39,165,,,Fee Schedule,165% of CMS OPPS Rate,202.5,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,561.23,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,769.7,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,964.12,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,195.39,100,,,Fee Schedule,100% of CMS OPPS Rate,202.5,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,239.38,14,,,percent of total billed charges,14% of total billed charges,195.39,1282.4,
21199- Osteotomy/mandible/genioglossus ad,3434692,CDM,510,RC,21199,HCPCS,Outpatient,,,2635.48,1317.74,,1976.61,75,,,percent of total billed charges,75% of total billed charges,1976.61,75,,,percent of total billed charges,75% of total billed charges,5020.17,100,,,Fee Schedule,100% of CMS OPPS Rate,2516.89,102,,,Fee Schedule,102% of WV Medicaid Rate,8283.28,165,,,Fee Schedule,165% of CMS OPPS Rate,5202.97,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,14419.76,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,19775.56,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,24770.9,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,2467.54,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,5020.17,100,,,Fee Schedule,100% of CMS OPPS Rate,5202.97,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,368.97,14,,,percent of total billed charges,14% of total billed charges,368.97,24770.9,
21315- Clsd tx/nasal bone fx w/o stable,3434695,CDM,510,RC,21315,HCPCS,Outpatient,,,373.06,186.53,,279.8,75,,,percent of total billed charges,75% of total billed charges,279.8,75,,,percent of total billed charges,75% of total billed charges,1305.07,100,,,Fee Schedule,100% of CMS OPPS Rate,414.77,102,,,Fee Schedule,102% of WV Medicaid Rate,2153.38,165,,,Fee Schedule,165% of CMS OPPS Rate,1352.6,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,3748.66,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5141,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6439.62,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,406.64,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1305.07,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,52.23,14,,,percent of total billed charges,14% of total billed charges,52.23,6439.62,
21320- Clsd tx/nasal bone fx/stabilize,3434696,CDM,510,RC,21320,HCPCS,Outpatient,,,545.49,272.75,,409.12,75,,,percent of total billed charges,75% of total billed charges,409.12,75,,,percent of total billed charges,75% of total billed charges,2674.8,100,,,Fee Schedule,100% of CMS OPPS Rate,874.26,102,,,Fee Schedule,102% of WV Medicaid Rate,4413.39,165,,,Fee Schedule,165% of CMS OPPS Rate,2772.2,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,7682.99,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,10536.61,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13198.18,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,857.12,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2674.8,100,,,Fee Schedule,100% of CMS OPPS Rate,2772.2,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,76.37,14,,,percent of total billed charges,14% of total billed charges,76.37,13198.18,
21325- Open tx/nasal fx/uncomplicated,3434697,CDM,510,RC,21325,HCPCS,Outpatient,,,1123.59,561.8,,842.69,75,,,percent of total billed charges,75% of total billed charges,842.69,75,,,percent of total billed charges,75% of total billed charges,2674.8,100,,,Fee Schedule,100% of CMS OPPS Rate,874.26,102,,,Fee Schedule,102% of WV Medicaid Rate,4413.39,165,,,Fee Schedule,165% of CMS OPPS Rate,2772.2,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,7682.99,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,10536.61,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13198.18,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,857.12,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2674.8,100,,,Fee Schedule,100% of CMS OPPS Rate,2772.2,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,157.3,14,,,percent of total billed charges,14% of total billed charges,157.3,13198.18,
21335- Open tx/nasal & septum fx uncomp,3434698,CDM,510,RC,21335,HCPCS,Outpatient,,,1839.64,919.82,,1379.73,75,,,percent of total billed charges,75% of total billed charges,1379.73,75,,,percent of total billed charges,75% of total billed charges,2674.8,100,,,Fee Schedule,100% of CMS OPPS Rate,874.26,102,,,Fee Schedule,102% of WV Medicaid Rate,4413.39,165,,,Fee Schedule,165% of CMS OPPS Rate,2772.2,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,7682.99,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,10536.61,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13198.18,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,857.12,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2674.8,100,,,Fee Schedule,100% of CMS OPPS Rate,2772.2,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,257.55,14,,,percent of total billed charges,14% of total billed charges,257.55,13198.18,
21344- Open tx/complicat frontal sinus fx,3434699,CDM,510,RC,21344,HCPCS,Outpatient,,,3648.68,1824.34,,2736.51,75,,,percent of total billed charges,75% of total billed charges,2736.51,75,,,percent of total billed charges,75% of total billed charges,3648.68,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,3648.68,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3648.68,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3648.68,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3648.68,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3648.68,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,3648.68,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3648.68,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,510.82,14,,,percent of total billed charges,14% of total billed charges,510.82,3648.68,
21360- Open tx/depressed malar fx,3434700,CDM,510,RC,21360,HCPCS,Outpatient,,,1347.08,673.54,,1010.31,75,,,percent of total billed charges,75% of total billed charges,1010.31,75,,,percent of total billed charges,75% of total billed charges,5020.17,100,,,Fee Schedule,100% of CMS OPPS Rate,1926.95,102,,,Fee Schedule,102% of WV Medicaid Rate,8283.28,165,,,Fee Schedule,165% of CMS OPPS Rate,5202.97,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,14419.76,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,19775.56,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,24770.9,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1889.17,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,5020.17,100,,,Fee Schedule,100% of CMS OPPS Rate,5202.97,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,188.59,14,,,percent of total billed charges,14% of total billed charges,188.59,24770.9,
21390- Orb flr blowout fx/periorb app/imp,3434701,CDM,510,RC,21390,HCPCS,Outpatient,,,2064.43,1032.22,,1548.32,75,,,percent of total billed charges,75% of total billed charges,1548.32,75,,,percent of total billed charges,75% of total billed charges,5020.17,100,,,Fee Schedule,100% of CMS OPPS Rate,1926.95,102,,,Fee Schedule,102% of WV Medicaid Rate,8283.28,165,,,Fee Schedule,165% of CMS OPPS Rate,5202.97,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,14419.76,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,19775.56,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,24770.9,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1889.17,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,5020.17,100,,,Fee Schedule,100% of CMS OPPS Rate,5202.97,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,289.02,14,,,percent of total billed charges,14% of total billed charges,289.02,24770.9,
21550- Biopsy/soft tissue/neck or thorax,3434704,CDM,360,RC,21550,HCPCS,Outpatient,,,669.91,334.96,,502.43,75,,,percent of total billed charges,75% of total billed charges,502.43,75,,,percent of total billed charges,75% of total billed charges,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,479.67,102,,,Fee Schedule,102% of WV Medicaid Rate,2326.19,165,,,Fee Schedule,165% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4049.52,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5553.61,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6956.46,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,470.26,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,93.79,14,,,percent of total billed charges,14% of total billed charges,93.79,6956.46,
21552- Exc SQ tum/neck/ant thorax 3cm/>,3434705,CDM,510,RC,21552,HCPCS,Outpatient,,,13385.48,6692.74,,10039.11,75,,,percent of total billed charges,75% of total billed charges,10039.11,75,,,percent of total billed charges,75% of total billed charges,2428.67,100,,,Fee Schedule,100% of CMS OPPS Rate,803.83,102,,,Fee Schedule,102% of WV Medicaid Rate,4007.32,165,,,Fee Schedule,165% of CMS OPPS Rate,2517.11,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,6976.06,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,9567.11,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,11983.78,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,788.07,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2428.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2517.11,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1873.97,14,,,percent of total billed charges,14% of total billed charges,788.07,11983.78,
21557- Rad resect tumor/neck/ant thor/<5c,3434709,CDM,510,RC,21557,HCPCS,Outpatient,,,2524.52,1262.26,,1893.39,75,,,percent of total billed charges,75% of total billed charges,1893.39,75,,,percent of total billed charges,75% of total billed charges,2428.67,100,,,Fee Schedule,100% of CMS OPPS Rate,803.83,102,,,Fee Schedule,102% of WV Medicaid Rate,4007.32,165,,,Fee Schedule,165% of CMS OPPS Rate,2517.11,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,6976.06,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,9567.11,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,11983.78,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,788.07,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2428.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2517.11,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,353.43,14,,,percent of total billed charges,14% of total billed charges,353.43,11983.78,
21558- Rad resect tumor/neck/ant thor/5cm,3434710,CDM,510,RC,21558,HCPCS,Outpatient,,,3572.38,1786.19,,2679.29,75,,,percent of total billed charges,75% of total billed charges,2679.29,75,,,percent of total billed charges,75% of total billed charges,2428.67,100,,,Fee Schedule,100% of CMS OPPS Rate,803.83,102,,,Fee Schedule,102% of WV Medicaid Rate,4007.32,165,,,Fee Schedule,165% of CMS OPPS Rate,2517.11,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,6976.06,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,9567.11,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,11983.78,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,788.07,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2428.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2517.11,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,500.13,14,,,percent of total billed charges,14% of total billed charges,500.13,11983.78,
21600- Excision of rib/ partial,3434711,CDM,510,RC,21600,HCPCS,Outpatient,,,1461.38,730.69,,1096.04,75,,,percent of total billed charges,75% of total billed charges,1096.04,75,,,percent of total billed charges,75% of total billed charges,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,2365.05,102,,,Fee Schedule,102% of WV Medicaid Rate,10261.1,165,,,Fee Schedule,165% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,17862.79,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,24497.4,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,30685.48,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,2318.68,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,204.59,14,,,percent of total billed charges,14% of total billed charges,204.59,30685.48,
21610- Costotransversectomy,3434712,CDM,510,RC,21610,HCPCS,Outpatient,,,3229.07,1614.54,,2421.8,75,,,percent of total billed charges,75% of total billed charges,2421.8,75,,,percent of total billed charges,75% of total billed charges,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,1073.09,102,,,Fee Schedule,102% of WV Medicaid Rate,4617.6,165,,,Fee Schedule,165% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8038.46,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11024.11,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13808.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1052.05,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,452.07,14,,,percent of total billed charges,14% of total billed charges,452.07,13808.81,
21935- Rad res sft tis tum/back/flnk/<5cm,3434722,CDM,510,RC,21935,HCPCS,Outpatient,,,2723.26,1361.63,,2042.45,75,,,percent of total billed charges,75% of total billed charges,2042.45,75,,,percent of total billed charges,75% of total billed charges,2428.67,100,,,Fee Schedule,100% of CMS OPPS Rate,803.83,102,,,Fee Schedule,102% of WV Medicaid Rate,4007.32,165,,,Fee Schedule,165% of CMS OPPS Rate,2517.11,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,6976.06,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,9567.11,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,11983.78,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,788.07,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2428.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2517.11,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,381.26,14,,,percent of total billed charges,14% of total billed charges,381.26,11983.78,
21936- Rad res sft tis tum/back/flnk/5cm>,3434723,CDM,510,RC,21936,HCPCS,Outpatient,,,3775.79,1887.9,,2831.84,75,,,percent of total billed charges,75% of total billed charges,2831.84,75,,,percent of total billed charges,75% of total billed charges,2428.67,100,,,Fee Schedule,100% of CMS OPPS Rate,803.83,102,,,Fee Schedule,102% of WV Medicaid Rate,4007.32,165,,,Fee Schedule,165% of CMS OPPS Rate,2517.11,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,6976.06,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,9567.11,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,11983.78,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,788.07,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2428.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2517.11,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,528.61,14,,,percent of total billed charges,14% of total billed charges,528.61,11983.78,
22015- I&D/open deep absc/lumbar/sacral,3434724,CDM,510,RC,22015,HCPCS,Outpatient,,,2505.51,1252.76,,1879.13,75,,,percent of total billed charges,75% of total billed charges,1879.13,75,,,percent of total billed charges,75% of total billed charges,2505.51,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,2505.51,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2505.51,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2505.51,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2505.51,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2505.51,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,2505.51,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2505.51,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,350.77,14,,,percent of total billed charges,14% of total billed charges,350.77,2505.51,
22101- Part exc/post vert comp/sng/thorac,3434725,CDM,510,RC,22101,HCPCS,Outpatient,,,2253.59,1126.8,,1690.19,75,,,percent of total billed charges,75% of total billed charges,1690.19,75,,,percent of total billed charges,75% of total billed charges,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,10261.1,165,,,Fee Schedule,165% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,17862.79,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,24497.4,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,30685.48,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,315.5,14,,,percent of total billed charges,14% of total billed charges,315.5,30685.48,
22103- Part exc/post vert comp/ea add seg,3434726,CDM,510,RC,22103,HCPCS,Outpatient,,,362.85,181.43,,272.14,75,,,percent of total billed charges,75% of total billed charges,272.14,75,,,percent of total billed charges,75% of total billed charges,116.11,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50.8,14,,,percent of total billed charges,14% of total billed charges,50.8,272.14,
22206- Osteotomy/spine/1 verteb/thoracic,3434727,CDM,510,RC,22206,HCPCS,Outpatient,,,6560.27,3280.14,,4920.2,75,,,percent of total billed charges,75% of total billed charges,4920.2,75,,,percent of total billed charges,75% of total billed charges,6560.27,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,6560.27,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6560.27,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6560.27,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6560.27,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6560.27,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,6560.27,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6560.27,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,918.44,14,,,percent of total billed charges,14% of total billed charges,918.44,6560.27,
22207- Osteotomy/spine/1 verteb/lumbar,3434728,CDM,510,RC,22207,HCPCS,Outpatient,,,6408.05,3204.03,,4806.04,75,,,percent of total billed charges,75% of total billed charges,4806.04,75,,,percent of total billed charges,75% of total billed charges,6408.05,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,6408.05,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6408.05,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6408.05,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6408.05,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6408.05,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,6408.05,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6408.05,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,897.13,14,,,percent of total billed charges,14% of total billed charges,897.13,6408.05,
22208- Osteotomy/spine/ea add verteb seg,3434729,CDM,510,RC,22208,HCPCS,Outpatient,,,1594.67,797.34,,1196,75,,,percent of total billed charges,75% of total billed charges,1196,75,,,percent of total billed charges,75% of total billed charges,1594.67,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,1594.67,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1594.67,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1594.67,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1594.67,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1594.67,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,1594.67,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1594.67,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,223.25,14,,,percent of total billed charges,14% of total billed charges,223.25,1594.67,
22212- Osteotomy/thorac spine/1 vert seg,3434730,CDM,510,RC,22212,HCPCS,Outpatient,,,4000.61,2000.31,,3000.46,75,,,percent of total billed charges,75% of total billed charges,3000.46,75,,,percent of total billed charges,75% of total billed charges,4000.61,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,4000.61,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4000.61,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4000.61,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4000.61,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4000.61,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,4000.61,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4000.61,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,560.09,14,,,percent of total billed charges,14% of total billed charges,560.09,4000.61,
22214- Osteotomy/lumbar spine/1 vert seg,3434731,CDM,510,RC,22214,HCPCS,Outpatient,,,4001.17,2000.59,,3000.88,75,,,percent of total billed charges,75% of total billed charges,3000.88,75,,,percent of total billed charges,75% of total billed charges,4001.17,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,4001.17,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4001.17,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4001.17,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4001.17,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4001.17,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,4001.17,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4001.17,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,560.16,14,,,percent of total billed charges,14% of total billed charges,560.16,4001.17,
22216- Osteotomy/spine/ea add verteb seg,3434732,CDM,510,RC,22216,HCPCS,Outpatient,,,976.56,488.28,,732.42,75,,,percent of total billed charges,75% of total billed charges,732.42,75,,,percent of total billed charges,75% of total billed charges,976.56,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,976.56,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,976.56,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,976.56,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,976.56,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,976.56,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,976.56,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,976.56,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,136.72,14,,,percent of total billed charges,14% of total billed charges,136.72,976.56,
22310- Clsd tx/vert bdy fx w/o manip/cast,3434734,CDM,510,RC,22310,HCPCS,Outpatient,,,799.75,399.88,,599.81,75,,,percent of total billed charges,75% of total billed charges,599.81,75,,,percent of total billed charges,75% of total billed charges,194.62,100,,,Fee Schedule,100% of CMS OPPS Rate,84.13,102,,,Fee Schedule,102% of WV Medicaid Rate,321.11,165,,,Fee Schedule,165% of CMS OPPS Rate,201.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,559.02,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,766.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,960.32,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,82.48,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,194.62,100,,,Fee Schedule,100% of CMS OPPS Rate,201.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,111.97,14,,,percent of total billed charges,14% of total billed charges,82.48,960.32,
22325- Open tx/vertebral fx/post app/1 fx,3434735,CDM,510,RC,22325,HCPCS,Outpatient,,,3901.39,1950.7,,2926.04,75,,,percent of total billed charges,75% of total billed charges,2926.04,75,,,percent of total billed charges,75% of total billed charges,3901.39,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,3901.39,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3901.39,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3901.39,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3901.39,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3901.39,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,3901.39,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3901.39,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,546.19,14,,,percent of total billed charges,14% of total billed charges,546.19,3901.39,
22326- Open tx cervical fx/post app/1 fx,3434736,CDM,510,RC,22326,HCPCS,Outpatient,,,4027.12,2013.56,,3020.34,75,,,percent of total billed charges,75% of total billed charges,3020.34,75,,,percent of total billed charges,75% of total billed charges,4027.12,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,4027.12,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4027.12,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4027.12,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4027.12,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4027.12,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,4027.12,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4027.12,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,563.8,14,,,percent of total billed charges,14% of total billed charges,563.8,4027.12,
22327- Open tx/thoracic fx/post app/1 fx,3434737,CDM,510,RC,22327,HCPCS,Outpatient,,,4068.3,2034.15,,3051.23,75,,,percent of total billed charges,75% of total billed charges,3051.23,75,,,percent of total billed charges,75% of total billed charges,4068.3,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,4068.3,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4068.3,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4068.3,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4068.3,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4068.3,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,4068.3,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4068.3,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,569.56,14,,,percent of total billed charges,14% of total billed charges,569.56,4068.3,
22328- Open tx/ea add fx vert/dislocate seg,3434738,CDM,510,RC,22328,HCPCS,Outpatient,,,758.65,379.33,,568.99,75,,,percent of total billed charges,75% of total billed charges,568.99,75,,,percent of total billed charges,75% of total billed charges,758.65,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,758.65,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,758.65,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,758.65,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,758.65,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,758.65,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,758.65,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,758.65,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,106.21,14,,,percent of total billed charges,14% of total billed charges,106.21,758.65,
22513- Perc vert augment/1 vert bdy/uni/bilat cannulat/image/thoracic,3434740,CDM,510,RC,22513,HCPCS,Outpatient,,,14338.99,7169.5,,10754.24,75,,,percent of total billed charges,75% of total billed charges,10754.24,75,,,percent of total billed charges,75% of total billed charges,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,10261.1,165,,,Fee Schedule,165% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,17862.79,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,24497.4,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,30685.48,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,2007.46,14,,,percent of total billed charges,14% of total billed charges,2007.46,30685.48,
22514- Perc vert augment/1 vert bdy/uni/bilat cannulat/image/lumbar,3434741,CDM,510,RC,22514,HCPCS,Outpatient,,,14256.81,7128.41,,10692.61,75,,,percent of total billed charges,75% of total billed charges,10692.61,75,,,percent of total billed charges,75% of total billed charges,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,10261.1,165,,,Fee Schedule,165% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,17862.79,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,24497.4,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,30685.48,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1995.95,14,,,percent of total billed charges,14% of total billed charges,1995.95,30685.48,
22515- Perc vert augment/1 vert bdy/uni/bilat cannulat/image/ad thor/lumb,3434742,CDM,510,RC,22515,HCPCS,Outpatient,,,7376.31,3688.16,,5532.23,75,,,percent of total billed charges,75% of total billed charges,5532.23,75,,,percent of total billed charges,75% of total billed charges,2360.42,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1032.68,14,,,percent of total billed charges,14% of total billed charges,1032.68,5532.23,
22551 - PF  Arthrd Ant Interbody Decompress Cervical Below C2,4363313,CDM,960,RC,22551,HCPCS,Outpatient,,,3446.36,1723.18,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
22551- Arthrodesis/discect/decompres/cerv/below C2,3434747,CDM,510,RC,22551,HCPCS,Outpatient,,,4560.49,2280.25,,3420.37,75,,,percent of total billed charges,75% of total billed charges,3420.37,75,,,percent of total billed charges,75% of total billed charges,12267.36,100,,,Fee Schedule,100% of CMS OPPS Rate,6896.99,102,,,Fee Schedule,102% of WV Medicaid Rate,20241.15,165,,,Fee Schedule,165% of CMS OPPS Rate,12714.07,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,35236.32,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,48323.81,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,60530.47,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,6761.75,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,12267.36,100,,,Fee Schedule,100% of CMS OPPS Rate,12714.07,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,638.47,14,,,percent of total billed charges,14% of total billed charges,638.47,60530.47,
22552 - PF Arthrd Ant Interbdy Cervical Below C2 Ea Addl Interspace,4363314,CDM,960,RC,22552,HCPCS,Outpatient,,,806.56,403.28,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
22552- Arthrodesis/cervical/below C2/add,3434749,CDM,510,RC,22552,HCPCS,Outpatient,,,1070.89,535.45,,803.17,75,,,percent of total billed charges,75% of total billed charges,803.17,75,,,percent of total billed charges,75% of total billed charges,342.68,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,149.92,14,,,percent of total billed charges,14% of total billed charges,149.92,803.17,
22554- Arthrodesis/ant tech/cerv/below C2,3434750,CDM,510,RC,22554,HCPCS,Outpatient,,,3352.64,1676.32,,2514.48,75,,,percent of total billed charges,75% of total billed charges,2514.48,75,,,percent of total billed charges,75% of total billed charges,12267.36,100,,,Fee Schedule,100% of CMS OPPS Rate,6854.48,102,,,Fee Schedule,102% of WV Medicaid Rate,20241.15,165,,,Fee Schedule,165% of CMS OPPS Rate,12714.07,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,35236.32,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,48323.81,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,60530.47,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,6720.08,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,12267.36,100,,,Fee Schedule,100% of CMS OPPS Rate,12714.07,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,469.37,14,,,percent of total billed charges,14% of total billed charges,469.37,60530.47,
22556- Arthrodesis/ant tech/thoracic,3434751,CDM,510,RC,22556,HCPCS,Outpatient,,,4447.36,2223.68,,3335.52,75,,,percent of total billed charges,75% of total billed charges,3335.52,75,,,percent of total billed charges,75% of total billed charges,4447.36,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,4447.36,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4447.36,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4447.36,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4447.36,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4447.36,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,4447.36,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4447.36,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,622.63,14,,,percent of total billed charges,14% of total billed charges,622.63,4447.36,
22558- Arthrodesis/ant tech/lumbar,3434752,CDM,510,RC,22558,HCPCS,Outpatient,,,4082.84,2041.42,,3062.13,75,,,percent of total billed charges,75% of total billed charges,3062.13,75,,,percent of total billed charges,75% of total billed charges,4082.84,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,4082.84,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4082.84,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4082.84,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4082.84,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4082.84,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,4082.84,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4082.84,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,571.6,14,,,percent of total billed charges,14% of total billed charges,571.6,4082.84,
22585- Arthrodesis/cerv/thor/lumb/ea add,3434753,CDM,510,RC,22585,HCPCS,Outpatient,,,878.35,439.18,,658.76,75,,,percent of total billed charges,75% of total billed charges,658.76,75,,,percent of total billed charges,75% of total billed charges,281.07,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,122.97,14,,,percent of total billed charges,14% of total billed charges,122.97,658.76,
22590- Arthrode/post/craniocer/Occiput-C2,3434754,CDM,510,RC,22590,HCPCS,Outpatient,,,4239.21,2119.61,,3179.41,75,,,percent of total billed charges,75% of total billed charges,3179.41,75,,,percent of total billed charges,75% of total billed charges,4239.21,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,4239.21,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4239.21,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4239.21,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4239.21,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4239.21,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,4239.21,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4239.21,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,593.49,14,,,percent of total billed charges,14% of total billed charges,593.49,4239.21,
22595- Arthrodesis/post/atlas-axis C 1-2,3434755,CDM,510,RC,22595,HCPCS,Outpatient,,,4047.49,2023.75,,3035.62,75,,,percent of total billed charges,75% of total billed charges,3035.62,75,,,percent of total billed charges,75% of total billed charges,4047.49,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,4047.49,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4047.49,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4047.49,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4047.49,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4047.49,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,4047.49,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4047.49,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,566.65,14,,,percent of total billed charges,14% of total billed charges,566.65,4047.49,
22600 - PF Arthrd Pst/Pstlat Tchnq Interspc CRV Below C2 Segment,4363315,CDM,960,RC,22600,HCPCS,Outpatient,,,2630.06,1315.03,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
22600- Arthrodesis/sg level/cerv/below C2,3434756,CDM,510,RC,22600,HCPCS,Outpatient,,,3453.33,1726.67,,2590,75,,,percent of total billed charges,75% of total billed charges,2590,75,,,percent of total billed charges,75% of total billed charges,3453.33,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,3453.33,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3453.33,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3453.33,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3453.33,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3453.33,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,3453.33,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3453.33,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,483.47,14,,,percent of total billed charges,14% of total billed charges,483.47,3453.33,
22610- Arthrodesis/single level/thoracic,3434757,CDM,510,RC,22610,HCPCS,Outpatient,,,3389.16,1694.58,,2541.87,75,,,percent of total billed charges,75% of total billed charges,2541.87,75,,,percent of total billed charges,75% of total billed charges,3389.16,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,3389.16,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3389.16,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3389.16,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3389.16,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3389.16,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,3389.16,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3389.16,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,474.48,14,,,percent of total billed charges,14% of total billed charges,474.48,3389.16,
22612 - PF Arthrodesis Posterior/Pstlat Tchnq Interspc Lumbar,4363316,CDM,960,RC,22612,HCPCS,Outpatient,,,3170.08,1585.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
22612- Arthrodesis/single level/lumbar,3434758,CDM,510,RC,22612,HCPCS,Outpatient,,,4227.11,2113.56,,3170.33,75,,,percent of total billed charges,75% of total billed charges,3170.33,75,,,percent of total billed charges,75% of total billed charges,20587.41,100,,,Fee Schedule,100% of CMS OPPS Rate,6952.88,102,,,Fee Schedule,102% of WV Medicaid Rate,33969.22,165,,,Fee Schedule,165% of CMS OPPS Rate,21337.09,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,59134.52,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,81098.28,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,101583.83,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,6816.55,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,20587.41,100,,,Fee Schedule,100% of CMS OPPS Rate,21337.09,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,591.8,14,,,percent of total billed charges,14% of total billed charges,591.8,101583.83,
22614 - PF Arthrodesis Pst/Pstlat Tchnq Interspc Ea Addl Interspace,4363317,CDM,960,RC,22614,HCPCS,Outpatient,,,795.74,397.87,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
22614- Arthrodesis/sng lev/ea add ver seg,3434759,CDM,510,RC,22614,HCPCS,Outpatient,,,1055.13,527.57,,791.35,75,,,percent of total billed charges,75% of total billed charges,791.35,75,,,percent of total billed charges,75% of total billed charges,337.64,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,147.72,14,,,percent of total billed charges,14% of total billed charges,147.72,791.35,
22630- Arthrodesis/post interbdy/sng/lum,3434760,CDM,510,RC,22630,HCPCS,Outpatient,,,4226.69,2113.35,,3170.02,75,,,percent of total billed charges,75% of total billed charges,3170.02,75,,,percent of total billed charges,75% of total billed charges,20587.41,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,33969.22,165,,,Fee Schedule,165% of CMS OPPS Rate,21337.09,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,59134.52,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,81098.28,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,101583.83,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,20587.41,100,,,Fee Schedule,100% of CMS OPPS Rate,21337.09,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,591.74,14,,,percent of total billed charges,14% of total billed charges,591.74,101583.83,
22632- Arthrodesis/post interbdy/ea add,3434761,CDM,510,RC,22632,HCPCS,Outpatient,,,868.37,434.19,,651.28,75,,,percent of total billed charges,75% of total billed charges,651.28,75,,,percent of total billed charges,75% of total billed charges,277.88,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,121.57,14,,,percent of total billed charges,14% of total billed charges,121.57,651.28,
22633 - PF Arthrodesis Combined Tchnq Interspc Lumbar,4363318,CDM,960,RC,22633,HCPCS,Outpatient,,,3649.72,1824.86,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
22633- Arthrodesis/combine app/sng/lumbar,3434762,CDM,510,RC,22633,HCPCS,Outpatient,,,4954.65,2477.33,,3715.99,75,,,percent of total billed charges,75% of total billed charges,3715.99,75,,,percent of total billed charges,75% of total billed charges,20587.41,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,33969.22,165,,,Fee Schedule,165% of CMS OPPS Rate,21337.09,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,59134.52,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,81098.28,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,101583.83,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,20587.41,100,,,Fee Schedule,100% of CMS OPPS Rate,21337.09,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,693.65,14,,,percent of total billed charges,14% of total billed charges,693.65,101583.83,
22634 - PF Arthrodesis Combined Interspc Ea Addl,4363319,CDM,960,RC,22634,HCPCS,Outpatient,,,985.58,492.79,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
22634- Arthrodesis/combine app/ea add,3434765,CDM,510,RC,22634,HCPCS,Outpatient,,,1339.89,669.95,,1004.92,75,,,percent of total billed charges,75% of total billed charges,1004.92,75,,,percent of total billed charges,75% of total billed charges,428.76,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,187.58,14,,,percent of total billed charges,14% of total billed charges,187.58,1004.92,
22802- Arthrodesis/spine deform/7-12 seg,3434766,CDM,510,RC,22802,HCPCS,Outpatient,,,5644.29,2822.15,,4233.22,75,,,percent of total billed charges,75% of total billed charges,4233.22,75,,,percent of total billed charges,75% of total billed charges,5644.29,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,5644.29,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5644.29,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5644.29,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5644.29,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5644.29,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,5644.29,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5644.29,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,790.2,14,,,percent of total billed charges,14% of total billed charges,790.2,5644.29,
22810- Arthrodesis/spine deform/4-7 vert,3434767,CDM,510,RC,22810,HCPCS,Outpatient,,,5308.47,2654.24,,3981.35,75,,,percent of total billed charges,75% of total billed charges,3981.35,75,,,percent of total billed charges,75% of total billed charges,5308.47,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,5308.47,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5308.47,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5308.47,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5308.47,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5308.47,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,5308.47,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5308.47,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,743.19,14,,,percent of total billed charges,14% of total billed charges,743.19,5308.47,
22830- Exploration/spinal fusion,3434768,CDM,510,RC,22830,HCPCS,Outpatient,,,2176.4,1088.2,,1632.3,75,,,percent of total billed charges,75% of total billed charges,1632.3,75,,,percent of total billed charges,75% of total billed charges,2176.4,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,2176.4,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2176.4,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2176.4,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2176.4,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2176.4,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,2176.4,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2176.4,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,304.7,14,,,percent of total billed charges,14% of total billed charges,304.7,2176.4,
22840 - PF Posterior Non-Segmental Instrumentation,4363320,CDM,960,RC,22840,HCPCS,Outpatient,,,1532.72,766.36,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
22840- Post non-seg/spine instrumentation,3434769,CDM,510,RC,22840,HCPCS,Outpatient,,,2046.54,1023.27,,1534.91,75,,,percent of total billed charges,75% of total billed charges,1534.91,75,,,percent of total billed charges,75% of total billed charges,654.89,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,286.52,14,,,percent of total billed charges,14% of total billed charges,286.52,1534.91,
22842 - PF Posterior Segmental Instrumentation 3-6 Vrt Seg,4363321,CDM,960,RC,22842,HCPCS,Outpatient,,,1550.14,775.07,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
22842- Post seg spine instrument/3-6 seg,3434771,CDM,510,RC,22842,HCPCS,Outpatient,,,2058.72,1029.36,,1544.04,75,,,percent of total billed charges,75% of total billed charges,1544.04,75,,,percent of total billed charges,75% of total billed charges,658.79,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,288.22,14,,,percent of total billed charges,14% of total billed charges,288.22,1544.04,
22843- Post seg spine instrument/7-12 seg,3434772,CDM,510,RC,22843,HCPCS,Outpatient,,,2200.91,1100.46,,1650.68,75,,,percent of total billed charges,75% of total billed charges,1650.68,75,,,percent of total billed charges,75% of total billed charges,2200.91,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,2200.91,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2200.91,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2200.91,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2200.91,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2200.91,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,2200.91,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2200.91,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,308.13,14,,,percent of total billed charges,14% of total billed charges,308.13,2200.91,
22844- Post seg spine instrument/13 or >,3434773,CDM,510,RC,22844,HCPCS,Outpatient,,,2645.26,1322.63,,1983.95,75,,,percent of total billed charges,75% of total billed charges,1983.95,75,,,percent of total billed charges,75% of total billed charges,2645.26,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,2645.26,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2645.26,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2645.26,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2645.26,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2645.26,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,2645.26,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2645.26,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,370.34,14,,,percent of total billed charges,14% of total billed charges,370.34,2645.26,
22845 - PF Anterior Instrumentation 2-3 Vertebral Segments,4363322,CDM,960,RC,22845,HCPCS,Outpatient,,,1477.82,738.91,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
22845- Ant instrumentation/2-3 vert seg,3434774,CDM,510,RC,22845,HCPCS,Outpatient,,,1965.99,983,,1474.49,75,,,percent of total billed charges,75% of total billed charges,1474.49,75,,,percent of total billed charges,75% of total billed charges,629.12,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,275.24,14,,,percent of total billed charges,14% of total billed charges,275.24,1474.49,
22846 - PF Anterior Instrumentation 4-7 Vertebral Segments,4363323,CDM,960,RC,22846,HCPCS,Outpatient,,,1539.08,769.54,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
22846- Ant instrumentation/4-7 vert seg,3434775,CDM,510,RC,22846,HCPCS,Outpatient,,,2043.83,1021.92,,1532.87,75,,,percent of total billed charges,75% of total billed charges,1532.87,75,,,percent of total billed charges,75% of total billed charges,2043.83,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,2043.83,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2043.83,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2043.83,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2043.83,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2043.83,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,2043.83,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2043.83,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,286.14,14,,,percent of total billed charges,14% of total billed charges,286.14,2043.83,
22848- Spine/pel fixation/oth than sacrum,3434776,CDM,510,RC,22848,HCPCS,Outpatient,,,966.58,483.29,,724.94,75,,,percent of total billed charges,75% of total billed charges,724.94,75,,,percent of total billed charges,75% of total billed charges,966.58,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,966.58,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,966.58,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,966.58,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,966.58,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,966.58,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,966.58,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,966.58,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,135.32,14,,,percent of total billed charges,14% of total billed charges,135.32,966.58,
22849- Reinsert spinal fixation device,3434777,CDM,510,RC,22849,HCPCS,Outpatient,,,3485.5,1742.75,,2614.13,75,,,percent of total billed charges,75% of total billed charges,2614.13,75,,,percent of total billed charges,75% of total billed charges,3485.5,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,3485.5,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3485.5,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3485.5,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3485.5,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3485.5,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,3485.5,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3485.5,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,487.97,14,,,percent of total billed charges,14% of total billed charges,487.97,3485.5,
22850- Rmv post nonseg/spine instrument,3434778,CDM,510,RC,22850,HCPCS,Outpatient,,,1947.53,973.77,,1460.65,75,,,percent of total billed charges,75% of total billed charges,1460.65,75,,,percent of total billed charges,75% of total billed charges,1947.53,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,1947.53,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1947.53,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1947.53,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1947.53,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1947.53,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,1947.53,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1947.53,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,272.65,14,,,percent of total billed charges,14% of total billed charges,272.65,1947.53,
22852- Rmv posterior seg/spine instrument,3434780,CDM,510,RC,22852,HCPCS,Outpatient,,,1867.65,933.83,,1400.74,75,,,percent of total billed charges,75% of total billed charges,1400.74,75,,,percent of total billed charges,75% of total billed charges,1867.65,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,1867.65,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1867.65,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1867.65,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1867.65,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1867.65,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,1867.65,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1867.65,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,261.47,14,,,percent of total billed charges,14% of total billed charges,261.47,1867.65,
22853 - PF Ins Biomechanical Dev Intervertebral Dsc Spc w/Arthrd,4363324,CDM,960,RC,22853,HCPCS,Outpatient,,,522.96,261.48,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
22855- Rmv anterior spine instrumentation,3434781,CDM,510,RC,22855,HCPCS,Outpatient,,,2951.98,1475.99,,2213.99,75,,,percent of total billed charges,75% of total billed charges,2213.99,75,,,percent of total billed charges,75% of total billed charges,2951.98,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,2951.98,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2951.98,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2951.98,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2951.98,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2951.98,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,2951.98,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2951.98,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,413.28,14,,,percent of total billed charges,14% of total billed charges,413.28,2951.98,
22856- Tot disc arthroplasty/ant app/cerv,3434782,CDM,510,RC,22856,HCPCS,Outpatient,,,4359.71,2179.86,,3269.78,75,,,percent of total billed charges,75% of total billed charges,3269.78,75,,,percent of total billed charges,75% of total billed charges,20587.41,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,33969.22,165,,,Fee Schedule,165% of CMS OPPS Rate,21337.09,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,59134.52,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,81098.28,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,101583.83,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,20587.41,100,,,Fee Schedule,100% of CMS OPPS Rate,21337.09,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,610.36,14,,,percent of total billed charges,14% of total billed charges,610.36,101583.83,
22857- Tot disc arthroplasty/ant app/lumb,3434783,CDM,510,RC,22857,HCPCS,Outpatient,,,4656.75,2328.38,,3492.56,75,,,percent of total billed charges,75% of total billed charges,3492.56,75,,,percent of total billed charges,75% of total billed charges,4656.75,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,4656.75,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4656.75,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4656.75,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4656.75,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4656.75,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,4656.75,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4656.75,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,651.95,14,,,percent of total billed charges,14% of total billed charges,651.95,4656.75,
22864- Rmv tot disc arthroplast/ant/cerv,3434784,CDM,510,RC,22864,HCPCS,Outpatient,,,5586.95,2793.48,,4190.21,75,,,percent of total billed charges,75% of total billed charges,4190.21,75,,,percent of total billed charges,75% of total billed charges,5586.95,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,5586.95,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5586.95,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5586.95,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5586.95,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5586.95,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,5586.95,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5586.95,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,782.17,14,,,percent of total billed charges,14% of total billed charges,782.17,5586.95,
"22999 - Unlisted procedure, abdomen, musculoskeletal system",3800919,CDM,983,RC,22999,HCPCS,Outpatient,,,725.57,362.79,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
23030- I&D/shoulder/deep abscess/hematoma,3434790,CDM,510,RC,23030,HCPCS,Outpatient,,,1119.63,559.82,,839.72,75,,,percent of total billed charges,75% of total billed charges,839.72,75,,,percent of total billed charges,75% of total billed charges,2428.67,100,,,Fee Schedule,100% of CMS OPPS Rate,803.83,102,,,Fee Schedule,102% of WV Medicaid Rate,4007.32,165,,,Fee Schedule,165% of CMS OPPS Rate,2517.11,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,6976.06,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,9567.11,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,11983.78,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,788.07,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2428.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2517.11,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,156.75,14,,,percent of total billed charges,14% of total billed charges,156.75,11983.78,
23031- I&D/shoulder/infected bursa,3434791,CDM,510,RC,23031,HCPCS,Outpatient,,,1065.01,532.51,,798.76,75,,,percent of total billed charges,75% of total billed charges,798.76,75,,,percent of total billed charges,75% of total billed charges,2428.67,100,,,Fee Schedule,100% of CMS OPPS Rate,803.83,102,,,Fee Schedule,102% of WV Medicaid Rate,4007.32,165,,,Fee Schedule,165% of CMS OPPS Rate,2517.11,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,6976.06,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,9567.11,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,11983.78,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,788.07,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2428.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2517.11,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,149.1,14,,,percent of total billed charges,14% of total billed charges,149.1,11983.78,
23035- Incision/bone cortex/shoulder area,3434792,CDM,510,RC,23035,HCPCS,Outpatient,,,1785.07,892.54,,1338.8,75,,,percent of total billed charges,75% of total billed charges,1338.8,75,,,percent of total billed charges,75% of total billed charges,1348.67,100,,,Fee Schedule,100% of CMS OPPS Rate,584.77,102,,,Fee Schedule,102% of WV Medicaid Rate,2225.32,165,,,Fee Schedule,165% of CMS OPPS Rate,1397.79,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,3873.91,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5312.76,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6654.78,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,573.3,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1348.67,100,,,Fee Schedule,100% of CMS OPPS Rate,1397.79,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,249.91,14,,,percent of total billed charges,14% of total billed charges,249.91,6654.78,
23040- Arthrotomy/glenohumeral joint,3434793,CDM,510,RC,23040,HCPCS,Outpatient,,,1881.5,940.75,,1411.13,75,,,percent of total billed charges,75% of total billed charges,1411.13,75,,,percent of total billed charges,75% of total billed charges,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,1073.09,102,,,Fee Schedule,102% of WV Medicaid Rate,4617.6,165,,,Fee Schedule,165% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8038.46,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11024.11,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13808.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1052.05,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,263.41,14,,,percent of total billed charges,14% of total billed charges,263.41,13808.81,
23075- Exc/tumor/shoulder/SQ/<3 cm,3434796,CDM,510,RC,23075,HCPCS,Outpatient,,,670.85,335.43,,503.14,75,,,percent of total billed charges,75% of total billed charges,503.14,75,,,percent of total billed charges,75% of total billed charges,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,479.67,102,,,Fee Schedule,102% of WV Medicaid Rate,2326.19,165,,,Fee Schedule,165% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4049.52,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5553.61,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6956.46,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,470.26,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,93.92,14,,,percent of total billed charges,14% of total billed charges,93.92,6956.46,
23076- Exc IM tumor/shoulder area < 5 cm,3434797,CDM,960,RC,23076,HCPCS,Outpatient,,,1112.53,556.27,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
23120- Partial claviculectomy,3434798,CDM,510,RC,23120,HCPCS,Outpatient,,,1525.82,762.91,,1144.37,75,,,percent of total billed charges,75% of total billed charges,1144.37,75,,,percent of total billed charges,75% of total billed charges,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,1073.09,102,,,Fee Schedule,102% of WV Medicaid Rate,4617.6,165,,,Fee Schedule,165% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8038.46,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11024.11,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13808.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1052.05,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,213.61,14,,,percent of total billed charges,14% of total billed charges,213.61,13808.81,
23190- Ostectomy of scapula/partial,3434800,CDM,510,RC,23190,HCPCS,Outpatient,,,1501.24,750.62,,1125.93,75,,,percent of total billed charges,75% of total billed charges,1125.93,75,,,percent of total billed charges,75% of total billed charges,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,1073.09,102,,,Fee Schedule,102% of WV Medicaid Rate,4617.6,165,,,Fee Schedule,165% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8038.46,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11024.11,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13808.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1052.05,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,210.17,14,,,percent of total billed charges,14% of total billed charges,210.17,13808.81,
23334- Rmv shoulder prosth/hum or glenoid,3434802,CDM,510,RC,23334,HCPCS,Outpatient,,,2781.95,1390.98,,2086.46,75,,,percent of total billed charges,75% of total billed charges,2086.46,75,,,percent of total billed charges,75% of total billed charges,2428.67,100,,,Fee Schedule,100% of CMS OPPS Rate,803.83,102,,,Fee Schedule,102% of WV Medicaid Rate,4007.32,165,,,Fee Schedule,165% of CMS OPPS Rate,2517.11,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,6976.06,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,9567.11,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,11983.78,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,788.07,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2428.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2517.11,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,389.47,14,,,percent of total billed charges,14% of total billed charges,389.47,11983.78,
23335- Rmv shoulder prosth/hum & glenoid,3434803,CDM,510,RC,23335,HCPCS,Outpatient,,,3329.34,1664.67,,2497.01,75,,,percent of total billed charges,75% of total billed charges,2497.01,75,,,percent of total billed charges,75% of total billed charges,3329.34,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,3329.34,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3329.34,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3329.34,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3329.34,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3329.34,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,3329.34,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3329.34,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,466.11,14,,,percent of total billed charges,14% of total billed charges,466.11,3329.34,
23350- Inj/shoulder arthrography,3434804,CDM,360,RC,23350,HCPCS,Outpatient,,,416.21,208.11,,312.16,75,,,percent of total billed charges,75% of total billed charges,312.16,75,,,percent of total billed charges,75% of total billed charges,133.19,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,58.27,14,,,percent of total billed charges,14% of total billed charges,58.27,312.16,
23395- Muscle trans/shoulder/up arm/sgn,3434805,CDM,510,RC,23395,HCPCS,Outpatient,,,3348.5,1674.25,,2511.38,75,,,percent of total billed charges,75% of total billed charges,2511.38,75,,,percent of total billed charges,75% of total billed charges,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,2365.05,102,,,Fee Schedule,102% of WV Medicaid Rate,10261.1,165,,,Fee Schedule,165% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,17862.79,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,24497.4,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,30685.48,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,2318.68,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,468.79,14,,,percent of total billed charges,14% of total billed charges,468.79,30685.48,
23405- Tenotomy/shoulder/single tendon,3434806,CDM,510,RC,23405,HCPCS,Outpatient,,,1616.77,808.39,,1212.58,75,,,percent of total billed charges,75% of total billed charges,1212.58,75,,,percent of total billed charges,75% of total billed charges,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,2365.05,102,,,Fee Schedule,102% of WV Medicaid Rate,10261.1,165,,,Fee Schedule,165% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,17862.79,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,24497.4,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,30685.48,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,2318.68,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,226.35,14,,,percent of total billed charges,14% of total billed charges,226.35,30685.48,
23410- Rpr/rupture/musc/tend cuff/acute,3434807,CDM,510,RC,23410,HCPCS,Outpatient,,,2145.57,1072.79,,1609.18,75,,,percent of total billed charges,75% of total billed charges,1609.18,75,,,percent of total billed charges,75% of total billed charges,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,2365.05,102,,,Fee Schedule,102% of WV Medicaid Rate,10261.1,165,,,Fee Schedule,165% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,17862.79,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,24497.4,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,30685.48,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,2318.68,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,300.38,14,,,percent of total billed charges,14% of total billed charges,300.38,30685.48,
23412- Rpr/rupture/musc/tend cuff/chronic,3434808,CDM,510,RC,23412,HCPCS,Outpatient,,,2231.09,1115.55,,1673.32,75,,,percent of total billed charges,75% of total billed charges,1673.32,75,,,percent of total billed charges,75% of total billed charges,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,2365.05,102,,,Fee Schedule,102% of WV Medicaid Rate,10261.1,165,,,Fee Schedule,165% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,17862.79,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,24497.4,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,30685.48,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,2318.68,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,312.35,14,,,percent of total billed charges,14% of total billed charges,312.35,30685.48,
23420- Reconstruc rotate cuff avuls/chron,3434809,CDM,510,RC,23420,HCPCS,Outpatient,,,2549.84,1274.92,,1912.38,75,,,percent of total billed charges,75% of total billed charges,1912.38,75,,,percent of total billed charges,75% of total billed charges,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,2365.05,102,,,Fee Schedule,102% of WV Medicaid Rate,10261.1,165,,,Fee Schedule,165% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,17862.79,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,24497.4,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,30685.48,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,2318.68,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,356.98,14,,,percent of total billed charges,14% of total billed charges,356.98,30685.48,
23430- Repair/long tendon/biceps,3434810,CDM,510,RC,23430,HCPCS,Outpatient,,,1945.56,972.78,,1459.17,75,,,percent of total billed charges,75% of total billed charges,1459.17,75,,,percent of total billed charges,75% of total billed charges,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,2365.05,102,,,Fee Schedule,102% of WV Medicaid Rate,10261.1,165,,,Fee Schedule,165% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,17862.79,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,24497.4,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,30685.48,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,2318.68,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,272.38,14,,,percent of total billed charges,14% of total billed charges,272.38,30685.48,
23440- Resect/transplant/long tend/bicep,3434811,CDM,510,RC,23440,HCPCS,Outpatient,,,1985.17,992.59,,1488.88,75,,,percent of total billed charges,75% of total billed charges,1488.88,75,,,percent of total billed charges,75% of total billed charges,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,3175.01,102,,,Fee Schedule,102% of WV Medicaid Rate,10261.1,165,,,Fee Schedule,165% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,17862.79,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,24497.4,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,30685.48,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,3112.75,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,277.92,14,,,percent of total billed charges,14% of total billed charges,277.92,30685.48,
23455- Capsulorrhapy/ant/w labral repair,3434812,CDM,510,RC,23455,HCPCS,Outpatient,,,2612.25,1306.13,,1959.19,75,,,percent of total billed charges,75% of total billed charges,1959.19,75,,,percent of total billed charges,75% of total billed charges,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,3183.52,102,,,Fee Schedule,102% of WV Medicaid Rate,10261.1,165,,,Fee Schedule,165% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,17862.79,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,24497.4,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,30685.48,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,3121.1,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,365.72,14,,,percent of total billed charges,14% of total billed charges,365.72,30685.48,
23460- Capsulorrhapy/ant/bone block,3434813,CDM,510,RC,23460,HCPCS,Outpatient,,,2866.6,1433.3,,2149.95,75,,,percent of total billed charges,75% of total billed charges,2149.95,75,,,percent of total billed charges,75% of total billed charges,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,3692.03,102,,,Fee Schedule,102% of WV Medicaid Rate,10261.1,165,,,Fee Schedule,165% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,17862.79,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,24497.4,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,30685.48,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,3619.64,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,401.32,14,,,percent of total billed charges,14% of total billed charges,401.32,30685.48,
23462- Capsulorrhapy/coracoid proc trans,3434814,CDM,510,RC,23462,HCPCS,Outpatient,,,2809.11,1404.56,,2106.83,75,,,percent of total billed charges,75% of total billed charges,2106.83,75,,,percent of total billed charges,75% of total billed charges,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,2365.05,102,,,Fee Schedule,102% of WV Medicaid Rate,10261.1,165,,,Fee Schedule,165% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,17862.79,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,24497.4,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,30685.48,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,2318.68,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,393.28,14,,,percent of total billed charges,14% of total billed charges,393.28,30685.48,
23472- Arthroplasty/total shoulder,3434815,CDM,510,RC,23472,HCPCS,Outpatient,,,3808.47,1904.24,,2856.35,75,,,percent of total billed charges,75% of total billed charges,2856.35,75,,,percent of total billed charges,75% of total billed charges,12267.36,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,20241.15,165,,,Fee Schedule,165% of CMS OPPS Rate,12714.07,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,35236.32,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,48323.81,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,60530.47,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,12267.36,100,,,Fee Schedule,100% of CMS OPPS Rate,12714.07,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,533.19,14,,,percent of total billed charges,14% of total billed charges,533.19,60530.47,
23473- Revis/tot shoulder arthro/hum/glen,3434816,CDM,510,RC,23473,HCPCS,Outpatient,,,4250.25,2125.13,,3187.69,75,,,percent of total billed charges,75% of total billed charges,3187.69,75,,,percent of total billed charges,75% of total billed charges,12267.36,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,20241.15,165,,,Fee Schedule,165% of CMS OPPS Rate,12714.07,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,35236.32,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,48323.81,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,60530.47,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,12267.36,100,,,Fee Schedule,100% of CMS OPPS Rate,12714.07,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,595.04,14,,,percent of total billed charges,14% of total billed charges,595.04,60530.47,
23474- Revis/tot shoulder arthro/hum&glen,3434817,CDM,510,RC,23474,HCPCS,Outpatient,,,4590.27,2295.14,,3442.7,75,,,percent of total billed charges,75% of total billed charges,3442.7,75,,,percent of total billed charges,75% of total billed charges,4590.27,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,4590.27,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4590.27,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4590.27,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4590.27,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4590.27,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,4590.27,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4590.27,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,642.64,14,,,percent of total billed charges,14% of total billed charges,642.64,4590.27,
23480- Osteotomy/clavicle w/w/o int fix,3434818,CDM,510,RC,23480,HCPCS,Outpatient,,,2152.4,1076.2,,1614.3,75,,,percent of total billed charges,75% of total billed charges,1614.3,75,,,percent of total billed charges,75% of total billed charges,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,2365.05,102,,,Fee Schedule,102% of WV Medicaid Rate,10261.1,165,,,Fee Schedule,165% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,17862.79,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,24497.4,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,30685.48,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,2318.68,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,301.34,14,,,percent of total billed charges,14% of total billed charges,301.34,30685.48,
23500- Clsd tx/clavicular fx w/o manip,3434819,CDM,510,RC,23500,HCPCS,Outpatient,,,570.27,285.14,,427.7,75,,,percent of total billed charges,75% of total billed charges,427.7,75,,,percent of total billed charges,75% of total billed charges,194.62,100,,,Fee Schedule,100% of CMS OPPS Rate,84.13,102,,,Fee Schedule,102% of WV Medicaid Rate,321.11,165,,,Fee Schedule,165% of CMS OPPS Rate,201.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,559.02,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,766.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,960.32,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,82.48,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,194.62,100,,,Fee Schedule,100% of CMS OPPS Rate,201.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,79.84,14,,,percent of total billed charges,14% of total billed charges,79.84,960.32,
23515- Open Tx Of Clavicle fx,3434820,CDM,510,RC,23515,HCPCS,Outpatient,,,1879.48,939.74,,1409.61,75,,,percent of total billed charges,75% of total billed charges,1409.61,75,,,percent of total billed charges,75% of total billed charges,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,3248.48,102,,,Fee Schedule,102% of WV Medicaid Rate,10261.1,165,,,Fee Schedule,165% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,17862.79,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,24497.4,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,30685.48,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,3184.78,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,263.13,14,,,percent of total billed charges,14% of total billed charges,263.13,30685.48,
23532- Open tx/sternoclavic dislocate/w gft,3434821,CDM,510,RC,23532,HCPCS,Outpatient,,,1635.51,817.76,,1226.63,75,,,percent of total billed charges,75% of total billed charges,1226.63,75,,,percent of total billed charges,75% of total billed charges,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,3271.97,102,,,Fee Schedule,102% of WV Medicaid Rate,10261.1,165,,,Fee Schedule,165% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,17862.79,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,24497.4,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,30685.48,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,3207.81,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,228.97,14,,,percent of total billed charges,14% of total billed charges,228.97,30685.48,
23550- Open tx/acromioclavicular dislocateat,3434822,CDM,510,RC,23550,HCPCS,Outpatient,,,1493.06,746.53,,1119.8,75,,,percent of total billed charges,75% of total billed charges,1119.8,75,,,percent of total billed charges,75% of total billed charges,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,3111.21,102,,,Fee Schedule,102% of WV Medicaid Rate,10261.1,165,,,Fee Schedule,165% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,17862.79,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,24497.4,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,30685.48,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,3050.21,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,209.03,14,,,percent of total billed charges,14% of total billed charges,209.03,30685.48,
23552- Open tx/acromioclav dislocate/fas gft,3434823,CDM,510,RC,23552,HCPCS,Outpatient,,,1709.13,854.57,,1281.85,75,,,percent of total billed charges,75% of total billed charges,1281.85,75,,,percent of total billed charges,75% of total billed charges,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,3152.21,102,,,Fee Schedule,102% of WV Medicaid Rate,10261.1,165,,,Fee Schedule,165% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,17862.79,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,24497.4,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,30685.48,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,3090.4,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,239.28,14,,,percent of total billed charges,14% of total billed charges,239.28,30685.48,
23570- Clsd tx/scapular fx w/o manip,3434824,CDM,510,RC,23570,HCPCS,Outpatient,,,603.19,301.6,,452.39,75,,,percent of total billed charges,75% of total billed charges,452.39,75,,,percent of total billed charges,75% of total billed charges,194.62,100,,,Fee Schedule,100% of CMS OPPS Rate,84.13,102,,,Fee Schedule,102% of WV Medicaid Rate,321.11,165,,,Fee Schedule,165% of CMS OPPS Rate,201.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,559.02,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,766.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,960.32,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,82.48,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,194.62,100,,,Fee Schedule,100% of CMS OPPS Rate,201.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,84.45,14,,,percent of total billed charges,14% of total billed charges,82.48,960.32,
23585- Open tx/scapular fracture,3434825,CDM,510,RC,23585,HCPCS,Outpatient,,,2570.54,1285.27,,1927.91,75,,,percent of total billed charges,75% of total billed charges,1927.91,75,,,percent of total billed charges,75% of total billed charges,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,3230.96,102,,,Fee Schedule,102% of WV Medicaid Rate,10261.1,165,,,Fee Schedule,165% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,17862.79,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,24497.4,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,30685.48,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,3167.61,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,359.88,14,,,percent of total billed charges,14% of total billed charges,359.88,30685.48,
23600- Open tx/acute shoulder dislocateation,3434826,CDM,510,RC,23600,HCPCS,Outpatient,,,850.75,425.38,,638.06,75,,,percent of total billed charges,75% of total billed charges,638.06,75,,,percent of total billed charges,75% of total billed charges,194.62,100,,,Fee Schedule,100% of CMS OPPS Rate,84.13,102,,,Fee Schedule,102% of WV Medicaid Rate,321.11,165,,,Fee Schedule,165% of CMS OPPS Rate,201.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,559.02,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,766.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,960.32,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,82.48,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,194.62,100,,,Fee Schedule,100% of CMS OPPS Rate,201.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,119.11,14,,,percent of total billed charges,14% of total billed charges,82.48,960.32,
23605- Clsd tx/prox humeral fx w/manip,3434827,CDM,510,RC,23605,HCPCS,Outpatient,,,1212.98,606.49,,909.74,75,,,percent of total billed charges,75% of total billed charges,909.74,75,,,percent of total billed charges,75% of total billed charges,1348.67,100,,,Fee Schedule,100% of CMS OPPS Rate,584.77,102,,,Fee Schedule,102% of WV Medicaid Rate,2225.32,165,,,Fee Schedule,165% of CMS OPPS Rate,1397.79,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,3873.91,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5312.76,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6654.78,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,573.3,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1348.67,100,,,Fee Schedule,100% of CMS OPPS Rate,1397.79,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,169.82,14,,,percent of total billed charges,14% of total billed charges,169.82,6654.78,
23615- Open tx/prox humeral fracture,3434828,CDM,510,RC,23615,HCPCS,Outpatient,,,2312.18,1156.09,,1734.14,75,,,percent of total billed charges,75% of total billed charges,1734.14,75,,,percent of total billed charges,75% of total billed charges,12267.36,100,,,Fee Schedule,100% of CMS OPPS Rate,6814.29,102,,,Fee Schedule,102% of WV Medicaid Rate,20241.15,165,,,Fee Schedule,165% of CMS OPPS Rate,12714.07,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,35236.32,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,48323.81,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,60530.47,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,6680.68,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,12267.36,100,,,Fee Schedule,100% of CMS OPPS Rate,12714.07,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,323.71,14,,,percent of total billed charges,14% of total billed charges,323.71,60530.47,
23616- Open tx prox humeral fx w/prosth,3434829,CDM,510,RC,23616,HCPCS,Outpatient,,,3245.82,1622.91,,2434.37,75,,,percent of total billed charges,75% of total billed charges,2434.37,75,,,percent of total billed charges,75% of total billed charges,20587.41,100,,,Fee Schedule,100% of CMS OPPS Rate,9382.86,102,,,Fee Schedule,102% of WV Medicaid Rate,33969.22,165,,,Fee Schedule,165% of CMS OPPS Rate,21337.09,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,59134.52,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,81098.28,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,101583.83,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,9198.88,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,20587.41,100,,,Fee Schedule,100% of CMS OPPS Rate,21337.09,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,454.41,14,,,percent of total billed charges,14% of total billed charges,454.41,101583.83,
23620- Clsd tx/grt hum tube fx w/o manip,3434830,CDM,510,RC,23620,HCPCS,Outpatient,,,693.61,346.81,,520.21,75,,,percent of total billed charges,75% of total billed charges,520.21,75,,,percent of total billed charges,75% of total billed charges,194.62,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,321.11,165,,,Fee Schedule,165% of CMS OPPS Rate,201.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,559.02,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,766.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,960.32,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,194.62,100,,,Fee Schedule,100% of CMS OPPS Rate,201.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,97.11,14,,,percent of total billed charges,14% of total billed charges,97.11,960.32,
23630- Open tx/grt humeral tuberosity fx,3434831,CDM,510,RC,23630,HCPCS,Outpatient,,,2032.26,1016.13,,1524.2,75,,,percent of total billed charges,75% of total billed charges,1524.2,75,,,percent of total billed charges,75% of total billed charges,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,3078.97,102,,,Fee Schedule,102% of WV Medicaid Rate,10261.1,165,,,Fee Schedule,165% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,17862.79,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,24497.4,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,30685.48,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,3018.6,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,284.52,14,,,percent of total billed charges,14% of total billed charges,284.52,30685.48,
23650- Clsd/shoulder dislo/manip/no anest,3434832,CDM,510,RC,23650,HCPCS,Outpatient,,,700.59,350.3,,525.44,75,,,percent of total billed charges,75% of total billed charges,525.44,75,,,percent of total billed charges,75% of total billed charges,194.62,100,,,Fee Schedule,100% of CMS OPPS Rate,84.13,102,,,Fee Schedule,102% of WV Medicaid Rate,321.11,165,,,Fee Schedule,165% of CMS OPPS Rate,201.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,559.02,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,766.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,960.32,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,82.48,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,194.62,100,,,Fee Schedule,100% of CMS OPPS Rate,201.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,98.08,14,,,percent of total billed charges,14% of total billed charges,82.48,960.32,
23655- Clsd tx/shoulder dislo/manip/anest,3434833,CDM,510,RC,23655,HCPCS,Outpatient,,,1060.77,530.39,,795.58,75,,,percent of total billed charges,75% of total billed charges,795.58,75,,,percent of total billed charges,75% of total billed charges,1348.67,100,,,Fee Schedule,100% of CMS OPPS Rate,584.77,102,,,Fee Schedule,102% of WV Medicaid Rate,2225.32,165,,,Fee Schedule,165% of CMS OPPS Rate,1397.79,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,3873.91,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5312.76,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6654.78,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,573.3,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1348.67,100,,,Fee Schedule,100% of CMS OPPS Rate,1397.79,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,148.51,14,,,percent of total billed charges,14% of total billed charges,148.51,6654.78,
23660- Open Tx Acute Shoulder dislocateation,3434834,CDM,510,RC,23660,HCPCS,Outpatient,,,1523.95,761.98,,1142.96,75,,,percent of total billed charges,75% of total billed charges,1142.96,75,,,percent of total billed charges,75% of total billed charges,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,2365.05,102,,,Fee Schedule,102% of WV Medicaid Rate,10261.1,165,,,Fee Schedule,165% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,17862.79,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,24497.4,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,30685.48,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,2318.68,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,213.35,14,,,percent of total billed charges,14% of total billed charges,213.35,30685.48,
23670- Open tx/shoulder dislocate/fx >tubero,3434835,CDM,510,RC,23670,HCPCS,Outpatient,,,2273.72,1136.86,,1705.29,75,,,percent of total billed charges,75% of total billed charges,1705.29,75,,,percent of total billed charges,75% of total billed charges,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,2365.05,102,,,Fee Schedule,102% of WV Medicaid Rate,10261.1,165,,,Fee Schedule,165% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,17862.79,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,24497.4,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,30685.48,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,2318.68,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,318.32,14,,,percent of total billed charges,14% of total billed charges,318.32,30685.48,
23700- Manip/anest/shoulder/fixate app,3434836,CDM,510,RC,23700,HCPCS,Outpatient,,,509.9,254.95,,382.43,75,,,percent of total billed charges,75% of total billed charges,382.43,75,,,percent of total billed charges,75% of total billed charges,1348.67,100,,,Fee Schedule,100% of CMS OPPS Rate,584.77,102,,,Fee Schedule,102% of WV Medicaid Rate,2225.32,165,,,Fee Schedule,165% of CMS OPPS Rate,1397.79,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,3873.91,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5312.76,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6654.78,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,573.3,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1348.67,100,,,Fee Schedule,100% of CMS OPPS Rate,1397.79,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,71.39,14,,,percent of total billed charges,14% of total billed charges,71.39,6654.78,
24101- Arthrotomy/elbow/joint exploration,3434847,CDM,510,RC,24101,HCPCS,Outpatient,,,1308.87,654.44,,981.65,75,,,percent of total billed charges,75% of total billed charges,981.65,75,,,percent of total billed charges,75% of total billed charges,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,1073.09,102,,,Fee Schedule,102% of WV Medicaid Rate,4617.6,165,,,Fee Schedule,165% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8038.46,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11024.11,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13808.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1052.05,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,183.24,14,,,percent of total billed charges,14% of total billed charges,183.24,13808.81,
24332- Tenolysis/triceps,3434854,CDM,510,RC,24332,HCPCS,Outpatient,,,1604.88,802.44,,1203.66,75,,,percent of total billed charges,75% of total billed charges,1203.66,75,,,percent of total billed charges,75% of total billed charges,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,1073.09,102,,,Fee Schedule,102% of WV Medicaid Rate,4617.6,165,,,Fee Schedule,165% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8038.46,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11024.11,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13808.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1052.05,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,224.68,14,,,percent of total billed charges,14% of total billed charges,224.68,13808.81,
24341- Rpr/tendon/musc/upper arm/elbow/ea,3434855,CDM,510,RC,24341,HCPCS,Outpatient,,,1930.59,965.3,,1447.94,75,,,percent of total billed charges,75% of total billed charges,1447.94,75,,,percent of total billed charges,75% of total billed charges,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,2365.05,102,,,Fee Schedule,102% of WV Medicaid Rate,10261.1,165,,,Fee Schedule,165% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,17862.79,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,24497.4,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,30685.48,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,2318.68,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,270.28,14,,,percent of total billed charges,14% of total billed charges,270.28,30685.48,
24342- Reinsert/rup bi/tricep tend/distal,3434856,CDM,510,RC,24342,HCPCS,Outpatient,,,2030.21,1015.11,,1522.66,75,,,percent of total billed charges,75% of total billed charges,1522.66,75,,,percent of total billed charges,75% of total billed charges,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,2365.05,102,,,Fee Schedule,102% of WV Medicaid Rate,10261.1,165,,,Fee Schedule,165% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,17862.79,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,24497.4,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,30685.48,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,2318.68,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,284.23,14,,,percent of total billed charges,14% of total billed charges,284.23,30685.48,
24343- Rpr lat collat lig/elbow/local tis,3434857,CDM,510,RC,24343,HCPCS,Outpatient,,,1854.9,927.45,,1391.18,75,,,percent of total billed charges,75% of total billed charges,1391.18,75,,,percent of total billed charges,75% of total billed charges,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,1073.09,102,,,Fee Schedule,102% of WV Medicaid Rate,4617.6,165,,,Fee Schedule,165% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8038.46,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11024.11,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13808.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1052.05,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,259.69,14,,,percent of total billed charges,14% of total billed charges,259.69,13808.81,
24346- Recon med collat lig/elbow/ten gft,3434858,CDM,510,RC,24346,HCPCS,Outpatient,,,2885.85,1442.93,,2164.39,75,,,percent of total billed charges,75% of total billed charges,2164.39,75,,,percent of total billed charges,75% of total billed charges,12267.36,100,,,Fee Schedule,100% of CMS OPPS Rate,4743.89,102,,,Fee Schedule,102% of WV Medicaid Rate,20241.15,165,,,Fee Schedule,165% of CMS OPPS Rate,12714.07,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,35236.32,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,48323.81,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,60530.47,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,4650.87,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,12267.36,100,,,Fee Schedule,100% of CMS OPPS Rate,12714.07,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,404.02,14,,,percent of total billed charges,14% of total billed charges,404.02,60530.47,
24358- Tenotomy/elbow/debride/open,3434859,CDM,510,RC,24358,HCPCS,Outpatient,,,1373.89,686.95,,1030.42,75,,,percent of total billed charges,75% of total billed charges,1030.42,75,,,percent of total billed charges,75% of total billed charges,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,1073.09,102,,,Fee Schedule,102% of WV Medicaid Rate,4617.6,165,,,Fee Schedule,165% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8038.46,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11024.11,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13808.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1052.05,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,192.34,14,,,percent of total billed charges,14% of total billed charges,192.34,13808.81,
24359- Tenotomy/elbow/debride/open/tend rpr/reattch,3434860,CDM,510,RC,24359,HCPCS,Outpatient,,,1729.07,864.54,,1296.8,75,,,percent of total billed charges,75% of total billed charges,1296.8,75,,,percent of total billed charges,75% of total billed charges,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,1073.09,102,,,Fee Schedule,102% of WV Medicaid Rate,4617.6,165,,,Fee Schedule,165% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8038.46,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11024.11,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13808.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1052.05,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,242.07,14,,,percent of total billed charges,14% of total billed charges,242.07,13808.81,
24363- Arthroplast/elbow/dis hum/prox uln,3434861,CDM,510,RC,24363,HCPCS,Outpatient,,,3802.54,1901.27,,2851.91,75,,,percent of total billed charges,75% of total billed charges,2851.91,75,,,percent of total billed charges,75% of total billed charges,20587.41,100,,,Fee Schedule,100% of CMS OPPS Rate,9935.92,102,,,Fee Schedule,102% of WV Medicaid Rate,33969.22,165,,,Fee Schedule,165% of CMS OPPS Rate,21337.09,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,59134.52,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,81098.28,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,101583.83,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,9741.1,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,20587.41,100,,,Fee Schedule,100% of CMS OPPS Rate,21337.09,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,532.36,14,,,percent of total billed charges,14% of total billed charges,532.36,101583.83,
24366- Arthroplasty/radial head w/implant,3434862,CDM,510,RC,24366,HCPCS,Outpatient,,,1782.18,891.09,,1336.64,75,,,percent of total billed charges,75% of total billed charges,1336.64,75,,,percent of total billed charges,75% of total billed charges,12267.36,100,,,Fee Schedule,100% of CMS OPPS Rate,7344.6,102,,,Fee Schedule,102% of WV Medicaid Rate,20241.15,165,,,Fee Schedule,165% of CMS OPPS Rate,12714.07,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,35236.32,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,48323.81,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,60530.47,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,7200.59,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,12267.36,100,,,Fee Schedule,100% of CMS OPPS Rate,12714.07,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,249.51,14,,,percent of total billed charges,14% of total billed charges,249.51,60530.47,
24430- Rpr non/malunion/humerus w/o gft,3434863,CDM,510,RC,24430,HCPCS,Outpatient,,,2765.89,1382.95,,2074.42,75,,,percent of total billed charges,75% of total billed charges,2074.42,75,,,percent of total billed charges,75% of total billed charges,12267.36,100,,,Fee Schedule,100% of CMS OPPS Rate,6630.91,102,,,Fee Schedule,102% of WV Medicaid Rate,20241.15,165,,,Fee Schedule,165% of CMS OPPS Rate,12714.07,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,35236.32,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,48323.81,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,60530.47,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,6500.89,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,12267.36,100,,,Fee Schedule,100% of CMS OPPS Rate,12714.07,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,387.22,14,,,percent of total billed charges,14% of total billed charges,387.22,60530.47,
25400- Rpr/non/malunion/radius or ulna,3434893,CDM,510,RC,24500,HCPCS,Outpatient,,,925.42,462.71,,694.07,75,,,percent of total billed charges,75% of total billed charges,694.07,75,,,percent of total billed charges,75% of total billed charges,194.62,100,,,Fee Schedule,100% of CMS OPPS Rate,84.13,102,,,Fee Schedule,102% of WV Medicaid Rate,321.11,165,,,Fee Schedule,165% of CMS OPPS Rate,201.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,559.02,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,766.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,960.32,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,82.48,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,194.62,100,,,Fee Schedule,100% of CMS OPPS Rate,201.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,129.56,14,,,percent of total billed charges,14% of total billed charges,82.48,960.32,
24505- Clsd tx.humeral shaft fx w/manip,3434865,CDM,510,RC,24505,HCPCS,Outpatient,,,1300.32,650.16,,975.24,75,,,percent of total billed charges,75% of total billed charges,975.24,75,,,percent of total billed charges,75% of total billed charges,1348.67,100,,,Fee Schedule,100% of CMS OPPS Rate,584.77,102,,,Fee Schedule,102% of WV Medicaid Rate,2225.32,165,,,Fee Schedule,165% of CMS OPPS Rate,1397.79,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,3873.91,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5312.76,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6654.78,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,573.3,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1348.67,100,,,Fee Schedule,100% of CMS OPPS Rate,1397.79,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,182.04,14,,,percent of total billed charges,14% of total billed charges,182.04,6654.78,
24515- Open tx humeral fx/w plate/screw,3434866,CDM,510,RC,24515,HCPCS,Outpatient,,,2304.63,1152.32,,1728.47,75,,,percent of total billed charges,75% of total billed charges,1728.47,75,,,percent of total billed charges,75% of total billed charges,12267.36,100,,,Fee Schedule,100% of CMS OPPS Rate,6484.94,102,,,Fee Schedule,102% of WV Medicaid Rate,20241.15,165,,,Fee Schedule,165% of CMS OPPS Rate,12714.07,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,35236.32,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,48323.81,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,60530.47,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,6357.78,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,12267.36,100,,,Fee Schedule,100% of CMS OPPS Rate,12714.07,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,322.65,14,,,percent of total billed charges,14% of total billed charges,322.65,60530.47,
24516- Tx humeral fx/intramedullary implt,3434867,CDM,510,RC,24516,HCPCS,Outpatient,,,2254.37,1127.19,,1690.78,75,,,percent of total billed charges,75% of total billed charges,1690.78,75,,,percent of total billed charges,75% of total billed charges,12267.36,100,,,Fee Schedule,100% of CMS OPPS Rate,6630.91,102,,,Fee Schedule,102% of WV Medicaid Rate,20241.15,165,,,Fee Schedule,165% of CMS OPPS Rate,12714.07,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,35236.32,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,48323.81,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,60530.47,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,6500.89,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,12267.36,100,,,Fee Schedule,100% of CMS OPPS Rate,12714.07,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,315.61,14,,,percent of total billed charges,14% of total billed charges,315.61,60530.47,
24530- Clsd tx/supra/transcon hum fx w/o manip,3434868,CDM,510,RC,24530,HCPCS,Outpatient,,,979.11,489.56,,734.33,75,,,percent of total billed charges,75% of total billed charges,734.33,75,,,percent of total billed charges,75% of total billed charges,194.62,100,,,Fee Schedule,100% of CMS OPPS Rate,84.13,102,,,Fee Schedule,102% of WV Medicaid Rate,321.11,165,,,Fee Schedule,165% of CMS OPPS Rate,201.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,559.02,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,766.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,960.32,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,82.48,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,194.62,100,,,Fee Schedule,100% of CMS OPPS Rate,201.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,137.08,14,,,percent of total billed charges,14% of total billed charges,82.48,960.32,
24535- Clsd tx/humeral fx w/ manip,3434869,CDM,510,RC,24535,HCPCS,Outpatient,,,1601.61,800.81,,1201.21,75,,,percent of total billed charges,75% of total billed charges,1201.21,75,,,percent of total billed charges,75% of total billed charges,1348.67,100,,,Fee Schedule,100% of CMS OPPS Rate,584.77,102,,,Fee Schedule,102% of WV Medicaid Rate,2225.32,165,,,Fee Schedule,165% of CMS OPPS Rate,1397.79,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,3873.91,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5312.76,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6654.78,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,573.3,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1348.67,100,,,Fee Schedule,100% of CMS OPPS Rate,1397.79,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,224.23,14,,,percent of total billed charges,14% of total billed charges,224.23,6654.78,
24538- Perc skel fix/supra/transcon hum f,3434870,CDM,510,RC,24538,HCPCS,Outpatient,,,2057.21,1028.61,,1542.91,75,,,percent of total billed charges,75% of total billed charges,1542.91,75,,,percent of total billed charges,75% of total billed charges,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,2365.05,102,,,Fee Schedule,102% of WV Medicaid Rate,10261.1,165,,,Fee Schedule,165% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,17862.79,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,24497.4,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,30685.48,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,2318.68,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.01,14,,,percent of total billed charges,14% of total billed charges,288.01,30685.48,
24545- Open tx supra/transcondylar fx,3434871,CDM,510,RC,24545,HCPCS,Outpatient,,,2432.84,1216.42,,1824.63,75,,,percent of total billed charges,75% of total billed charges,1824.63,75,,,percent of total billed charges,75% of total billed charges,12267.36,100,,,Fee Schedule,100% of CMS OPPS Rate,6694.2,102,,,Fee Schedule,102% of WV Medicaid Rate,20241.15,165,,,Fee Schedule,165% of CMS OPPS Rate,12714.07,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,35236.32,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,48323.81,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,60530.47,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,6562.94,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,12267.36,100,,,Fee Schedule,100% of CMS OPPS Rate,12714.07,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,340.6,14,,,percent of total billed charges,14% of total billed charges,340.6,60530.47,
24546- Open tx/humeral condylar fx w/ext,3434872,CDM,510,RC,24546,HCPCS,Outpatient,,,2718.35,1359.18,,2038.76,75,,,percent of total billed charges,75% of total billed charges,2038.76,75,,,percent of total billed charges,75% of total billed charges,12267.36,100,,,Fee Schedule,100% of CMS OPPS Rate,9038.79,102,,,Fee Schedule,102% of WV Medicaid Rate,20241.15,165,,,Fee Schedule,165% of CMS OPPS Rate,12714.07,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,35236.32,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,48323.81,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,60530.47,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,8861.56,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,12267.36,100,,,Fee Schedule,100% of CMS OPPS Rate,12714.07,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,380.57,14,,,percent of total billed charges,14% of total billed charges,380.57,60530.47,
24560- Clsd tx/hum epicon fx w/o manip,3434873,CDM,510,RC,24560,HCPCS,Outpatient,,,849.71,424.86,,637.28,75,,,percent of total billed charges,75% of total billed charges,637.28,75,,,percent of total billed charges,75% of total billed charges,194.62,100,,,Fee Schedule,100% of CMS OPPS Rate,84.13,102,,,Fee Schedule,102% of WV Medicaid Rate,321.11,165,,,Fee Schedule,165% of CMS OPPS Rate,201.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,559.02,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,766.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,960.32,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,82.48,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,194.62,100,,,Fee Schedule,100% of CMS OPPS Rate,201.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,118.96,14,,,percent of total billed charges,14% of total billed charges,82.48,960.32,
24565- Clsd tx/humeral epicond fx w/manip,3434874,CDM,510,RC,24565,HCPCS,Outpatient,,,1395.56,697.78,,1046.67,75,,,percent of total billed charges,75% of total billed charges,1046.67,75,,,percent of total billed charges,75% of total billed charges,1348.67,100,,,Fee Schedule,100% of CMS OPPS Rate,584.77,102,,,Fee Schedule,102% of WV Medicaid Rate,2225.32,165,,,Fee Schedule,165% of CMS OPPS Rate,1397.79,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,3873.91,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5312.76,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6654.78,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,573.3,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1348.67,100,,,Fee Schedule,100% of CMS OPPS Rate,1397.79,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,195.38,14,,,percent of total billed charges,14% of total billed charges,195.38,6654.78,
24575- Open tx/hum epicon fx/med/lat,3434875,CDM,510,RC,24575,HCPCS,Outpatient,,,1908.94,954.47,,1431.71,75,,,percent of total billed charges,75% of total billed charges,1431.71,75,,,percent of total billed charges,75% of total billed charges,12267.36,100,,,Fee Schedule,100% of CMS OPPS Rate,6517.73,102,,,Fee Schedule,102% of WV Medicaid Rate,20241.15,165,,,Fee Schedule,165% of CMS OPPS Rate,12714.07,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,35236.32,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,48323.81,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,60530.47,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,6389.93,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,12267.36,100,,,Fee Schedule,100% of CMS OPPS Rate,12714.07,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,267.25,14,,,percent of total billed charges,14% of total billed charges,267.25,60530.47,
24576- Clsd tx/hum condylar fx/med/lat,3434876,CDM,510,RC,24576,HCPCS,Outpatient,,,894.17,447.09,,670.63,75,,,percent of total billed charges,75% of total billed charges,670.63,75,,,percent of total billed charges,75% of total billed charges,194.62,100,,,Fee Schedule,100% of CMS OPPS Rate,84.13,102,,,Fee Schedule,102% of WV Medicaid Rate,321.11,165,,,Fee Schedule,165% of CMS OPPS Rate,201.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,559.02,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,766.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,960.32,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,82.48,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,194.62,100,,,Fee Schedule,100% of CMS OPPS Rate,201.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,125.18,14,,,percent of total billed charges,14% of total billed charges,82.48,960.32,
24579- Open tx/hum condylar fx/med/lat,3434877,CDM,510,RC,24579,HCPCS,Outpatient,,,2176.87,1088.44,,1632.65,75,,,percent of total billed charges,75% of total billed charges,1632.65,75,,,percent of total billed charges,75% of total billed charges,12267.36,100,,,Fee Schedule,100% of CMS OPPS Rate,6255.81,102,,,Fee Schedule,102% of WV Medicaid Rate,20241.15,165,,,Fee Schedule,165% of CMS OPPS Rate,12714.07,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,35236.32,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,48323.81,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,60530.47,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,6133.15,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,12267.36,100,,,Fee Schedule,100% of CMS OPPS Rate,12714.07,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,304.76,14,,,percent of total billed charges,14% of total billed charges,304.76,60530.47,
24600- Tx/clsd elbow dislocateate w/o anesth,3434878,CDM,510,RC,24600,HCPCS,Outpatient,,,975.16,487.58,,731.37,75,,,percent of total billed charges,75% of total billed charges,731.37,75,,,percent of total billed charges,75% of total billed charges,194.62,100,,,Fee Schedule,100% of CMS OPPS Rate,84.13,102,,,Fee Schedule,102% of WV Medicaid Rate,321.11,165,,,Fee Schedule,165% of CMS OPPS Rate,201.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,559.02,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,766.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,960.32,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,82.48,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,194.62,100,,,Fee Schedule,100% of CMS OPPS Rate,201.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,136.52,14,,,percent of total billed charges,14% of total billed charges,82.48,960.32,
TX CLOSED ELBOW DISLOCATION W/O ANESTHESIA,3428535,CDM,981,RC,24600,HCPCS,Outpatient,,,975.16,487.58,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
24605- Tx/clsd elbow dislocateate/anesth,3434879,CDM,510,RC,24605,HCPCS,Outpatient,,,1240.25,620.13,,930.19,75,,,percent of total billed charges,75% of total billed charges,930.19,75,,,percent of total billed charges,75% of total billed charges,1348.67,100,,,Fee Schedule,100% of CMS OPPS Rate,584.77,102,,,Fee Schedule,102% of WV Medicaid Rate,2225.32,165,,,Fee Schedule,165% of CMS OPPS Rate,1397.79,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,3873.91,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5312.76,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6654.78,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,573.3,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1348.67,100,,,Fee Schedule,100% of CMS OPPS Rate,1397.79,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,173.64,14,,,percent of total billed charges,14% of total billed charges,173.64,6654.78,
24620- Clsd tx/Monteggia fx/elbow/manip,3434881,CDM,510,RC,24620,HCPCS,Outpatient,,,1472.41,736.21,,1104.31,75,,,percent of total billed charges,75% of total billed charges,1104.31,75,,,percent of total billed charges,75% of total billed charges,1348.67,100,,,Fee Schedule,100% of CMS OPPS Rate,584.77,102,,,Fee Schedule,102% of WV Medicaid Rate,2225.32,165,,,Fee Schedule,165% of CMS OPPS Rate,1397.79,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,3873.91,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5312.76,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6654.78,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,573.3,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1348.67,100,,,Fee Schedule,100% of CMS OPPS Rate,1397.79,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,206.14,14,,,percent of total billed charges,14% of total billed charges,206.14,6654.78,
24635- Open tx/Monteggia fx/elbow,3434882,CDM,510,RC,24635,HCPCS,Outpatient,,,1756.25,878.13,,1317.19,75,,,percent of total billed charges,75% of total billed charges,1317.19,75,,,percent of total billed charges,75% of total billed charges,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,3277.26,102,,,Fee Schedule,102% of WV Medicaid Rate,10261.1,165,,,Fee Schedule,165% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,17862.79,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,24497.4,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,30685.48,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,3213,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,245.88,14,,,percent of total billed charges,14% of total billed charges,245.88,30685.48,
24650- Clsd tx/radial head/neck fx/no manip,3434883,CDM,510,RC,24650,HCPCS,Outpatient,,,669.8,334.9,,502.35,75,,,percent of total billed charges,75% of total billed charges,502.35,75,,,percent of total billed charges,75% of total billed charges,194.62,100,,,Fee Schedule,100% of CMS OPPS Rate,84.13,102,,,Fee Schedule,102% of WV Medicaid Rate,321.11,165,,,Fee Schedule,165% of CMS OPPS Rate,201.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,559.02,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,766.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,960.32,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,82.48,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,194.62,100,,,Fee Schedule,100% of CMS OPPS Rate,201.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,93.77,14,,,percent of total billed charges,14% of total billed charges,82.48,960.32,
24670- Clsd/ulnar fx/prox end w/o manip,3434884,CDM,510,RC,24670,HCPCS,Outpatient,,,748.5,374.25,,561.38,75,,,percent of total billed charges,75% of total billed charges,561.38,75,,,percent of total billed charges,75% of total billed charges,194.62,100,,,Fee Schedule,100% of CMS OPPS Rate,84.13,102,,,Fee Schedule,102% of WV Medicaid Rate,321.11,165,,,Fee Schedule,165% of CMS OPPS Rate,201.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,559.02,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,766.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,960.32,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,82.48,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,194.62,100,,,Fee Schedule,100% of CMS OPPS Rate,201.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,104.79,14,,,percent of total billed charges,14% of total billed charges,82.48,960.32,
24685- Open tx/ulnar fracture,3434885,CDM,510,RC,24685,HCPCS,Outpatient,,,1699.5,849.75,,1274.63,75,,,percent of total billed charges,75% of total billed charges,1274.63,75,,,percent of total billed charges,75% of total billed charges,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,3129.18,102,,,Fee Schedule,102% of WV Medicaid Rate,10261.1,165,,,Fee Schedule,165% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,17862.79,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,24497.4,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,30685.48,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,3067.82,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,237.93,14,,,percent of total billed charges,14% of total billed charges,237.93,30685.48,
25065- Bx/soft tis/forearm/wrist/superfic,3434888,CDM,510,RC,25065,HCPCS,Outpatient,,,315.37,157.69,,236.53,75,,,percent of total billed charges,75% of total billed charges,236.53,75,,,percent of total billed charges,75% of total billed charges,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,147.41,102,,,Fee Schedule,102% of WV Medicaid Rate,2326.19,165,,,Fee Schedule,165% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4049.52,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5553.61,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6956.46,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,144.52,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,44.15,14,,,percent of total billed charges,14% of total billed charges,44.15,6956.46,
25075- Exc SQ tumor/forearm/wrist/<3cm,3434889,CDM,960,RC,25075,HCPCS,Outpatient,,,641.19,320.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
25248- Exp w remove/deep FB/forearm/wrist,3434890,CDM,510,RC,25248,HCPCS,Outpatient,,,1094.47,547.24,,820.85,75,,,percent of total billed charges,75% of total billed charges,820.85,75,,,percent of total billed charges,75% of total billed charges,1348.67,100,,,Fee Schedule,100% of CMS OPPS Rate,584.77,102,,,Fee Schedule,102% of WV Medicaid Rate,2225.32,165,,,Fee Schedule,165% of CMS OPPS Rate,1397.79,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,3873.91,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5312.76,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6654.78,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,573.3,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1348.67,100,,,Fee Schedule,100% of CMS OPPS Rate,1397.79,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,153.23,14,,,percent of total billed charges,14% of total billed charges,153.23,6654.78,
25265- Rpr flex ten/mus/forearm/wrist/gft,3434891,CDM,510,RC,25265,HCPCS,Outpatient,,,1955.42,977.71,,1466.57,75,,,percent of total billed charges,75% of total billed charges,1466.57,75,,,percent of total billed charges,75% of total billed charges,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,1073.09,102,,,Fee Schedule,102% of WV Medicaid Rate,4617.6,165,,,Fee Schedule,165% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8038.46,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11024.11,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13808.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1052.05,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,273.76,14,,,percent of total billed charges,14% of total billed charges,273.76,13808.81,
25270- Rpr extensor ten/mus/forearm/wrist,3434892,CDM,510,RC,25270,HCPCS,Outpatient,,,1280.81,640.41,,960.61,75,,,percent of total billed charges,75% of total billed charges,960.61,75,,,percent of total billed charges,75% of total billed charges,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,1073.09,102,,,Fee Schedule,102% of WV Medicaid Rate,4617.6,165,,,Fee Schedule,165% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8038.46,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11024.11,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13808.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1052.05,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,179.31,14,,,percent of total billed charges,14% of total billed charges,179.31,13808.81,
25500- Clsd tx/radial shaft fx w/o manip,3434894,CDM,510,RC,25500,HCPCS,Outpatient,,,726.31,363.16,,544.73,75,,,percent of total billed charges,75% of total billed charges,544.73,75,,,percent of total billed charges,75% of total billed charges,194.62,100,,,Fee Schedule,100% of CMS OPPS Rate,84.13,102,,,Fee Schedule,102% of WV Medicaid Rate,321.11,165,,,Fee Schedule,165% of CMS OPPS Rate,201.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,559.02,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,766.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,960.32,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,82.48,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,194.62,100,,,Fee Schedule,100% of CMS OPPS Rate,201.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,101.68,14,,,percent of total billed charges,14% of total billed charges,82.48,960.32,
25526- Open tx/rad shaft fx/dis radiouln dislocateat/rpr triang fibrocart comp,3434895,CDM,510,RC,25526,HCPCS,Outpatient,,,2502.3,1251.15,,1876.73,75,,,percent of total billed charges,75% of total billed charges,1876.73,75,,,percent of total billed charges,75% of total billed charges,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,3078.97,102,,,Fee Schedule,102% of WV Medicaid Rate,10261.1,165,,,Fee Schedule,165% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,17862.79,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,24497.4,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,30685.48,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,3018.6,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,350.32,14,,,percent of total billed charges,14% of total billed charges,350.32,30685.48,
25530- Clsd tx/ulnar shaft fx w/o manip,3434896,CDM,510,RC,25530,HCPCS,Outpatient,,,668.58,334.29,,501.44,75,,,percent of total billed charges,75% of total billed charges,501.44,75,,,percent of total billed charges,75% of total billed charges,194.62,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,321.11,165,,,Fee Schedule,165% of CMS OPPS Rate,201.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,559.02,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,766.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,960.32,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,194.62,100,,,Fee Schedule,100% of CMS OPPS Rate,201.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,93.6,14,,,percent of total billed charges,14% of total billed charges,93.6,960.32,
PHY-CLOSED RADIAL/ULNAR SHAFT FX W/ MANIPULATION,3428505,CDM,981,RC,25565,HCPCS,Outpatient,,,1347.38,673.69,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
25606- Perc skeletal fix/distal radial fx,3434897,CDM,510,RC,25606,HCPCS,Outpatient,,,1733.27,866.64,,1299.95,75,,,percent of total billed charges,75% of total billed charges,1299.95,75,,,percent of total billed charges,75% of total billed charges,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,1073.09,102,,,Fee Schedule,102% of WV Medicaid Rate,4617.6,165,,,Fee Schedule,165% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8038.46,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11024.11,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13808.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1052.05,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,242.66,14,,,percent of total billed charges,14% of total billed charges,242.66,13808.81,
25607- Open tx/dis radial extra-artic fx,3434898,CDM,510,RC,25607,HCPCS,Outpatient,,,1918.39,959.2,,1438.79,75,,,percent of total billed charges,75% of total billed charges,1438.79,75,,,percent of total billed charges,75% of total billed charges,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,3396.1,102,,,Fee Schedule,102% of WV Medicaid Rate,10261.1,165,,,Fee Schedule,165% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,17862.79,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,24497.4,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,30685.48,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,3329.51,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,268.57,14,,,percent of total billed charges,14% of total billed charges,268.57,30685.48,
25628- Open tx/carpal scaphoid fracture,3434899,CDM,510,RC,25628,HCPCS,Outpatient,,,1875.15,937.58,,1406.36,75,,,percent of total billed charges,75% of total billed charges,1406.36,75,,,percent of total billed charges,75% of total billed charges,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,2365.05,102,,,Fee Schedule,102% of WV Medicaid Rate,10261.1,165,,,Fee Schedule,165% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,17862.79,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,24497.4,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,30685.48,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,2318.68,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,262.52,14,,,percent of total billed charges,14% of total billed charges,262.52,30685.48,
26037- Decompr fasciotomy/hand,3434902,CDM,510,RC,26037,HCPCS,Outpatient,,,1461.22,730.61,,1095.92,75,,,percent of total billed charges,75% of total billed charges,1095.92,75,,,percent of total billed charges,75% of total billed charges,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,1073.09,102,,,Fee Schedule,102% of WV Medicaid Rate,4617.6,165,,,Fee Schedule,165% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8038.46,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11024.11,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13808.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1052.05,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,204.57,14,,,percent of total billed charges,14% of total billed charges,204.57,13808.81,
26070- Arthrotomy/carpometacarpal joint,3434903,CDM,510,RC,26070,HCPCS,Outpatient,,,826.9,413.45,,620.18,75,,,percent of total billed charges,75% of total billed charges,620.18,75,,,percent of total billed charges,75% of total billed charges,1348.67,100,,,Fee Schedule,100% of CMS OPPS Rate,584.77,102,,,Fee Schedule,102% of WV Medicaid Rate,2225.32,165,,,Fee Schedule,165% of CMS OPPS Rate,1397.79,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,3873.91,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5312.76,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6654.78,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,573.3,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1348.67,100,,,Fee Schedule,100% of CMS OPPS Rate,1397.79,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,115.77,14,,,percent of total billed charges,14% of total billed charges,115.77,6654.78,
26075- Arthrotomy/metacarpophalangeal/ea,3434904,CDM,510,RC,26075,HCPCS,Outpatient,,,870.67,435.34,,653,75,,,percent of total billed charges,75% of total billed charges,653,75,,,percent of total billed charges,75% of total billed charges,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,1073.09,102,,,Fee Schedule,102% of WV Medicaid Rate,4617.6,165,,,Fee Schedule,165% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8038.46,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11024.11,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13808.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1052.05,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,121.89,14,,,percent of total billed charges,14% of total billed charges,121.89,13808.81,
26080- Arthrotomy/explore/interphalangeal,3434905,CDM,510,RC,26080,HCPCS,Outpatient,,,1025.13,512.57,,768.85,75,,,percent of total billed charges,75% of total billed charges,768.85,75,,,percent of total billed charges,75% of total billed charges,1348.67,100,,,Fee Schedule,100% of CMS OPPS Rate,584.77,102,,,Fee Schedule,102% of WV Medicaid Rate,2225.32,165,,,Fee Schedule,165% of CMS OPPS Rate,1397.79,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,3873.91,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5312.76,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6654.78,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,573.3,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1348.67,100,,,Fee Schedule,100% of CMS OPPS Rate,1397.79,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,143.52,14,,,percent of total billed charges,14% of total billed charges,143.52,6654.78,
26111- Exc SQ tum/vasc malform/hand/fngr,3434906,CDM,510,RC,26111,HCPCS,Outpatient,,,1077.9,538.95,,808.43,75,,,percent of total billed charges,75% of total billed charges,808.43,75,,,percent of total billed charges,75% of total billed charges,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,479.67,102,,,Fee Schedule,102% of WV Medicaid Rate,2326.19,165,,,Fee Schedule,165% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4049.52,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5553.61,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6956.46,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,470.26,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,150.91,14,,,percent of total billed charges,14% of total billed charges,150.91,6956.46,
26115- Exc hand les sc < 1.5 cm,3434907,CDM,960,RC,26115,HCPCS,Outpatient,,,672.8,336.4,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
26123- Fasciect/part palm/rls sng digit,3434908,CDM,510,RC,26123,HCPCS,Outpatient,,,2168.04,1084.02,,1626.03,75,,,percent of total billed charges,75% of total billed charges,1626.03,75,,,percent of total billed charges,75% of total billed charges,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,1073.09,102,,,Fee Schedule,102% of WV Medicaid Rate,4617.6,165,,,Fee Schedule,165% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8038.46,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11024.11,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13808.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1052.05,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,303.53,14,,,percent of total billed charges,14% of total billed charges,303.53,13808.81,
26210- Exc/curet/bone cyst/bgn tum/phalan,3434909,CDM,510,RC,26210,HCPCS,Outpatient,,,1152.9,576.45,,864.68,75,,,percent of total billed charges,75% of total billed charges,864.68,75,,,percent of total billed charges,75% of total billed charges,1348.67,100,,,Fee Schedule,100% of CMS OPPS Rate,584.77,102,,,Fee Schedule,102% of WV Medicaid Rate,2225.32,165,,,Fee Schedule,165% of CMS OPPS Rate,1397.79,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,3873.91,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5312.76,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6654.78,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,573.3,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1348.67,100,,,Fee Schedule,100% of CMS OPPS Rate,1397.79,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,161.41,14,,,percent of total billed charges,14% of total billed charges,161.41,6654.78,
26215- Exc/curet/bone cyst/bgn tum/phalanx/autogft,3434910,CDM,510,RC,26215,HCPCS,Outpatient,,,1480.03,740.02,,1110.02,75,,,percent of total billed charges,75% of total billed charges,1110.02,75,,,percent of total billed charges,75% of total billed charges,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,1073.09,102,,,Fee Schedule,102% of WV Medicaid Rate,4617.6,165,,,Fee Schedule,165% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8038.46,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11024.11,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13808.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1052.05,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,207.2,14,,,percent of total billed charges,14% of total billed charges,207.2,13808.81,
26370- Repair/fngr/hand tendon/ea tendon,3434911,CDM,510,RC,26370,HCPCS,Outpatient,,,2020.13,1010.07,,1515.1,75,,,percent of total billed charges,75% of total billed charges,1515.1,75,,,percent of total billed charges,75% of total billed charges,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,1073.09,102,,,Fee Schedule,102% of WV Medicaid Rate,4617.6,165,,,Fee Schedule,165% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8038.46,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11024.11,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13808.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1052.05,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,282.82,14,,,percent of total billed charges,14% of total billed charges,282.82,13808.81,
"26410-Closed treatment of radial head subluxation in child, nursemaid elbow, with manipulation",3783562,CDM,510,RC,26410,HCPCS,Outpatient,,,1535.51,767.76,,1151.63,75,,,percent of total billed charges,75% of total billed charges,1151.63,75,,,percent of total billed charges,75% of total billed charges,1348.67,100,,,Fee Schedule,100% of CMS OPPS Rate,584.77,102,,,Fee Schedule,102% of WV Medicaid Rate,2225.32,165,,,Fee Schedule,165% of CMS OPPS Rate,1397.79,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,3873.91,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5312.76,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6654.78,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,573.3,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1348.67,100,,,Fee Schedule,100% of CMS OPPS Rate,1397.79,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,214.97,14,,,percent of total billed charges,14% of total billed charges,214.97,6654.78,
26440- Tenolysis/flex tend/palm/finger/ea,3434912,CDM,510,RC,26440,HCPCS,Outpatient,,,1661.87,830.94,,1246.4,75,,,percent of total billed charges,75% of total billed charges,1246.4,75,,,percent of total billed charges,75% of total billed charges,1348.67,100,,,Fee Schedule,100% of CMS OPPS Rate,584.77,102,,,Fee Schedule,102% of WV Medicaid Rate,2225.32,165,,,Fee Schedule,165% of CMS OPPS Rate,1397.79,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,3873.91,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5312.76,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6654.78,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,573.3,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1348.67,100,,,Fee Schedule,100% of CMS OPPS Rate,1397.79,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,232.66,14,,,percent of total billed charges,14% of total billed charges,232.66,6654.78,
26442- Tenolysis/flex ten/palm & fing/ea,3434913,CDM,510,RC,26442,HCPCS,Outpatient,,,2539.31,1269.66,,1904.48,75,,,percent of total billed charges,75% of total billed charges,1904.48,75,,,percent of total billed charges,75% of total billed charges,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,1073.09,102,,,Fee Schedule,102% of WV Medicaid Rate,4617.6,165,,,Fee Schedule,165% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8038.46,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11024.11,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13808.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1052.05,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,355.5,14,,,percent of total billed charges,14% of total billed charges,355.5,13808.81,
26445- Tenolysis/ext tend/hand/finger/ea,3434914,CDM,510,RC,26445,HCPCS,Outpatient,,,1547.28,773.64,,1160.46,75,,,percent of total billed charges,75% of total billed charges,1160.46,75,,,percent of total billed charges,75% of total billed charges,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,1073.09,102,,,Fee Schedule,102% of WV Medicaid Rate,4617.6,165,,,Fee Schedule,165% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8038.46,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11024.11,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13808.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1052.05,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,216.62,14,,,percent of total billed charges,14% of total billed charges,216.62,13808.81,
26546- Repair non-union/metacarp/phalanx,3434915,CDM,510,RC,26546,HCPCS,Outpatient,,,2665.64,1332.82,,1999.23,75,,,percent of total billed charges,75% of total billed charges,1999.23,75,,,percent of total billed charges,75% of total billed charges,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,2365.05,102,,,Fee Schedule,102% of WV Medicaid Rate,10261.1,165,,,Fee Schedule,165% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,17862.79,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,24497.4,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,30685.48,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,2318.68,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,373.19,14,,,percent of total billed charges,14% of total billed charges,373.19,30685.48,
26548- Repair/reconst/finger/volar plate,3434916,CDM,510,RC,26548,HCPCS,Outpatient,,,2062.68,1031.34,,1547.01,75,,,percent of total billed charges,75% of total billed charges,1547.01,75,,,percent of total billed charges,75% of total billed charges,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,1073.09,102,,,Fee Schedule,102% of WV Medicaid Rate,4617.6,165,,,Fee Schedule,165% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8038.46,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11024.11,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13808.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1052.05,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.78,14,,,percent of total billed charges,14% of total billed charges,288.78,13808.81,
26567- Osteotomy/phalanx of finger/each,3434917,CDM,510,RC,26567,HCPCS,Outpatient,,,1854.64,927.32,,1390.98,75,,,percent of total billed charges,75% of total billed charges,1390.98,75,,,percent of total billed charges,75% of total billed charges,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,1073.09,102,,,Fee Schedule,102% of WV Medicaid Rate,4617.6,165,,,Fee Schedule,165% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8038.46,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11024.11,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13808.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1052.05,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,259.65,14,,,percent of total billed charges,14% of total billed charges,259.65,13808.81,
26591- Rpr/intrinsic muscles/hand/ea,3434918,CDM,510,RC,26591,HCPCS,Outpatient,,,1233.61,616.81,,925.21,75,,,percent of total billed charges,75% of total billed charges,925.21,75,,,percent of total billed charges,75% of total billed charges,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,1073.09,102,,,Fee Schedule,102% of WV Medicaid Rate,4617.6,165,,,Fee Schedule,165% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8038.46,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11024.11,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13808.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1052.05,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,172.71,14,,,percent of total billed charges,14% of total billed charges,172.71,13808.81,
26600- Clsd tx/metacarpal fx/sg w/o manip,3434919,CDM,510,RC,26600,HCPCS,Outpatient,,,765.01,382.51,,573.76,75,,,percent of total billed charges,75% of total billed charges,573.76,75,,,percent of total billed charges,75% of total billed charges,194.62,100,,,Fee Schedule,100% of CMS OPPS Rate,84.13,102,,,Fee Schedule,102% of WV Medicaid Rate,321.11,165,,,Fee Schedule,165% of CMS OPPS Rate,201.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,559.02,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,766.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,960.32,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,82.48,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,194.62,100,,,Fee Schedule,100% of CMS OPPS Rate,201.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,107.1,14,,,percent of total billed charges,14% of total billed charges,82.48,960.32,
26605- Clsd tx/metacarpal fx/sng/w manip,3434920,CDM,510,RC,26605,HCPCS,Outpatient,,,846.41,423.21,,634.81,75,,,percent of total billed charges,75% of total billed charges,634.81,75,,,percent of total billed charges,75% of total billed charges,194.62,100,,,Fee Schedule,100% of CMS OPPS Rate,84.13,102,,,Fee Schedule,102% of WV Medicaid Rate,321.11,165,,,Fee Schedule,165% of CMS OPPS Rate,201.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,559.02,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,766.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,960.32,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,82.48,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,194.62,100,,,Fee Schedule,100% of CMS OPPS Rate,201.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,118.5,14,,,percent of total billed charges,14% of total billed charges,82.48,960.32,
26608- Perc skel fix/metacarpal fx/each,3434921,CDM,510,RC,26608,HCPCS,Outpatient,,,1244.01,622.01,,933.01,75,,,percent of total billed charges,75% of total billed charges,933.01,75,,,percent of total billed charges,75% of total billed charges,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,1073.09,102,,,Fee Schedule,102% of WV Medicaid Rate,4617.6,165,,,Fee Schedule,165% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8038.46,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11024.11,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13808.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1052.05,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,174.16,14,,,percent of total billed charges,14% of total billed charges,174.16,13808.81,
26615- Open tx/metacarpal fx/single,3434922,CDM,510,RC,26615,HCPCS,Outpatient,,,1488.19,744.1,,1116.14,75,,,percent of total billed charges,75% of total billed charges,1116.14,75,,,percent of total billed charges,75% of total billed charges,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,1073.09,102,,,Fee Schedule,102% of WV Medicaid Rate,4617.6,165,,,Fee Schedule,165% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8038.46,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11024.11,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13808.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1052.05,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,208.35,14,,,percent of total billed charges,14% of total billed charges,208.35,13808.81,
26641- Clsd tx/carpometa dislocate/thum,3434923,CDM,510,RC,26641,HCPCS,Outpatient,,,1078.17,539.09,,808.63,75,,,percent of total billed charges,75% of total billed charges,808.63,75,,,percent of total billed charges,75% of total billed charges,194.62,100,,,Fee Schedule,100% of CMS OPPS Rate,84.13,102,,,Fee Schedule,102% of WV Medicaid Rate,321.11,165,,,Fee Schedule,165% of CMS OPPS Rate,201.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,559.02,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,766.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,960.32,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,82.48,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,194.62,100,,,Fee Schedule,100% of CMS OPPS Rate,201.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,150.94,14,,,percent of total billed charges,14% of total billed charges,82.48,960.32,
26645- Clsd tx/carpometa fx disloc/manip,3434924,CDM,510,RC,26645,HCPCS,Outpatient,,,1120.8,560.4,,840.6,75,,,percent of total billed charges,75% of total billed charges,840.6,75,,,percent of total billed charges,75% of total billed charges,1348.67,100,,,Fee Schedule,100% of CMS OPPS Rate,584.77,102,,,Fee Schedule,102% of WV Medicaid Rate,2225.32,165,,,Fee Schedule,165% of CMS OPPS Rate,1397.79,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,3873.91,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5312.76,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6654.78,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,573.3,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1348.67,100,,,Fee Schedule,100% of CMS OPPS Rate,1397.79,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,156.91,14,,,percent of total billed charges,14% of total billed charges,156.91,6654.78,
26650- Perc skel fix/thumb fx/manipulatio,3434925,CDM,510,RC,26650,HCPCS,Outpatient,,,1239.35,619.68,,929.51,75,,,percent of total billed charges,75% of total billed charges,929.51,75,,,percent of total billed charges,75% of total billed charges,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,1073.09,102,,,Fee Schedule,102% of WV Medicaid Rate,4617.6,165,,,Fee Schedule,165% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8038.46,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11024.11,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13808.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1052.05,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,173.51,14,,,percent of total billed charges,14% of total billed charges,173.51,13808.81,
26675- Clsd tx/carpometacar disloc/anesth,3434926,CDM,510,RC,26675,HCPCS,Outpatient,,,1192.75,596.38,,894.56,75,,,percent of total billed charges,75% of total billed charges,894.56,75,,,percent of total billed charges,75% of total billed charges,1348.67,100,,,Fee Schedule,100% of CMS OPPS Rate,584.77,102,,,Fee Schedule,102% of WV Medicaid Rate,2225.32,165,,,Fee Schedule,165% of CMS OPPS Rate,1397.79,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,3873.91,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5312.76,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6654.78,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,573.3,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1348.67,100,,,Fee Schedule,100% of CMS OPPS Rate,1397.79,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,166.99,14,,,percent of total billed charges,14% of total billed charges,166.99,6654.78,
26676- Perc fix/carpomet/not thumb/ea jnt,3434927,CDM,510,RC,26676,HCPCS,Outpatient,,,1311.07,655.54,,983.3,75,,,percent of total billed charges,75% of total billed charges,983.3,75,,,percent of total billed charges,75% of total billed charges,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,1073.09,102,,,Fee Schedule,102% of WV Medicaid Rate,4617.6,165,,,Fee Schedule,165% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8038.46,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11024.11,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13808.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1052.05,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,183.55,14,,,percent of total billed charges,14% of total billed charges,183.55,13808.81,
26686- Open tx/carpometacarp dislocate/compl,3434928,CDM,510,RC,26686,HCPCS,Outpatient,,,1629.59,814.8,,1222.19,75,,,percent of total billed charges,75% of total billed charges,1222.19,75,,,percent of total billed charges,75% of total billed charges,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,1073.09,102,,,Fee Schedule,102% of WV Medicaid Rate,4617.6,165,,,Fee Schedule,165% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8038.46,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11024.11,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13808.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1052.05,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,228.14,14,,,percent of total billed charges,14% of total billed charges,228.14,13808.81,
26700- Clsd tx/metacarpophalan/dislocat,3434929,CDM,510,RC,26700,HCPCS,Outpatient,,,878.45,439.23,,658.84,75,,,percent of total billed charges,75% of total billed charges,658.84,75,,,percent of total billed charges,75% of total billed charges,194.62,100,,,Fee Schedule,100% of CMS OPPS Rate,84.13,102,,,Fee Schedule,102% of WV Medicaid Rate,321.11,165,,,Fee Schedule,165% of CMS OPPS Rate,201.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,559.02,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,766.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,960.32,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,82.48,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,194.62,100,,,Fee Schedule,100% of CMS OPPS Rate,201.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,122.98,14,,,percent of total billed charges,14% of total billed charges,82.48,960.32,
26705- Clsd tx/metacarpophalan/anesth,3434930,CDM,510,RC,26705,HCPCS,Outpatient,,,1088.69,544.35,,816.52,75,,,percent of total billed charges,75% of total billed charges,816.52,75,,,percent of total billed charges,75% of total billed charges,1348.67,100,,,Fee Schedule,100% of CMS OPPS Rate,584.77,102,,,Fee Schedule,102% of WV Medicaid Rate,2225.32,165,,,Fee Schedule,165% of CMS OPPS Rate,1397.79,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,3873.91,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5312.76,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6654.78,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,573.3,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1348.67,100,,,Fee Schedule,100% of CMS OPPS Rate,1397.79,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,152.42,14,,,percent of total billed charges,14% of total billed charges,152.42,6654.78,
26706- Perc fix/metacarphalang/sng/manip,3434931,CDM,510,RC,26706,HCPCS,Outpatient,,,1156.38,578.19,,867.29,75,,,percent of total billed charges,75% of total billed charges,867.29,75,,,percent of total billed charges,75% of total billed charges,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,1073.09,102,,,Fee Schedule,102% of WV Medicaid Rate,4617.6,165,,,Fee Schedule,165% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8038.46,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11024.11,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13808.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1052.05,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,161.89,14,,,percent of total billed charges,14% of total billed charges,161.89,13808.81,
26715- Open tx/metacarpophalan/int fix,3434932,CDM,510,RC,26715,HCPCS,Outpatient,,,1482.92,741.46,,1112.19,75,,,percent of total billed charges,75% of total billed charges,1112.19,75,,,percent of total billed charges,75% of total billed charges,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,1073.09,102,,,Fee Schedule,102% of WV Medicaid Rate,4617.6,165,,,Fee Schedule,165% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8038.46,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11024.11,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13808.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1052.05,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,207.61,14,,,percent of total billed charges,14% of total billed charges,207.61,13808.81,
26720- Clsd tx/prox/mid phalnx fx/no manp,3434933,CDM,510,RC,26720,HCPCS,Outpatient,,,509,254.5,,381.75,75,,,percent of total billed charges,75% of total billed charges,381.75,75,,,percent of total billed charges,75% of total billed charges,194.62,100,,,Fee Schedule,100% of CMS OPPS Rate,84.13,102,,,Fee Schedule,102% of WV Medicaid Rate,321.11,165,,,Fee Schedule,165% of CMS OPPS Rate,201.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,559.02,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,766.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,960.32,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,82.48,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,194.62,100,,,Fee Schedule,100% of CMS OPPS Rate,201.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,71.26,14,,,percent of total billed charges,14% of total billed charges,71.26,960.32,
26725- Clsd tx/prox/mid phalanx w/manip,3434934,CDM,510,RC,26725,HCPCS,Outpatient,,,879.73,439.87,,659.8,75,,,percent of total billed charges,75% of total billed charges,659.8,75,,,percent of total billed charges,75% of total billed charges,194.62,100,,,Fee Schedule,100% of CMS OPPS Rate,84.13,102,,,Fee Schedule,102% of WV Medicaid Rate,321.11,165,,,Fee Schedule,165% of CMS OPPS Rate,201.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,559.02,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,766.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,960.32,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,82.48,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,194.62,100,,,Fee Schedule,100% of CMS OPPS Rate,201.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,123.16,14,,,percent of total billed charges,14% of total billed charges,82.48,960.32,
26727- Perc fix/unstab phalang fx/manip,3434935,CDM,510,RC,26727,HCPCS,Outpatient,,,1222.89,611.45,,917.17,75,,,percent of total billed charges,75% of total billed charges,917.17,75,,,percent of total billed charges,75% of total billed charges,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,1073.09,102,,,Fee Schedule,102% of WV Medicaid Rate,4617.6,165,,,Fee Schedule,165% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8038.46,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11024.11,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13808.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1052.05,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,171.2,14,,,percent of total billed charges,14% of total billed charges,171.2,13808.81,
26735- Open tx/phalan fx/prox/mid phalanx,3434936,CDM,510,RC,26735,HCPCS,Outpatient,,,1539.97,769.99,,1154.98,75,,,percent of total billed charges,75% of total billed charges,1154.98,75,,,percent of total billed charges,75% of total billed charges,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,1073.09,102,,,Fee Schedule,102% of WV Medicaid Rate,4617.6,165,,,Fee Schedule,165% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8038.46,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11024.11,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13808.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1052.05,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,215.6,14,,,percent of total billed charges,14% of total billed charges,215.6,13808.81,
26740- Clsd tx/metacar/interphal artic fx,3434937,CDM,510,RC,26740,HCPCS,Outpatient,,,592,296,,444,75,,,percent of total billed charges,75% of total billed charges,444,75,,,percent of total billed charges,75% of total billed charges,194.62,100,,,Fee Schedule,100% of CMS OPPS Rate,84.13,102,,,Fee Schedule,102% of WV Medicaid Rate,321.11,165,,,Fee Schedule,165% of CMS OPPS Rate,201.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,559.02,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,766.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,960.32,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,82.48,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,194.62,100,,,Fee Schedule,100% of CMS OPPS Rate,201.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,82.88,14,,,percent of total billed charges,14% of total billed charges,82.48,960.32,
26746- Open tx/articular fx,3434938,CDM,510,RC,26746,HCPCS,Outpatient,,,1929.26,964.63,,1446.95,75,,,percent of total billed charges,75% of total billed charges,1446.95,75,,,percent of total billed charges,75% of total billed charges,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,1073.09,102,,,Fee Schedule,102% of WV Medicaid Rate,4617.6,165,,,Fee Schedule,165% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8038.46,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11024.11,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13808.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1052.05,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,270.1,14,,,percent of total billed charges,14% of total billed charges,270.1,13808.81,
26750- Clsd tx/dis phalan fx w/o manip/ea,3434939,CDM,510,RC,26750,HCPCS,Outpatient,,,478.71,239.36,,359.03,75,,,percent of total billed charges,75% of total billed charges,359.03,75,,,percent of total billed charges,75% of total billed charges,194.62,100,,,Fee Schedule,100% of CMS OPPS Rate,84.13,102,,,Fee Schedule,102% of WV Medicaid Rate,321.11,165,,,Fee Schedule,165% of CMS OPPS Rate,201.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,559.02,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,766.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,960.32,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,82.48,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,194.62,100,,,Fee Schedule,100% of CMS OPPS Rate,201.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,67.02,14,,,percent of total billed charges,14% of total billed charges,67.02,960.32,
26755- Clsd tx/distal phalangeal fx,3434940,CDM,510,RC,26755,HCPCS,Outpatient,,,823.43,411.72,,617.57,75,,,percent of total billed charges,75% of total billed charges,617.57,75,,,percent of total billed charges,75% of total billed charges,194.62,100,,,Fee Schedule,100% of CMS OPPS Rate,84.13,102,,,Fee Schedule,102% of WV Medicaid Rate,321.11,165,,,Fee Schedule,165% of CMS OPPS Rate,201.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,559.02,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,766.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,960.32,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,82.48,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,194.62,100,,,Fee Schedule,100% of CMS OPPS Rate,201.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,115.28,14,,,percent of total billed charges,14% of total billed charges,82.48,960.32,
26765- Open tx/dis phalan fx/finger/thumb,3434941,CDM,510,RC,26765,HCPCS,Outpatient,,,1293.53,646.77,,970.15,75,,,percent of total billed charges,75% of total billed charges,970.15,75,,,percent of total billed charges,75% of total billed charges,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,1073.09,102,,,Fee Schedule,102% of WV Medicaid Rate,4617.6,165,,,Fee Schedule,165% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8038.46,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11024.11,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13808.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1052.05,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,181.09,14,,,percent of total billed charges,14% of total billed charges,181.09,13808.81,
26770- Closed tx/interpha dislocate/manipulation w/o anesthesia,3434942,CDM,510,RC,26770,HCPCS,Outpatient,,,739.32,369.66,,554.49,75,,,percent of total billed charges,75% of total billed charges,554.49,75,,,percent of total billed charges,75% of total billed charges,194.62,100,,,Fee Schedule,100% of CMS OPPS Rate,84.13,102,,,Fee Schedule,102% of WV Medicaid Rate,321.11,165,,,Fee Schedule,165% of CMS OPPS Rate,201.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,559.02,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,766.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,960.32,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,82.48,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,194.62,100,,,Fee Schedule,100% of CMS OPPS Rate,201.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,103.5,14,,,percent of total billed charges,14% of total billed charges,82.48,960.32,
26775- Clsd tx/interpha dislo/manip/anest,3434943,CDM,510,RC,26775,HCPCS,Outpatient,,,1007.14,503.57,,755.36,75,,,percent of total billed charges,75% of total billed charges,755.36,75,,,percent of total billed charges,75% of total billed charges,225.55,100,,,Fee Schedule,100% of CMS OPPS Rate,98.46,102,,,Fee Schedule,102% of WV Medicaid Rate,372.16,165,,,Fee Schedule,165% of CMS OPPS Rate,233.76,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,647.87,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,888.5,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1112.94,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,96.53,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,225.55,100,,,Fee Schedule,100% of CMS OPPS Rate,233.76,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,141,14,,,percent of total billed charges,14% of total billed charges,96.53,1112.94,
26776- Perc fix/interphalan jnt/sng/manip,3434944,CDM,510,RC,26776,HCPCS,Outpatient,,,1160.13,580.07,,870.1,75,,,percent of total billed charges,75% of total billed charges,870.1,75,,,percent of total billed charges,75% of total billed charges,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,1073.09,102,,,Fee Schedule,102% of WV Medicaid Rate,4617.6,165,,,Fee Schedule,165% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8038.46,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11024.11,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13808.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1052.05,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,162.42,14,,,percent of total billed charges,14% of total billed charges,162.42,13808.81,
26785- Open tx/interphalang dislocateate/sng,3434945,CDM,510,RC,26785,HCPCS,Outpatient,,,1411.33,705.67,,1058.5,75,,,percent of total billed charges,75% of total billed charges,1058.5,75,,,percent of total billed charges,75% of total billed charges,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,1073.09,102,,,Fee Schedule,102% of WV Medicaid Rate,4617.6,165,,,Fee Schedule,165% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8038.46,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11024.11,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13808.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1052.05,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,197.59,14,,,percent of total billed charges,14% of total billed charges,197.59,13808.81,
26852- Arthrode/metacarpophalang/autogft,3434946,CDM,510,RC,26852,HCPCS,Outpatient,,,2150.22,1075.11,,1612.67,75,,,percent of total billed charges,75% of total billed charges,1612.67,75,,,percent of total billed charges,75% of total billed charges,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,2365.05,102,,,Fee Schedule,102% of WV Medicaid Rate,10261.1,165,,,Fee Schedule,165% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,17862.79,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,24497.4,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,30685.48,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,2318.68,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,301.03,14,,,percent of total billed charges,14% of total billed charges,301.03,30685.48,
26860- Arthrodesis/interphalangeal joint,3434947,CDM,510,RC,26860,HCPCS,Outpatient,,,1559.03,779.52,,1169.27,75,,,percent of total billed charges,75% of total billed charges,1169.27,75,,,percent of total billed charges,75% of total billed charges,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,1073.09,102,,,Fee Schedule,102% of WV Medicaid Rate,4617.6,165,,,Fee Schedule,165% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8038.46,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11024.11,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13808.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1052.05,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,218.26,14,,,percent of total billed charges,14% of total billed charges,218.26,13808.81,
26862- Arthrodesis/interphalan jnt/autogft,3434948,CDM,510,RC,26862,HCPCS,Outpatient,,,1973.09,986.55,,1479.82,75,,,percent of total billed charges,75% of total billed charges,1479.82,75,,,percent of total billed charges,75% of total billed charges,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,1073.09,102,,,Fee Schedule,102% of WV Medicaid Rate,4617.6,165,,,Fee Schedule,165% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8038.46,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11024.11,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13808.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1052.05,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,276.23,14,,,percent of total billed charges,14% of total billed charges,276.23,13808.81,
26863- Arthrode/interphal jnt/autogft/add,3434949,CDM,510,RC,26863,HCPCS,Outpatient,,,600.99,300.5,,450.74,75,,,percent of total billed charges,75% of total billed charges,450.74,75,,,percent of total billed charges,75% of total billed charges,192.32,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,84.14,14,,,percent of total billed charges,14% of total billed charges,84.14,450.74,
26910- Amputate metacarpal w/finger/thumb,3434950,CDM,510,RC,26910,HCPCS,Outpatient,,,1969.26,984.63,,1476.95,75,,,percent of total billed charges,75% of total billed charges,1476.95,75,,,percent of total billed charges,75% of total billed charges,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,1073.09,102,,,Fee Schedule,102% of WV Medicaid Rate,4617.6,165,,,Fee Schedule,165% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8038.46,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11024.11,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13808.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1052.05,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,275.7,14,,,percent of total billed charges,14% of total billed charges,275.7,13808.81,
26951- Amputate finger/thumb/direct close,3434951,CDM,510,RC,26951,HCPCS,Outpatient,,,1787.15,893.58,,1340.36,75,,,percent of total billed charges,75% of total billed charges,1340.36,75,,,percent of total billed charges,75% of total billed charges,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,1073.09,102,,,Fee Schedule,102% of WV Medicaid Rate,4617.6,165,,,Fee Schedule,165% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8038.46,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11024.11,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13808.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1052.05,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,250.2,14,,,percent of total billed charges,14% of total billed charges,250.2,13808.81,
26952- Amputate finger/thumb/loc adv flap,3434952,CDM,510,RC,26952,HCPCS,Outpatient,,,1758.61,879.31,,1318.96,75,,,percent of total billed charges,75% of total billed charges,1318.96,75,,,percent of total billed charges,75% of total billed charges,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,1073.09,102,,,Fee Schedule,102% of WV Medicaid Rate,4617.6,165,,,Fee Schedule,165% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8038.46,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11024.11,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13808.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1052.05,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,246.21,14,,,percent of total billed charges,14% of total billed charges,246.21,13808.81,
26990- I&D/pelvis/hip joint/deep absc/hem,3434954,CDM,510,RC,26990,HCPCS,Outpatient,,,1770.42,885.21,,1327.82,75,,,percent of total billed charges,75% of total billed charges,1327.82,75,,,percent of total billed charges,75% of total billed charges,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,1073.09,102,,,Fee Schedule,102% of WV Medicaid Rate,4617.6,165,,,Fee Schedule,165% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8038.46,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11024.11,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13808.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1052.05,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,247.86,14,,,percent of total billed charges,14% of total billed charges,247.86,13808.81,
27030- Arthrotomy/hip w/drainage,3434955,CDM,510,RC,27030,HCPCS,Outpatient,,,2463.46,1231.73,,1847.6,75,,,percent of total billed charges,75% of total billed charges,1847.6,75,,,percent of total billed charges,75% of total billed charges,2463.46,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,2463.46,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2463.46,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2463.46,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2463.46,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2463.46,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,2463.46,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2463.46,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,344.88,14,,,percent of total billed charges,14% of total billed charges,344.88,2463.46,
27033- Arthrotomy/hip/explore/remove FB,3434956,CDM,510,RC,27033,HCPCS,Outpatient,,,2553.33,1276.67,,1915,75,,,percent of total billed charges,75% of total billed charges,1915,75,,,percent of total billed charges,75% of total billed charges,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,2365.05,102,,,Fee Schedule,102% of WV Medicaid Rate,10261.1,165,,,Fee Schedule,165% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,17862.79,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,24497.4,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,30685.48,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,2318.68,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,357.47,14,,,percent of total billed charges,14% of total billed charges,357.47,30685.48,
27035- Denervation/hip joint,3434957,CDM,510,RC,27035,HCPCS,Outpatient,,,2931.61,1465.81,,2198.71,75,,,percent of total billed charges,75% of total billed charges,2198.71,75,,,percent of total billed charges,75% of total billed charges,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,1073.09,102,,,Fee Schedule,102% of WV Medicaid Rate,4617.6,165,,,Fee Schedule,165% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8038.46,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11024.11,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13808.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1052.05,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,410.43,14,,,percent of total billed charges,14% of total billed charges,410.43,13808.81,
27062- Exc/trochanteric bursa/calcific,3434961,CDM,510,RC,27062,HCPCS,Outpatient,,,1184.52,592.26,,888.39,75,,,percent of total billed charges,75% of total billed charges,888.39,75,,,percent of total billed charges,75% of total billed charges,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,1073.09,102,,,Fee Schedule,102% of WV Medicaid Rate,4617.6,165,,,Fee Schedule,165% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8038.46,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11024.11,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13808.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1052.05,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,165.83,14,,,percent of total billed charges,14% of total billed charges,165.83,13808.81,
27080- Remove coccyx/tail bone,3434962,CDM,510,RC,27080,HCPCS,Outpatient,,,1346.31,673.16,,1009.73,75,,,percent of total billed charges,75% of total billed charges,1009.73,75,,,percent of total billed charges,75% of total billed charges,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,1073.09,102,,,Fee Schedule,102% of WV Medicaid Rate,4617.6,165,,,Fee Schedule,165% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8038.46,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11024.11,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13808.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1052.05,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,188.48,14,,,percent of total billed charges,14% of total billed charges,188.48,13808.81,
27091- Remove/hip prosthesis/complicated,3434963,CDM,510,RC,27091,HCPCS,Outpatient,,,4197.98,2098.99,,3148.49,75,,,percent of total billed charges,75% of total billed charges,3148.49,75,,,percent of total billed charges,75% of total billed charges,4197.98,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,4197.98,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4197.98,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4197.98,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4197.98,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4197.98,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,4197.98,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4197.98,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,587.72,14,,,percent of total billed charges,14% of total billed charges,587.72,4197.98,
27093- Inj/hip arthography w/o anesthesia,3434964,CDM,510,RC,27093,HCPCS,Outpatient,,,591.62,295.81,,443.72,75,,,percent of total billed charges,75% of total billed charges,443.72,75,,,percent of total billed charges,75% of total billed charges,189.32,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,82.83,14,,,percent of total billed charges,14% of total billed charges,82.83,443.72,
27096- Inj/sacroiliac w/image guide,3434965,CDM,510,RC,27096,HCPCS,Outpatient,,,406.05,203.03,,304.54,75,,,percent of total billed charges,75% of total billed charges,304.54,75,,,percent of total billed charges,75% of total billed charges,129.94,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.85,14,,,percent of total billed charges,14% of total billed charges,56.85,304.54,
27125- Hemiarthroplasty/hip/partial,3434966,CDM,510,RC,27125,HCPCS,Outpatient,,,2972.52,1486.26,,2229.39,75,,,percent of total billed charges,75% of total billed charges,2229.39,75,,,percent of total billed charges,75% of total billed charges,2972.52,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,2972.52,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2972.52,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2972.52,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2972.52,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2972.52,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,2972.52,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2972.52,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,416.15,14,,,percent of total billed charges,14% of total billed charges,416.15,2972.52,
27130- Arthroplas/acetab/prox fem replac,3434967,CDM,510,RC,27130,HCPCS,Outpatient,,,3383.7,1691.85,,2537.78,75,,,percent of total billed charges,75% of total billed charges,2537.78,75,,,percent of total billed charges,75% of total billed charges,12267.36,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,20241.15,165,,,Fee Schedule,165% of CMS OPPS Rate,12714.07,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,35236.32,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,48323.81,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,60530.47,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,12267.36,100,,,Fee Schedule,100% of CMS OPPS Rate,12714.07,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,473.72,14,,,percent of total billed charges,14% of total billed charges,473.72,60530.47,
27130- Total Hip Arthroplasty,3434968,CDM,510,RC,27130,HCPCS,Outpatient,,,3383.7,1691.85,,2537.78,75,,,percent of total billed charges,75% of total billed charges,2537.78,75,,,percent of total billed charges,75% of total billed charges,12267.36,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,20241.15,165,,,Fee Schedule,165% of CMS OPPS Rate,12714.07,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,35236.32,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,48323.81,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,60530.47,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,12267.36,100,,,Fee Schedule,100% of CMS OPPS Rate,12714.07,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,473.72,14,,,percent of total billed charges,14% of total billed charges,473.72,60530.47,
27132- Prev hip surg/total arthroplasty,3434969,CDM,510,RC,27132,HCPCS,Outpatient,,,4403.98,2201.99,,3302.99,75,,,percent of total billed charges,75% of total billed charges,3302.99,75,,,percent of total billed charges,75% of total billed charges,4403.98,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,4403.98,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4403.98,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4403.98,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4403.98,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4403.98,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,4403.98,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4403.98,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,616.56,14,,,percent of total billed charges,14% of total billed charges,616.56,4403.98,
27134- Revise hip arthroplast/both comp,3434970,CDM,510,RC,27134,HCPCS,Outpatient,,,5037.41,2518.71,,3778.06,75,,,percent of total billed charges,75% of total billed charges,3778.06,75,,,percent of total billed charges,75% of total billed charges,5037.41,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,5037.41,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5037.41,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5037.41,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5037.41,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5037.41,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,5037.41,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5037.41,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,705.24,14,,,percent of total billed charges,14% of total billed charges,705.24,5037.41,
27137- Revise hip arthroplast/acetab comp,3434971,CDM,510,RC,27137,HCPCS,Outpatient,,,3866.53,1933.27,,2899.9,75,,,percent of total billed charges,75% of total billed charges,2899.9,75,,,percent of total billed charges,75% of total billed charges,3866.53,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,3866.53,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3866.53,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3866.53,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3866.53,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3866.53,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,3866.53,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3866.53,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,541.31,14,,,percent of total billed charges,14% of total billed charges,541.31,3866.53,
27140- Osteot/transf/grt trochanter/femur,3434972,CDM,510,RC,27140,HCPCS,Outpatient,,,2346.19,1173.1,,1759.64,75,,,percent of total billed charges,75% of total billed charges,1759.64,75,,,percent of total billed charges,75% of total billed charges,2346.19,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,2346.19,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2346.19,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2346.19,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2346.19,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2346.19,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,2346.19,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2346.19,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,328.47,14,,,percent of total billed charges,14% of total billed charges,328.47,2346.19,
27220- Closed tx/acetabululm w/o manip,3434976,CDM,510,RC,27220,HCPCS,Outpatient,,,1094.42,547.21,,820.82,75,,,percent of total billed charges,75% of total billed charges,820.82,75,,,percent of total billed charges,75% of total billed charges,194.62,100,,,Fee Schedule,100% of CMS OPPS Rate,84.13,102,,,Fee Schedule,102% of WV Medicaid Rate,321.11,165,,,Fee Schedule,165% of CMS OPPS Rate,201.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,559.02,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,766.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,960.32,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,82.48,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,194.62,100,,,Fee Schedule,100% of CMS OPPS Rate,201.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,153.22,14,,,percent of total billed charges,14% of total billed charges,82.48,960.32,
27222- Clsd tx/acetabulum/w manipulation,3434977,CDM,510,RC,27222,HCPCS,Outpatient,,,2585.05,1292.53,,1938.79,75,,,percent of total billed charges,75% of total billed charges,1938.79,75,,,percent of total billed charges,75% of total billed charges,2585.05,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,2585.05,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2585.05,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2585.05,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2585.05,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2585.05,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,2585.05,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2585.05,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,361.91,14,,,percent of total billed charges,14% of total billed charges,361.91,2585.05,
27226- Open tx/post/ant acetab wall fx,3434978,CDM,510,RC,27226,HCPCS,Outpatient,,,2775.86,1387.93,,2081.9,75,,,percent of total billed charges,75% of total billed charges,2081.9,75,,,percent of total billed charges,75% of total billed charges,2775.86,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,2775.86,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2775.86,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2775.86,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2775.86,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2775.86,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,2775.86,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2775.86,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,388.62,14,,,percent of total billed charges,14% of total billed charges,388.62,2775.86,
27227- Open tx/post/ant acetab column fx,3434979,CDM,510,RC,27227,HCPCS,Outpatient,,,4350.45,2175.23,,3262.84,75,,,percent of total billed charges,75% of total billed charges,3262.84,75,,,percent of total billed charges,75% of total billed charges,4350.45,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,4350.45,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4350.45,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4350.45,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4350.45,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4350.45,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,4350.45,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4350.45,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,609.06,14,,,percent of total billed charges,14% of total billed charges,609.06,4350.45,
27235- Perc fx/femoral fx/proximal /neck,3434980,CDM,510,RC,27235,HCPCS,Outpatient,,,2381.9,1190.95,,1786.43,75,,,percent of total billed charges,75% of total billed charges,1786.43,75,,,percent of total billed charges,75% of total billed charges,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,10261.1,165,,,Fee Schedule,165% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,17862.79,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,24497.4,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,30685.48,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,333.47,14,,,percent of total billed charges,14% of total billed charges,333.47,30685.48,
27236- Open tx/femoral fx/proximal/neck,3434981,CDM,510,RC,27236,HCPCS,Outpatient,,,3135.65,1567.83,,2351.74,75,,,percent of total billed charges,75% of total billed charges,2351.74,75,,,percent of total billed charges,75% of total billed charges,3135.65,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,3135.65,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3135.65,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3135.65,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3135.65,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3135.65,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,3135.65,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3135.65,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,438.99,14,,,percent of total billed charges,14% of total billed charges,438.99,3135.65,
27238- Clsd tx/trochanter fem fx w/o manip,3434982,CDM,510,RC,27238,HCPCS,Outpatient,,,1215.63,607.82,,911.72,75,,,percent of total billed charges,75% of total billed charges,911.72,75,,,percent of total billed charges,75% of total billed charges,1348.67,100,,,Fee Schedule,100% of CMS OPPS Rate,584.77,102,,,Fee Schedule,102% of WV Medicaid Rate,2225.32,165,,,Fee Schedule,165% of CMS OPPS Rate,1397.79,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,3873.91,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5312.76,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6654.78,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,573.3,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1348.67,100,,,Fee Schedule,100% of CMS OPPS Rate,1397.79,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,170.19,14,,,percent of total billed charges,14% of total billed charges,170.19,6654.78,
27240- Clsd tx/trochanter fem fx w/manip,3434983,CDM,510,RC,27240,HCPCS,Outpatient,,,2519.42,1259.71,,1889.57,75,,,percent of total billed charges,75% of total billed charges,1889.57,75,,,percent of total billed charges,75% of total billed charges,2519.42,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,2519.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2519.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2519.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2519.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2519.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,2519.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2519.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,352.72,14,,,percent of total billed charges,14% of total billed charges,352.72,2519.42,
27245- Treat Thigh Fracture,3434984,CDM,510,RC,27245,HCPCS,Outpatient,,,3223.91,1611.96,,2417.93,75,,,percent of total billed charges,75% of total billed charges,2417.93,75,,,percent of total billed charges,75% of total billed charges,3223.91,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,3223.91,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3223.91,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3223.91,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3223.91,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3223.91,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,3223.91,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3223.91,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,451.35,14,,,percent of total billed charges,14% of total billed charges,451.35,3223.91,
27246- Clsd tx/great trochan fx w/o manip,3434985,CDM,510,RC,27246,HCPCS,Outpatient,,,1018.42,509.21,,763.82,75,,,percent of total billed charges,75% of total billed charges,763.82,75,,,percent of total billed charges,75% of total billed charges,194.62,100,,,Fee Schedule,100% of CMS OPPS Rate,84.13,102,,,Fee Schedule,102% of WV Medicaid Rate,321.11,165,,,Fee Schedule,165% of CMS OPPS Rate,201.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,559.02,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,766.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,960.32,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,82.48,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,194.62,100,,,Fee Schedule,100% of CMS OPPS Rate,201.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,142.58,14,,,percent of total billed charges,14% of total billed charges,82.48,960.32,
27248- Open tx/great trochan fx/int fix,3434986,CDM,510,RC,27248,HCPCS,Outpatient,,,1962.63,981.32,,1471.97,75,,,percent of total billed charges,75% of total billed charges,1471.97,75,,,percent of total billed charges,75% of total billed charges,1962.63,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,1962.63,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1962.63,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1962.63,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1962.63,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1962.63,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,1962.63,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1962.63,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,274.77,14,,,percent of total billed charges,14% of total billed charges,274.77,1962.63,
27250- Clsd tx/hip dislo/traumat w/o anes,3434987,CDM,510,RC,27250,HCPCS,Outpatient,,,495.19,247.6,,371.39,75,,,percent of total billed charges,75% of total billed charges,371.39,75,,,percent of total billed charges,75% of total billed charges,194.62,100,,,Fee Schedule,100% of CMS OPPS Rate,84.13,102,,,Fee Schedule,102% of WV Medicaid Rate,321.11,165,,,Fee Schedule,165% of CMS OPPS Rate,201.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,559.02,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,766.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,960.32,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,82.48,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,194.62,100,,,Fee Schedule,100% of CMS OPPS Rate,201.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,69.33,14,,,percent of total billed charges,14% of total billed charges,69.33,960.32,
27252- Clsd tx/hip dislo/traumat w/anes,3434988,CDM,510,RC,27252,HCPCS,Outpatient,,,1988.96,994.48,,1491.72,75,,,percent of total billed charges,75% of total billed charges,1491.72,75,,,percent of total billed charges,75% of total billed charges,1348.67,100,,,Fee Schedule,100% of CMS OPPS Rate,584.77,102,,,Fee Schedule,102% of WV Medicaid Rate,2225.32,165,,,Fee Schedule,165% of CMS OPPS Rate,1397.79,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,3873.91,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5312.76,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6654.78,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,573.3,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1348.67,100,,,Fee Schedule,100% of CMS OPPS Rate,1397.79,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,278.45,14,,,percent of total billed charges,14% of total billed charges,278.45,6654.78,
27253- Open tx/hip dislocateate/traumatic,3434989,CDM,510,RC,27253,HCPCS,Outpatient,,,2471.74,1235.87,,1853.81,75,,,percent of total billed charges,75% of total billed charges,1853.81,75,,,percent of total billed charges,75% of total billed charges,2471.74,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,2471.74,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2471.74,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2471.74,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2471.74,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2471.74,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,2471.74,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2471.74,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,346.04,14,,,percent of total billed charges,14% of total billed charges,346.04,2471.74,
27254- Open tx/hip dislocate/trauma/acetab fx,3434990,CDM,510,RC,27254,HCPCS,Outpatient,,,3347.17,1673.59,,2510.38,75,,,percent of total billed charges,75% of total billed charges,2510.38,75,,,percent of total billed charges,75% of total billed charges,3347.17,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,3347.17,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3347.17,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3347.17,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3347.17,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3347.17,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,3347.17,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3347.17,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,468.6,14,,,percent of total billed charges,14% of total billed charges,468.6,3347.17,
27266- Clsd tx/post hip arthro dislocat/anesth,3434991,CDM,510,RC,27266,HCPCS,Outpatient,,,1530.08,765.04,,1147.56,75,,,percent of total billed charges,75% of total billed charges,1147.56,75,,,percent of total billed charges,75% of total billed charges,1348.67,100,,,Fee Schedule,100% of CMS OPPS Rate,584.77,102,,,Fee Schedule,102% of WV Medicaid Rate,2225.32,165,,,Fee Schedule,165% of CMS OPPS Rate,1397.79,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,3873.91,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5312.76,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6654.78,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,573.3,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1348.67,100,,,Fee Schedule,100% of CMS OPPS Rate,1397.79,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,214.21,14,,,percent of total billed charges,14% of total billed charges,214.21,6654.78,
27275- Manipulate/hip jnt/gen anesthesia,3434992,CDM,510,RC,27275,HCPCS,Outpatient,,,473.33,236.67,,355,75,,,percent of total billed charges,75% of total billed charges,355,75,,,percent of total billed charges,75% of total billed charges,1348.67,100,,,Fee Schedule,100% of CMS OPPS Rate,584.77,102,,,Fee Schedule,102% of WV Medicaid Rate,2225.32,165,,,Fee Schedule,165% of CMS OPPS Rate,1397.79,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,3873.91,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5312.76,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6654.78,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,573.3,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1348.67,100,,,Fee Schedule,100% of CMS OPPS Rate,1397.79,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,66.27,14,,,percent of total billed charges,14% of total billed charges,66.27,6654.78,
27279- Arthrodes/sacroiliac/transfix dev,3434993,CDM,510,RC,27279,HCPCS,Outpatient,,,2210.35,1105.18,,1657.76,75,,,percent of total billed charges,75% of total billed charges,1657.76,75,,,percent of total billed charges,75% of total billed charges,20587.41,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,33969.22,165,,,Fee Schedule,165% of CMS OPPS Rate,21337.09,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,59134.52,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,81098.28,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,101583.83,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,20587.41,100,,,Fee Schedule,100% of CMS OPPS Rate,21337.09,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,309.45,14,,,percent of total billed charges,14% of total billed charges,309.45,101583.83,
27280- Arthrode/open/sacroiliac jnt/gft,3434994,CDM,510,RC,27280,HCPCS,Outpatient,,,3632.75,1816.38,,2724.56,75,,,percent of total billed charges,75% of total billed charges,2724.56,75,,,percent of total billed charges,75% of total billed charges,3632.75,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,3632.75,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3632.75,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3632.75,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3632.75,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3632.75,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,3632.75,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3632.75,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,508.59,14,,,percent of total billed charges,14% of total billed charges,508.59,3632.75,
27282- Arthrodesis/symphysis pubis/graft,3434995,CDM,510,RC,27282,HCPCS,Outpatient,,,2252.13,1126.07,,1689.1,75,,,percent of total billed charges,75% of total billed charges,1689.1,75,,,percent of total billed charges,75% of total billed charges,2252.13,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,2252.13,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2252.13,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2252.13,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2252.13,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2252.13,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,2252.13,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2252.13,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,315.3,14,,,percent of total billed charges,14% of total billed charges,315.3,2252.13,
27307- Tenotomy/perc/adductor/hamstring,3434998,CDM,510,RC,27307,HCPCS,Outpatient,,,1080.22,540.11,,810.17,75,,,percent of total billed charges,75% of total billed charges,810.17,75,,,percent of total billed charges,75% of total billed charges,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,1073.09,102,,,Fee Schedule,102% of WV Medicaid Rate,4617.6,165,,,Fee Schedule,165% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8038.46,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11024.11,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13808.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1052.05,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,151.23,14,,,percent of total billed charges,14% of total billed charges,151.23,13808.81,
27310- Arthrotomy/knee/explore/drain,3434999,CDM,510,RC,27310,HCPCS,Outpatient,,,1915.54,957.77,,1436.66,75,,,percent of total billed charges,75% of total billed charges,1436.66,75,,,percent of total billed charges,75% of total billed charges,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,1073.09,102,,,Fee Schedule,102% of WV Medicaid Rate,4617.6,165,,,Fee Schedule,165% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8038.46,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11024.11,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13808.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1052.05,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,268.18,14,,,percent of total billed charges,14% of total billed charges,268.18,13808.81,
27324- Biopsy/soft tissue/thigh/knee/deep,3435001,CDM,510,RC,27324,HCPCS,Outpatient,,,1058.39,529.2,,793.79,75,,,percent of total billed charges,75% of total billed charges,793.79,75,,,percent of total billed charges,75% of total billed charges,2428.67,100,,,Fee Schedule,100% of CMS OPPS Rate,803.83,102,,,Fee Schedule,102% of WV Medicaid Rate,4007.32,165,,,Fee Schedule,165% of CMS OPPS Rate,2517.11,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,6976.06,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,9567.11,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,11983.78,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,788.07,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2428.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2517.11,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,148.17,14,,,percent of total billed charges,14% of total billed charges,148.17,11983.78,
27327- Exc/tumor/thigh/knee/SQ/<3cm,3435002,CDM,510,RC,27327,HCPCS,Outpatient,,,1281.56,640.78,,961.17,75,,,percent of total billed charges,75% of total billed charges,961.17,75,,,percent of total billed charges,75% of total billed charges,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,479.67,102,,,Fee Schedule,102% of WV Medicaid Rate,2326.19,165,,,Fee Schedule,165% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4049.52,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5553.61,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6956.46,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,470.26,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,179.42,14,,,percent of total billed charges,14% of total billed charges,179.42,6956.46,
27331- Arthrot/knee/jnt explore/bx/rmv FB,3435003,CDM,510,RC,27331,HCPCS,Outpatient,,,1239.35,619.68,,929.51,75,,,percent of total billed charges,75% of total billed charges,929.51,75,,,percent of total billed charges,75% of total billed charges,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,1073.09,102,,,Fee Schedule,102% of WV Medicaid Rate,4617.6,165,,,Fee Schedule,165% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8038.46,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11024.11,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13808.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1052.05,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,173.51,14,,,percent of total billed charges,14% of total billed charges,173.51,13808.81,
27340- Remove/prepatellar bursa,3435006,CDM,510,RC,27340,HCPCS,Outpatient,,,969.45,484.73,,727.09,75,,,percent of total billed charges,75% of total billed charges,727.09,75,,,percent of total billed charges,75% of total billed charges,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,1073.09,102,,,Fee Schedule,102% of WV Medicaid Rate,4617.6,165,,,Fee Schedule,165% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8038.46,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11024.11,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13808.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1052.05,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,135.72,14,,,percent of total billed charges,14% of total billed charges,135.72,13808.81,
27345- Exc/synov cyst/popliteal space,3435007,CDM,510,RC,27345,HCPCS,Outpatient,,,1264.1,632.05,,948.08,75,,,percent of total billed charges,75% of total billed charges,948.08,75,,,percent of total billed charges,75% of total billed charges,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,1073.09,102,,,Fee Schedule,102% of WV Medicaid Rate,4617.6,165,,,Fee Schedule,165% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8038.46,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11024.11,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13808.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1052.05,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,176.97,14,,,percent of total billed charges,14% of total billed charges,176.97,13808.81,
27347- Exc lesion/meniscus/capsule/knee,3435008,CDM,510,RC,27347,HCPCS,Outpatient,,,1370.52,685.26,,1027.89,75,,,percent of total billed charges,75% of total billed charges,1027.89,75,,,percent of total billed charges,75% of total billed charges,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,1073.09,102,,,Fee Schedule,102% of WV Medicaid Rate,4617.6,165,,,Fee Schedule,165% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8038.46,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11024.11,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13808.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1052.05,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,191.87,14,,,percent of total billed charges,14% of total billed charges,191.87,13808.81,
27350- Remove patella/total or partial,3435009,CDM,510,RC,27350,HCPCS,Outpatient,,,1709.55,854.78,,1282.16,75,,,percent of total billed charges,75% of total billed charges,1282.16,75,,,percent of total billed charges,75% of total billed charges,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,2365.05,102,,,Fee Schedule,102% of WV Medicaid Rate,10261.1,165,,,Fee Schedule,165% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,17862.79,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,24497.4,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,30685.48,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,2318.68,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,239.34,14,,,percent of total billed charges,14% of total billed charges,239.34,30685.48,
27355- Exc/bone cyst/bgn tumor/femur,3435010,CDM,510,RC,27355,HCPCS,Outpatient,,,1589.8,794.9,,1192.35,75,,,percent of total billed charges,75% of total billed charges,1192.35,75,,,percent of total billed charges,75% of total billed charges,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,1073.09,102,,,Fee Schedule,102% of WV Medicaid Rate,4617.6,165,,,Fee Schedule,165% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8038.46,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11024.11,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13808.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1052.05,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,222.57,14,,,percent of total billed charges,14% of total billed charges,222.57,13808.81,
27360- Part exc/bone/fem/prox tib/fib,3435011,CDM,510,RC,27360,HCPCS,Outpatient,,,2358.87,1179.44,,1769.15,75,,,percent of total billed charges,75% of total billed charges,1769.15,75,,,percent of total billed charges,75% of total billed charges,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,1073.09,102,,,Fee Schedule,102% of WV Medicaid Rate,4617.6,165,,,Fee Schedule,165% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8038.46,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11024.11,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13808.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1052.05,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,330.24,14,,,percent of total billed charges,14% of total billed charges,330.24,13808.81,
27364- Resect/sft tis tum/thigh/knee/5cm>,3435012,CDM,510,RC,27364,HCPCS,Outpatient,,,4146.79,2073.4,,3110.09,75,,,percent of total billed charges,75% of total billed charges,3110.09,75,,,percent of total billed charges,75% of total billed charges,2428.67,100,,,Fee Schedule,100% of CMS OPPS Rate,803.83,102,,,Fee Schedule,102% of WV Medicaid Rate,4007.32,165,,,Fee Schedule,165% of CMS OPPS Rate,2517.11,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,6976.06,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,9567.11,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,11983.78,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,788.07,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2428.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2517.11,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,580.55,14,,,percent of total billed charges,14% of total billed charges,580.55,11983.78,
27372- Rmv/foreign body/deep/thigh/knee,3435013,CDM,510,RC,27372,HCPCS,Outpatient,,,1511.03,755.52,,1133.27,75,,,percent of total billed charges,75% of total billed charges,1133.27,75,,,percent of total billed charges,75% of total billed charges,2428.67,100,,,Fee Schedule,100% of CMS OPPS Rate,803.83,102,,,Fee Schedule,102% of WV Medicaid Rate,4007.32,165,,,Fee Schedule,165% of CMS OPPS Rate,2517.11,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,6976.06,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,9567.11,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,11983.78,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,788.07,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2428.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2517.11,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,211.54,14,,,percent of total billed charges,14% of total billed charges,211.54,11983.78,
27380- Suture/infrapatellar ten/primary,3435014,CDM,510,RC,27380,HCPCS,Outpatient,,,1620.09,810.05,,1215.07,75,,,percent of total billed charges,75% of total billed charges,1215.07,75,,,percent of total billed charges,75% of total billed charges,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,2365.05,102,,,Fee Schedule,102% of WV Medicaid Rate,10261.1,165,,,Fee Schedule,165% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,17862.79,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,24497.4,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,30685.48,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,2318.68,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,226.81,14,,,percent of total billed charges,14% of total billed charges,226.81,30685.48,
27385- Suture/quadricep/hamstring mus rup,3435015,CDM,510,RC,27385,HCPCS,Outpatient,,,1571.93,785.97,,1178.95,75,,,percent of total billed charges,75% of total billed charges,1178.95,75,,,percent of total billed charges,75% of total billed charges,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,2365.05,102,,,Fee Schedule,102% of WV Medicaid Rate,10261.1,165,,,Fee Schedule,165% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,17862.79,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,24497.4,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,30685.48,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,2318.68,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,220.07,14,,,percent of total billed charges,14% of total billed charges,220.07,30685.48,
27386- Suture/quadricep/hamstring rup/sec,3435016,CDM,510,RC,27386,HCPCS,Outpatient,,,2241.36,1120.68,,1681.02,75,,,percent of total billed charges,75% of total billed charges,1681.02,75,,,percent of total billed charges,75% of total billed charges,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,2365.05,102,,,Fee Schedule,102% of WV Medicaid Rate,10261.1,165,,,Fee Schedule,165% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,17862.79,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,24497.4,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,30685.48,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,2318.68,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,313.79,14,,,percent of total billed charges,14% of total billed charges,313.79,30685.48,
"27400 - (50) Transfer, tendon or muscle, hamstrings to femur (eg, Egger's type procedure)",3698911,CDM,510,RC,27400,HCPCS,Outpatient,,,1821.08,910.54,,1365.81,75,,,percent of total billed charges,75% of total billed charges,1365.81,75,,,percent of total billed charges,75% of total billed charges,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,2365.05,102,,,Fee Schedule,102% of WV Medicaid Rate,10261.1,165,,,Fee Schedule,165% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,17862.79,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,24497.4,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,30685.48,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,2318.68,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,254.95,14,,,percent of total billed charges,14% of total billed charges,254.95,30685.48,
"27400 - PF Transfer, tendon or muscle, hamstrings to femur (eg, Egger's type procedure)",3698908,CDM,510,RC,27400,HCPCS,Outpatient,,,1821.08,910.54,,1365.81,75,,,percent of total billed charges,75% of total billed charges,1365.81,75,,,percent of total billed charges,75% of total billed charges,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,2365.05,102,,,Fee Schedule,102% of WV Medicaid Rate,10261.1,165,,,Fee Schedule,165% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,17862.79,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,24497.4,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,30685.48,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,2318.68,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,254.95,14,,,percent of total billed charges,14% of total billed charges,254.95,30685.48,
27403- Arthrotomy/meniscus repair/knee,3435017,CDM,510,RC,27403,HCPCS,Outpatient,,,1685.82,842.91,,1264.37,75,,,percent of total billed charges,75% of total billed charges,1264.37,75,,,percent of total billed charges,75% of total billed charges,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,3078.97,102,,,Fee Schedule,102% of WV Medicaid Rate,10261.1,165,,,Fee Schedule,165% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,17862.79,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,24497.4,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,30685.48,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,3018.6,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,236.01,14,,,percent of total billed charges,14% of total billed charges,236.01,30685.48,
27405- Rpr/torn lig/capsule/knee/collater,3435018,CDM,510,RC,27405,HCPCS,Outpatient,,,1769.35,884.68,,1327.01,75,,,percent of total billed charges,75% of total billed charges,1327.01,75,,,percent of total billed charges,75% of total billed charges,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,2365.05,102,,,Fee Schedule,102% of WV Medicaid Rate,10261.1,165,,,Fee Schedule,165% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,17862.79,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,24497.4,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,30685.48,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,2318.68,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,247.71,14,,,percent of total billed charges,14% of total billed charges,247.71,30685.48,
27407- Rpr/torn lig/capsule/knee/cruciate,3435019,CDM,510,RC,27407,HCPCS,Outpatient,,,2086.11,1043.06,,1564.58,75,,,percent of total billed charges,75% of total billed charges,1564.58,75,,,percent of total billed charges,75% of total billed charges,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,3078.97,102,,,Fee Schedule,102% of WV Medicaid Rate,10261.1,165,,,Fee Schedule,165% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,17862.79,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,24497.4,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,30685.48,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,3018.6,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,292.06,14,,,percent of total billed charges,14% of total billed charges,292.06,30685.48,
27415- Osteochondral allograft/knee/open,3435020,CDM,510,RC,27415,HCPCS,Outpatient,,,3600.84,1800.42,,2700.63,75,,,percent of total billed charges,75% of total billed charges,2700.63,75,,,percent of total billed charges,75% of total billed charges,12267.36,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,20241.15,165,,,Fee Schedule,165% of CMS OPPS Rate,12714.07,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,35236.32,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,48323.81,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,60530.47,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,12267.36,100,,,Fee Schedule,100% of CMS OPPS Rate,12714.07,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,504.12,14,,,percent of total billed charges,14% of total billed charges,504.12,60530.47,
27418- Repair/upper end/tibia at knee jnt,3435021,CDM,510,RC,27418,HCPCS,Outpatient,,,2177.37,1088.69,,1633.03,75,,,percent of total billed charges,75% of total billed charges,1633.03,75,,,percent of total billed charges,75% of total billed charges,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,2365.05,102,,,Fee Schedule,102% of WV Medicaid Rate,10261.1,165,,,Fee Schedule,165% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,17862.79,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,24497.4,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,30685.48,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,2318.68,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,304.83,14,,,percent of total billed charges,14% of total billed charges,304.83,30685.48,
27420- Revise dislocateating patella,3435022,CDM,510,RC,27420,HCPCS,Outpatient,,,1943.73,971.87,,1457.8,75,,,percent of total billed charges,75% of total billed charges,1457.8,75,,,percent of total billed charges,75% of total billed charges,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,2365.05,102,,,Fee Schedule,102% of WV Medicaid Rate,10261.1,165,,,Fee Schedule,165% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,17862.79,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,24497.4,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,30685.48,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,2318.68,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,272.12,14,,,percent of total billed charges,14% of total billed charges,272.12,30685.48,
27422- Revise dislocateat patella/ext realig,3435023,CDM,510,RC,27422,HCPCS,Outpatient,,,1943.88,971.94,,1457.91,75,,,percent of total billed charges,75% of total billed charges,1457.91,75,,,percent of total billed charges,75% of total billed charges,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,2365.05,102,,,Fee Schedule,102% of WV Medicaid Rate,10261.1,165,,,Fee Schedule,165% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,17862.79,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,24497.4,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,30685.48,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,2318.68,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,272.14,14,,,percent of total billed charges,14% of total billed charges,272.14,30685.48,
27425- Lateral retinacular release/open,3435024,CDM,510,RC,27425,HCPCS,Outpatient,,,1174.46,587.23,,880.85,75,,,percent of total billed charges,75% of total billed charges,880.85,75,,,percent of total billed charges,75% of total billed charges,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,1073.09,102,,,Fee Schedule,102% of WV Medicaid Rate,4617.6,165,,,Fee Schedule,165% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8038.46,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11024.11,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13808.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1052.05,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,164.42,14,,,percent of total billed charges,14% of total billed charges,164.42,13808.81,
27427- Reconstruct knee/extra-articular,3435025,CDM,510,RC,27427,HCPCS,Outpatient,,,1860.25,930.13,,1395.19,75,,,percent of total billed charges,75% of total billed charges,1395.19,75,,,percent of total billed charges,75% of total billed charges,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,3126.65,102,,,Fee Schedule,102% of WV Medicaid Rate,10261.1,165,,,Fee Schedule,165% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,17862.79,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,24497.4,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,30685.48,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,3065.34,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,260.44,14,,,percent of total billed charges,14% of total billed charges,260.44,30685.48,
27428- Reconstruct knee/intra-articular,3435026,CDM,510,RC,27428,HCPCS,Outpatient,,,2923.8,1461.9,,2192.85,75,,,percent of total billed charges,75% of total billed charges,2192.85,75,,,percent of total billed charges,75% of total billed charges,12267.36,100,,,Fee Schedule,100% of CMS OPPS Rate,6175.9,102,,,Fee Schedule,102% of WV Medicaid Rate,20241.15,165,,,Fee Schedule,165% of CMS OPPS Rate,12714.07,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,35236.32,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,48323.81,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,60530.47,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,6054.8,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,12267.36,100,,,Fee Schedule,100% of CMS OPPS Rate,12714.07,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,409.33,14,,,percent of total billed charges,14% of total billed charges,409.33,60530.47,
27438- Arthroplasty/patella/with prosth,3435027,CDM,510,RC,27438,HCPCS,Outpatient,,,2202.62,1101.31,,1651.97,75,,,percent of total billed charges,75% of total billed charges,1651.97,75,,,percent of total billed charges,75% of total billed charges,12267.36,100,,,Fee Schedule,100% of CMS OPPS Rate,6570.39,102,,,Fee Schedule,102% of WV Medicaid Rate,20241.15,165,,,Fee Schedule,165% of CMS OPPS Rate,12714.07,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,35236.32,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,48323.81,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,60530.47,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,6441.56,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,12267.36,100,,,Fee Schedule,100% of CMS OPPS Rate,12714.07,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,308.37,14,,,percent of total billed charges,14% of total billed charges,308.37,60530.47,
27441- Arthroplas/knee/debrd/part synovec,3435028,CDM,510,RC,27441,HCPCS,Outpatient,,,2160.3,1080.15,,1620.23,75,,,percent of total billed charges,75% of total billed charges,1620.23,75,,,percent of total billed charges,75% of total billed charges,12267.36,100,,,Fee Schedule,100% of CMS OPPS Rate,4743.89,102,,,Fee Schedule,102% of WV Medicaid Rate,20241.15,165,,,Fee Schedule,165% of CMS OPPS Rate,12714.07,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,35236.32,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,48323.81,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,60530.47,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,4650.87,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,12267.36,100,,,Fee Schedule,100% of CMS OPPS Rate,12714.07,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,302.44,14,,,percent of total billed charges,14% of total billed charges,302.44,60530.47,
27442- Arthroplast/fem cond/tib plat/knee,3435029,CDM,510,RC,27442,HCPCS,Outpatient,,,2285.43,1142.72,,1714.07,75,,,percent of total billed charges,75% of total billed charges,1714.07,75,,,percent of total billed charges,75% of total billed charges,12267.36,100,,,Fee Schedule,100% of CMS OPPS Rate,6966.27,102,,,Fee Schedule,102% of WV Medicaid Rate,20241.15,165,,,Fee Schedule,165% of CMS OPPS Rate,12714.07,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,35236.32,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,48323.81,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,60530.47,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,6829.68,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,12267.36,100,,,Fee Schedule,100% of CMS OPPS Rate,12714.07,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,319.96,14,,,percent of total billed charges,14% of total billed charges,319.96,60530.47,
27446- Arthroplast/knee/med or lat comp,3435030,CDM,510,RC,27446,HCPCS,Outpatient,,,3039.03,1519.52,,2279.27,75,,,percent of total billed charges,75% of total billed charges,2279.27,75,,,percent of total billed charges,75% of total billed charges,12267.36,100,,,Fee Schedule,100% of CMS OPPS Rate,6975.05,102,,,Fee Schedule,102% of WV Medicaid Rate,20241.15,165,,,Fee Schedule,165% of CMS OPPS Rate,12714.07,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,35236.32,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,48323.81,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,60530.47,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,6838.28,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,12267.36,100,,,Fee Schedule,100% of CMS OPPS Rate,12714.07,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,425.46,14,,,percent of total billed charges,14% of total billed charges,425.46,60530.47,
27447- Total Knee Arthroplasty,3435031,CDM,510,RC,27447,HCPCS,Outpatient,,,3380.24,1690.12,,2535.18,75,,,percent of total billed charges,75% of total billed charges,2535.18,75,,,percent of total billed charges,75% of total billed charges,12267.36,100,,,Fee Schedule,100% of CMS OPPS Rate,7071.59,102,,,Fee Schedule,102% of WV Medicaid Rate,20241.15,165,,,Fee Schedule,165% of CMS OPPS Rate,12714.07,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,35236.32,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,48323.81,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,60530.47,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,6932.93,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,12267.36,100,,,Fee Schedule,100% of CMS OPPS Rate,12714.07,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,473.23,14,,,percent of total billed charges,14% of total billed charges,473.23,60530.47,
27472- Rpr/non/malun/femor w/autogen gft,3435032,CDM,510,RC,27472,HCPCS,Outpatient,,,3322.68,1661.34,,2492.01,75,,,percent of total billed charges,75% of total billed charges,2492.01,75,,,percent of total billed charges,75% of total billed charges,3322.68,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,3322.68,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3322.68,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3322.68,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3322.68,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3322.68,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,3322.68,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3322.68,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,465.18,14,,,percent of total billed charges,14% of total billed charges,465.18,3322.68,
27486- Revise total knee/1 component,3435033,CDM,510,RC,27486,HCPCS,Outpatient,,,3692.8,1846.4,,2769.6,75,,,percent of total billed charges,75% of total billed charges,2769.6,75,,,percent of total billed charges,75% of total billed charges,3692.8,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,3692.8,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3692.8,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3692.8,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3692.8,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3692.8,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,3692.8,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3692.8,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,516.99,14,,,percent of total billed charges,14% of total billed charges,516.99,3692.8,
27487- Revise tot knee/fem/tibial comp,3435034,CDM,510,RC,27487,HCPCS,Outpatient,,,4622.38,2311.19,,3466.79,75,,,percent of total billed charges,75% of total billed charges,3466.79,75,,,percent of total billed charges,75% of total billed charges,4622.38,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,4622.38,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4622.38,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4622.38,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4622.38,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4622.38,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,4622.38,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4622.38,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,647.13,14,,,percent of total billed charges,14% of total billed charges,647.13,4622.38,
27488- Remove/total knee prosthesis,3435035,CDM,510,RC,27488,HCPCS,Outpatient,,,3150.83,1575.42,,2363.12,75,,,percent of total billed charges,75% of total billed charges,2363.12,75,,,percent of total billed charges,75% of total billed charges,3150.83,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,3150.83,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3150.83,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3150.83,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3150.83,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3150.83,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,3150.83,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3150.83,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,441.12,14,,,percent of total billed charges,14% of total billed charges,441.12,3150.83,
27499- Decompr fasciot/thigh/knee/debrid,3435036,CDM,510,RC,27499,HCPCS,Outpatient,,,1834.22,917.11,,1375.67,75,,,percent of total billed charges,75% of total billed charges,1375.67,75,,,percent of total billed charges,75% of total billed charges,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,2365.05,102,,,Fee Schedule,102% of WV Medicaid Rate,10261.1,165,,,Fee Schedule,165% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,17862.79,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,24497.4,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,30685.48,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,2318.68,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,256.79,14,,,percent of total billed charges,14% of total billed charges,256.79,30685.48,
27500- Clsd tx/fem shaft fx w/o manip,3435037,CDM,510,RC,27500,HCPCS,Outpatient,,,1354.67,677.34,,1016,75,,,percent of total billed charges,75% of total billed charges,1016,75,,,percent of total billed charges,75% of total billed charges,194.62,100,,,Fee Schedule,100% of CMS OPPS Rate,84.13,102,,,Fee Schedule,102% of WV Medicaid Rate,321.11,165,,,Fee Schedule,165% of CMS OPPS Rate,201.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,559.02,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,766.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,960.32,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,82.48,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,194.62,100,,,Fee Schedule,100% of CMS OPPS Rate,201.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,189.65,14,,,percent of total billed charges,14% of total billed charges,82.48,1016,
27501- Clsd tx/supracond fem fx w/o manip,3435038,CDM,510,RC,27501,HCPCS,Outpatient,,,1323.44,661.72,,992.58,75,,,percent of total billed charges,75% of total billed charges,992.58,75,,,percent of total billed charges,75% of total billed charges,194.62,100,,,Fee Schedule,100% of CMS OPPS Rate,84.13,102,,,Fee Schedule,102% of WV Medicaid Rate,321.11,165,,,Fee Schedule,165% of CMS OPPS Rate,201.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,559.02,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,766.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,960.32,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,82.48,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,194.62,100,,,Fee Schedule,100% of CMS OPPS Rate,201.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,185.28,14,,,percent of total billed charges,14% of total billed charges,82.48,992.58,
27502- Clsd tx/fem shaft fx/manipulation,3435039,CDM,510,RC,27502,HCPCS,Outpatient,,,2005.88,1002.94,,1504.41,75,,,percent of total billed charges,75% of total billed charges,1504.41,75,,,percent of total billed charges,75% of total billed charges,1348.67,100,,,Fee Schedule,100% of CMS OPPS Rate,584.77,102,,,Fee Schedule,102% of WV Medicaid Rate,2225.32,165,,,Fee Schedule,165% of CMS OPPS Rate,1397.79,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,3873.91,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5312.76,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6654.78,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,573.3,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1348.67,100,,,Fee Schedule,100% of CMS OPPS Rate,1397.79,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,280.82,14,,,percent of total billed charges,14% of total billed charges,280.82,6654.78,
27506- Open tx/fem sft fx/intrmedu implnt,3435040,CDM,510,RC,27506,HCPCS,Outpatient,,,3510.39,1755.2,,2632.79,75,,,percent of total billed charges,75% of total billed charges,2632.79,75,,,percent of total billed charges,75% of total billed charges,3510.39,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,3510.39,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3510.39,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3510.39,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3510.39,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3510.39,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,3510.39,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3510.39,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,491.45,14,,,percent of total billed charges,14% of total billed charges,491.45,3510.39,
27507- Open tx/fem shaft fx/plate/screws,3435041,CDM,510,RC,27507,HCPCS,Outpatient,,,2549.93,1274.97,,1912.45,75,,,percent of total billed charges,75% of total billed charges,1912.45,75,,,percent of total billed charges,75% of total billed charges,2549.93,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,2549.93,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2549.93,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2549.93,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2549.93,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2549.93,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,2549.93,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2549.93,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,356.99,14,,,percent of total billed charges,14% of total billed charges,356.99,2549.93,
27508- Clsd tx/fem fx/dis/med/lat condyle,3435042,CDM,510,RC,27508,HCPCS,Outpatient,,,1363.79,681.9,,1022.84,75,,,percent of total billed charges,75% of total billed charges,1022.84,75,,,percent of total billed charges,75% of total billed charges,194.62,100,,,Fee Schedule,100% of CMS OPPS Rate,84.13,102,,,Fee Schedule,102% of WV Medicaid Rate,321.11,165,,,Fee Schedule,165% of CMS OPPS Rate,201.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,559.02,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,766.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,960.32,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,82.48,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,194.62,100,,,Fee Schedule,100% of CMS OPPS Rate,201.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,190.93,14,,,percent of total billed charges,14% of total billed charges,82.48,1022.84,
27509- Perc skeletal fix/distal fem fx/med/lat condyle or supra/trans,3435043,CDM,510,RC,27509,HCPCS,Outpatient,,,1759.34,879.67,,1319.51,75,,,percent of total billed charges,75% of total billed charges,1319.51,75,,,percent of total billed charges,75% of total billed charges,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,3409.69,102,,,Fee Schedule,102% of WV Medicaid Rate,10261.1,165,,,Fee Schedule,165% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,17862.79,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,24497.4,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,30685.48,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,3342.83,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,246.31,14,,,percent of total billed charges,14% of total billed charges,246.31,30685.48,
27511- Open tx/fem supr/transcon fx/no ex,3435044,CDM,510,RC,27511,HCPCS,Outpatient,,,2625.72,1312.86,,1969.29,75,,,percent of total billed charges,75% of total billed charges,1969.29,75,,,percent of total billed charges,75% of total billed charges,2625.72,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,2625.72,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2625.72,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2625.72,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2625.72,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2625.72,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,2625.72,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2625.72,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,367.6,14,,,percent of total billed charges,14% of total billed charges,367.6,2625.72,
27513- Open tx/fem supra/transcondylar fx,3435045,CDM,510,RC,27513,HCPCS,Outpatient,,,3268.76,1634.38,,2451.57,75,,,percent of total billed charges,75% of total billed charges,2451.57,75,,,percent of total billed charges,75% of total billed charges,3268.76,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,3268.76,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3268.76,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3268.76,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3268.76,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3268.76,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,3268.76,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3268.76,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,457.63,14,,,percent of total billed charges,14% of total billed charges,457.63,3268.76,
27514- Open tx/fem fx/distal/internal fix,3435046,CDM,510,RC,27514,HCPCS,Outpatient,,,2548.32,1274.16,,1911.24,75,,,percent of total billed charges,75% of total billed charges,1911.24,75,,,percent of total billed charges,75% of total billed charges,2548.32,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,2548.32,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2548.32,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2548.32,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2548.32,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2548.32,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,2548.32,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2548.32,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,356.76,14,,,percent of total billed charges,14% of total billed charges,356.76,2548.32,
27516- Clsd tx/dis fem epiphyseal separat,3435047,CDM,510,RC,27516,HCPCS,Outpatient,,,1336.4,668.2,,1002.3,75,,,percent of total billed charges,75% of total billed charges,1002.3,75,,,percent of total billed charges,75% of total billed charges,194.62,100,,,Fee Schedule,100% of CMS OPPS Rate,84.13,102,,,Fee Schedule,102% of WV Medicaid Rate,321.11,165,,,Fee Schedule,165% of CMS OPPS Rate,201.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,559.02,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,766.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,960.32,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,82.48,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,194.62,100,,,Fee Schedule,100% of CMS OPPS Rate,201.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,187.1,14,,,percent of total billed charges,14% of total billed charges,82.48,1002.3,
27519- Open tx/dis fem epiphyseal separat,3435048,CDM,510,RC,27519,HCPCS,Outpatient,,,2347.57,1173.79,,1760.68,75,,,percent of total billed charges,75% of total billed charges,1760.68,75,,,percent of total billed charges,75% of total billed charges,2347.57,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,2347.57,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2347.57,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2347.57,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2347.57,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2347.57,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,2347.57,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2347.57,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,328.66,14,,,percent of total billed charges,14% of total billed charges,328.66,2347.57,
27520- Clsd tx/patellar fx w/o manip,3435049,CDM,510,RC,27520,HCPCS,Outpatient,,,832.32,416.16,,624.24,75,,,percent of total billed charges,75% of total billed charges,624.24,75,,,percent of total billed charges,75% of total billed charges,194.62,100,,,Fee Schedule,100% of CMS OPPS Rate,84.13,102,,,Fee Schedule,102% of WV Medicaid Rate,321.11,165,,,Fee Schedule,165% of CMS OPPS Rate,201.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,559.02,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,766.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,960.32,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,82.48,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,194.62,100,,,Fee Schedule,100% of CMS OPPS Rate,201.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,116.52,14,,,percent of total billed charges,14% of total billed charges,82.48,960.32,
27524- Open tx/patellar fx/internal fix,3435050,CDM,510,RC,27524,HCPCS,Outpatient,,,1972.64,986.32,,1479.48,75,,,percent of total billed charges,75% of total billed charges,1479.48,75,,,percent of total billed charges,75% of total billed charges,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,2365.05,102,,,Fee Schedule,102% of WV Medicaid Rate,10261.1,165,,,Fee Schedule,165% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,17862.79,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,24497.4,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,30685.48,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,2318.68,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,276.17,14,,,percent of total billed charges,14% of total billed charges,276.17,30685.48,
27530- Clsd tx/tib fx/prox w/o manip,3435051,CDM,510,RC,27530,HCPCS,Outpatient,,,784.28,392.14,,588.21,75,,,percent of total billed charges,75% of total billed charges,588.21,75,,,percent of total billed charges,75% of total billed charges,194.62,100,,,Fee Schedule,100% of CMS OPPS Rate,84.13,102,,,Fee Schedule,102% of WV Medicaid Rate,321.11,165,,,Fee Schedule,165% of CMS OPPS Rate,201.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,559.02,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,766.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,960.32,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,82.48,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,194.62,100,,,Fee Schedule,100% of CMS OPPS Rate,201.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,109.8,14,,,percent of total billed charges,14% of total billed charges,82.48,960.32,
27532- Clsd tx/tib fx/prox w/skel trac,3435052,CDM,510,RC,27532,HCPCS,Outpatient,,,1612.38,806.19,,1209.29,75,,,percent of total billed charges,75% of total billed charges,1209.29,75,,,percent of total billed charges,75% of total billed charges,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,1073.09,102,,,Fee Schedule,102% of WV Medicaid Rate,4617.6,165,,,Fee Schedule,165% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8038.46,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11024.11,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13808.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1052.05,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,225.73,14,,,percent of total billed charges,14% of total billed charges,225.73,13808.81,
27535- Open tx/tib fx/prox unicondylar,3435053,CDM,510,RC,27535,HCPCS,Outpatient,,,2363.08,1181.54,,1772.31,75,,,percent of total billed charges,75% of total billed charges,1772.31,75,,,percent of total billed charges,75% of total billed charges,2363.08,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,2363.08,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2363.08,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2363.08,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2363.08,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2363.08,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,2363.08,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2363.08,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,330.83,14,,,percent of total billed charges,14% of total billed charges,330.83,2363.08,
27536- Open tx/tib fx/prox bicondylar,3435054,CDM,510,RC,27536,HCPCS,Outpatient,,,3116.5,1558.25,,2337.38,75,,,percent of total billed charges,75% of total billed charges,2337.38,75,,,percent of total billed charges,75% of total billed charges,3116.5,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,3116.5,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3116.5,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3116.5,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3116.5,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3116.5,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,3116.5,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3116.5,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,436.31,14,,,percent of total billed charges,14% of total billed charges,436.31,3116.5,
27538- Clsd tx/intercondyl spine fx/knee,3435055,CDM,510,RC,27538,HCPCS,Outpatient,,,1253.47,626.74,,940.1,75,,,percent of total billed charges,75% of total billed charges,940.1,75,,,percent of total billed charges,75% of total billed charges,194.62,100,,,Fee Schedule,100% of CMS OPPS Rate,84.13,102,,,Fee Schedule,102% of WV Medicaid Rate,321.11,165,,,Fee Schedule,165% of CMS OPPS Rate,201.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,559.02,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,766.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,960.32,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,82.48,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,194.62,100,,,Fee Schedule,100% of CMS OPPS Rate,201.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,175.49,14,,,percent of total billed charges,14% of total billed charges,82.48,960.32,
27540- Open tx/intercondyl spine fx/knee,3435056,CDM,510,RC,27540,HCPCS,Outpatient,,,2131.61,1065.81,,1598.71,75,,,percent of total billed charges,75% of total billed charges,1598.71,75,,,percent of total billed charges,75% of total billed charges,2131.61,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,2131.61,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2131.61,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2131.61,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2131.61,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2131.61,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,2131.61,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2131.61,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,298.43,14,,,percent of total billed charges,14% of total billed charges,298.43,2131.61,
27550- Clsd tx/knee dislocate w/o anesth,3435057,CDM,510,RC,27550,HCPCS,Outpatient,,,1337.69,668.85,,1003.27,75,,,percent of total billed charges,75% of total billed charges,1003.27,75,,,percent of total billed charges,75% of total billed charges,194.62,100,,,Fee Schedule,100% of CMS OPPS Rate,84.13,102,,,Fee Schedule,102% of WV Medicaid Rate,321.11,165,,,Fee Schedule,165% of CMS OPPS Rate,201.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,559.02,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,766.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,960.32,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,82.48,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,194.62,100,,,Fee Schedule,100% of CMS OPPS Rate,201.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,187.28,14,,,percent of total billed charges,14% of total billed charges,82.48,1003.27,
27558- Open tx/knee dislocatet/ligament rpr,3435058,CDM,510,RC,27558,HCPCS,Outpatient,,,3143.89,1571.95,,2357.92,75,,,percent of total billed charges,75% of total billed charges,2357.92,75,,,percent of total billed charges,75% of total billed charges,3143.89,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,3143.89,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3143.89,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3143.89,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3143.89,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3143.89,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,3143.89,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3143.89,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,440.14,14,,,percent of total billed charges,14% of total billed charges,440.14,3143.89,
27570- Manip/knee jnt/general anesthesia,3435059,CDM,510,RC,27570,HCPCS,Outpatient,,,393.45,196.73,,295.09,75,,,percent of total billed charges,75% of total billed charges,295.09,75,,,percent of total billed charges,75% of total billed charges,1348.67,100,,,Fee Schedule,100% of CMS OPPS Rate,584.77,102,,,Fee Schedule,102% of WV Medicaid Rate,2225.32,165,,,Fee Schedule,165% of CMS OPPS Rate,1397.79,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,3873.91,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5312.76,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6654.78,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,573.3,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1348.67,100,,,Fee Schedule,100% of CMS OPPS Rate,1397.79,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,55.08,14,,,percent of total billed charges,14% of total billed charges,55.08,6654.78,
27594- Amputate thigh/sec close/scar rev,3435061,CDM,510,RC,27594,HCPCS,Outpatient,,,1340.94,670.47,,1005.71,75,,,percent of total billed charges,75% of total billed charges,1005.71,75,,,percent of total billed charges,75% of total billed charges,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,1073.09,102,,,Fee Schedule,102% of WV Medicaid Rate,4617.6,165,,,Fee Schedule,165% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8038.46,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11024.11,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13808.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1052.05,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,187.73,14,,,percent of total billed charges,14% of total billed charges,187.73,13808.81,
"27596 - (50) Amputation, thigh, through femur, any level; re-amputation",3698912,CDM,510,RC,27596,HCPCS,Outpatient,,,1907.11,953.56,,1430.33,75,,,percent of total billed charges,75% of total billed charges,1430.33,75,,,percent of total billed charges,75% of total billed charges,1907.11,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,1907.11,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1907.11,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1907.11,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1907.11,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1907.11,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,1907.11,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1907.11,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,267,14,,,percent of total billed charges,14% of total billed charges,267,1907.11,
27601- Decompress fasciotomy/leg/posterio,3435064,CDM,510,RC,27601,HCPCS,Outpatient,,,1168.37,584.19,,876.28,75,,,percent of total billed charges,75% of total billed charges,876.28,75,,,percent of total billed charges,75% of total billed charges,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,1073.09,102,,,Fee Schedule,102% of WV Medicaid Rate,4617.6,165,,,Fee Schedule,165% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8038.46,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11024.11,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13808.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1052.05,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,163.57,14,,,percent of total billed charges,14% of total billed charges,163.57,13808.81,
27603- I&D leg/ankle/deep abscess/hema,3435065,CDM,510,RC,27603,HCPCS,Outpatient,,,1358.89,679.45,,1019.17,75,,,percent of total billed charges,75% of total billed charges,1019.17,75,,,percent of total billed charges,75% of total billed charges,2428.67,100,,,Fee Schedule,100% of CMS OPPS Rate,803.83,102,,,Fee Schedule,102% of WV Medicaid Rate,4007.32,165,,,Fee Schedule,165% of CMS OPPS Rate,2517.11,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,6976.06,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,9567.11,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,11983.78,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,788.07,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2428.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2517.11,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,190.24,14,,,percent of total billed charges,14% of total billed charges,190.24,11983.78,
27604- I&D/leg/ankle/infected bursa,3435066,CDM,510,RC,27604,HCPCS,Outpatient,,,1137.61,568.81,,853.21,75,,,percent of total billed charges,75% of total billed charges,853.21,75,,,percent of total billed charges,75% of total billed charges,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,1073.09,102,,,Fee Schedule,102% of WV Medicaid Rate,4617.6,165,,,Fee Schedule,165% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8038.46,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11024.11,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13808.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1052.05,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,159.27,14,,,percent of total billed charges,14% of total billed charges,159.27,13808.81,
27605- Tenotomy/perc/Achilles/local anes,3435067,CDM,510,RC,27605,HCPCS,Outpatient,,,827.52,413.76,,620.64,75,,,percent of total billed charges,75% of total billed charges,620.64,75,,,percent of total billed charges,75% of total billed charges,1348.67,100,,,Fee Schedule,100% of CMS OPPS Rate,584.77,102,,,Fee Schedule,102% of WV Medicaid Rate,2225.32,165,,,Fee Schedule,165% of CMS OPPS Rate,1397.79,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,3873.91,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5312.76,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6654.78,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,573.3,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1348.67,100,,,Fee Schedule,100% of CMS OPPS Rate,1397.79,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,115.85,14,,,percent of total billed charges,14% of total billed charges,115.85,6654.78,
27606- Tenotomy/perc/Achilles/gen anesth,3435068,CDM,510,RC,27606,HCPCS,Outpatient,,,712.96,356.48,,534.72,75,,,percent of total billed charges,75% of total billed charges,534.72,75,,,percent of total billed charges,75% of total billed charges,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,1073.09,102,,,Fee Schedule,102% of WV Medicaid Rate,4617.6,165,,,Fee Schedule,165% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8038.46,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11024.11,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13808.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1052.05,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,99.81,14,,,percent of total billed charges,14% of total billed charges,99.81,13808.81,
27610- Arthrot/ankle/explore/drain/rmv FB,3435069,CDM,510,RC,27610,HCPCS,Outpatient,,,1690.32,845.16,,1267.74,75,,,percent of total billed charges,75% of total billed charges,1267.74,75,,,percent of total billed charges,75% of total billed charges,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,1073.09,102,,,Fee Schedule,102% of WV Medicaid Rate,4617.6,165,,,Fee Schedule,165% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8038.46,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11024.11,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13808.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1052.05,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,236.64,14,,,percent of total billed charges,14% of total billed charges,236.64,13808.81,
"27613 - Biopsy, soft tissue of leg or ankle area; superficial",3715297,CDM,510,RC,27613,HCPCS,Outpatient,,,634.25,317.13,,475.69,75,,,percent of total billed charges,75% of total billed charges,475.69,75,,,percent of total billed charges,75% of total billed charges,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,137.59,102,,,Fee Schedule,102% of WV Medicaid Rate,2326.19,165,,,Fee Schedule,165% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4049.52,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5553.61,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6956.46,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,134.89,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,88.8,14,,,percent of total billed charges,14% of total billed charges,88.8,6956.46,
27615- Rad resect/tumor/leg/ankle/<5 cm,3435070,CDM,510,RC,27615,HCPCS,Outpatient,,,2702.65,1351.33,,2026.99,75,,,percent of total billed charges,75% of total billed charges,2026.99,75,,,percent of total billed charges,75% of total billed charges,2428.67,100,,,Fee Schedule,100% of CMS OPPS Rate,803.83,102,,,Fee Schedule,102% of WV Medicaid Rate,4007.32,165,,,Fee Schedule,165% of CMS OPPS Rate,2517.11,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,6976.06,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,9567.11,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,11983.78,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,788.07,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2428.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2517.11,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,378.37,14,,,percent of total billed charges,14% of total billed charges,378.37,11983.78,
27616- Resect/sft tis tum/leg/ankle/5cm/>,3435071,CDM,510,RC,27616,HCPCS,Outpatient,,,3362.7,1681.35,,2522.03,75,,,percent of total billed charges,75% of total billed charges,2522.03,75,,,percent of total billed charges,75% of total billed charges,2428.67,100,,,Fee Schedule,100% of CMS OPPS Rate,803.83,102,,,Fee Schedule,102% of WV Medicaid Rate,4007.32,165,,,Fee Schedule,165% of CMS OPPS Rate,2517.11,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,6976.06,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,9567.11,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,11983.78,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,788.07,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2428.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2517.11,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,470.78,14,,,percent of total billed charges,14% of total billed charges,470.78,11983.78,
27618- Exc SQ tum/leg or ankle area <3 cm,3435072,CDM,510,RC,27618,HCPCS,Outpatient,,,620.48,310.24,,465.36,75,,,percent of total billed charges,75% of total billed charges,465.36,75,,,percent of total billed charges,75% of total billed charges,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,479.67,102,,,Fee Schedule,102% of WV Medicaid Rate,2326.19,165,,,Fee Schedule,165% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4049.52,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5553.61,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6956.46,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,470.26,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,86.87,14,,,percent of total billed charges,14% of total billed charges,86.87,6956.46,
27620- Arthrot/ankle w/joint exploration,3435073,CDM,510,RC,27620,HCPCS,Outpatient,,,1167.53,583.77,,875.65,75,,,percent of total billed charges,75% of total billed charges,875.65,75,,,percent of total billed charges,75% of total billed charges,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,1073.09,102,,,Fee Schedule,102% of WV Medicaid Rate,4617.6,165,,,Fee Schedule,165% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8038.46,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11024.11,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13808.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1052.05,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,163.45,14,,,percent of total billed charges,14% of total billed charges,163.45,13808.81,
27630- Exc/tendon sheath lesion/leg/ankle,3435074,CDM,510,RC,27630,HCPCS,Outpatient,,,1364.98,682.49,,1023.74,75,,,percent of total billed charges,75% of total billed charges,1023.74,75,,,percent of total billed charges,75% of total billed charges,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,1073.09,102,,,Fee Schedule,102% of WV Medicaid Rate,4617.6,165,,,Fee Schedule,165% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8038.46,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11024.11,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13808.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1052.05,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,191.1,14,,,percent of total billed charges,14% of total billed charges,191.1,13808.81,
27635- Exc/bone cyst/bgn tumor/tib/fibula,3435076,CDM,510,RC,27635,HCPCS,Outpatient,,,1508.76,754.38,,1131.57,75,,,percent of total billed charges,75% of total billed charges,1131.57,75,,,percent of total billed charges,75% of total billed charges,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,1073.09,102,,,Fee Schedule,102% of WV Medicaid Rate,4617.6,165,,,Fee Schedule,165% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8038.46,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11024.11,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13808.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1052.05,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,211.23,14,,,percent of total billed charges,14% of total billed charges,211.23,13808.81,
27640- Partial excision/bone/tibia,3435077,CDM,510,RC,27640,HCPCS,Outpatient,,,2179.74,1089.87,,1634.81,75,,,percent of total billed charges,75% of total billed charges,1634.81,75,,,percent of total billed charges,75% of total billed charges,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,1073.09,102,,,Fee Schedule,102% of WV Medicaid Rate,4617.6,165,,,Fee Schedule,165% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8038.46,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11024.11,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13808.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1052.05,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,305.16,14,,,percent of total billed charges,14% of total billed charges,305.16,13808.81,
27650- Repair/open/perc/Achilles tendon,3435078,CDM,510,RC,27650,HCPCS,Outpatient,,,1709.09,854.55,,1281.82,75,,,percent of total billed charges,75% of total billed charges,1281.82,75,,,percent of total billed charges,75% of total billed charges,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,2365.05,102,,,Fee Schedule,102% of WV Medicaid Rate,10261.1,165,,,Fee Schedule,165% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,17862.79,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,24497.4,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,30685.48,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,2318.68,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,239.27,14,,,percent of total billed charges,14% of total billed charges,239.27,30685.48,
27652- Rpr/open/per/Achilles tend w/graft,3435079,CDM,510,RC,27652,HCPCS,Outpatient,,,1722.07,861.04,,1291.55,75,,,percent of total billed charges,75% of total billed charges,1291.55,75,,,percent of total billed charges,75% of total billed charges,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,3335.29,102,,,Fee Schedule,102% of WV Medicaid Rate,10261.1,165,,,Fee Schedule,165% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,17862.79,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,24497.4,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,30685.48,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,3269.89,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,241.09,14,,,percent of total billed charges,14% of total billed charges,241.09,30685.48,
27654- Rpr/secondary/Achilles tendon,3435080,CDM,510,RC,27654,HCPCS,Outpatient,,,1855.18,927.59,,1391.39,75,,,percent of total billed charges,75% of total billed charges,1391.39,75,,,percent of total billed charges,75% of total billed charges,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,3078.97,102,,,Fee Schedule,102% of WV Medicaid Rate,10261.1,165,,,Fee Schedule,165% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,17862.79,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,24497.4,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,30685.48,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,3018.6,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,259.73,14,,,percent of total billed charges,14% of total billed charges,259.73,30685.48,
27658- Rpr/flexor ten/leg/pri w/o graft,3435081,CDM,510,RC,27658,HCPCS,Outpatient,,,952.79,476.4,,714.59,75,,,percent of total billed charges,75% of total billed charges,714.59,75,,,percent of total billed charges,75% of total billed charges,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,1073.09,102,,,Fee Schedule,102% of WV Medicaid Rate,4617.6,165,,,Fee Schedule,165% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8038.46,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11024.11,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13808.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1052.05,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,133.39,14,,,percent of total billed charges,14% of total billed charges,133.39,13808.81,
27659- Rpr/flexor ten/leg/secondary,3435082,CDM,510,RC,27659,HCPCS,Outpatient,,,1222.75,611.38,,917.06,75,,,percent of total billed charges,75% of total billed charges,917.06,75,,,percent of total billed charges,75% of total billed charges,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,2365.05,102,,,Fee Schedule,102% of WV Medicaid Rate,10261.1,165,,,Fee Schedule,165% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,17862.79,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,24497.4,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,30685.48,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,2318.68,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,171.19,14,,,percent of total billed charges,14% of total billed charges,171.19,30685.48,
27664- Rpr/extensor ten/leg/pri w/o graft,3435083,CDM,510,RC,27664,HCPCS,Outpatient,,,941.85,470.93,,706.39,75,,,percent of total billed charges,75% of total billed charges,706.39,75,,,percent of total billed charges,75% of total billed charges,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,2365.05,102,,,Fee Schedule,102% of WV Medicaid Rate,10261.1,165,,,Fee Schedule,165% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,17862.79,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,24497.4,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,30685.48,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,2318.68,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,131.86,14,,,percent of total billed charges,14% of total billed charges,131.86,30685.48,
27665- Rpr/extensor ten/leg/secondary,3435084,CDM,510,RC,27665,HCPCS,Outpatient,,,1092.05,546.03,,819.04,75,,,percent of total billed charges,75% of total billed charges,819.04,75,,,percent of total billed charges,75% of total billed charges,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,2365.05,102,,,Fee Schedule,102% of WV Medicaid Rate,10261.1,165,,,Fee Schedule,165% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,17862.79,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,24497.4,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,30685.48,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,2318.68,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,152.89,14,,,percent of total billed charges,14% of total billed charges,152.89,30685.48,
27675- Rpr/peroneal ten w/o fib osteotomy,3435085,CDM,510,RC,27675,HCPCS,Outpatient,,,1278.9,639.45,,959.18,75,,,percent of total billed charges,75% of total billed charges,959.18,75,,,percent of total billed charges,75% of total billed charges,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,1073.09,102,,,Fee Schedule,102% of WV Medicaid Rate,4617.6,165,,,Fee Schedule,165% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8038.46,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11024.11,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13808.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1052.05,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,179.05,14,,,percent of total billed charges,14% of total billed charges,179.05,13808.81,
27676- Rpr/peroneal ten/fibular osteotomy,3435086,CDM,510,RC,27676,HCPCS,Outpatient,,,1585.33,792.67,,1189,75,,,percent of total billed charges,75% of total billed charges,1189,75,,,percent of total billed charges,75% of total billed charges,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,2365.05,102,,,Fee Schedule,102% of WV Medicaid Rate,10261.1,165,,,Fee Schedule,165% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,17862.79,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,24497.4,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,30685.48,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,2318.68,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,221.95,14,,,percent of total billed charges,14% of total billed charges,221.95,30685.48,
27680-Tenolysis/flex/externalten/leg/ankle ea,3435087,CDM,510,RC,27680,HCPCS,Outpatient,,,1083.81,541.91,,812.86,75,,,percent of total billed charges,75% of total billed charges,812.86,75,,,percent of total billed charges,75% of total billed charges,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,1073.09,102,,,Fee Schedule,102% of WV Medicaid Rate,4617.6,165,,,Fee Schedule,165% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8038.46,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11024.11,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13808.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1052.05,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,151.73,14,,,percent of total billed charges,14% of total billed charges,151.73,13808.81,
27685- Revise tendon/leg/ankle/sng tendon,3435088,CDM,510,RC,27685,HCPCS,Outpatient,,,1657.85,828.93,,1243.39,75,,,percent of total billed charges,75% of total billed charges,1243.39,75,,,percent of total billed charges,75% of total billed charges,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,1073.09,102,,,Fee Schedule,102% of WV Medicaid Rate,4617.6,165,,,Fee Schedule,165% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8038.46,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11024.11,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13808.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1052.05,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,232.1,14,,,percent of total billed charges,14% of total billed charges,232.1,13808.81,
27686- Revise tendon/leg/ankle/multip/ea,3435089,CDM,510,RC,27686,HCPCS,Outpatient,,,1385.62,692.81,,1039.22,75,,,percent of total billed charges,75% of total billed charges,1039.22,75,,,percent of total billed charges,75% of total billed charges,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,1073.09,102,,,Fee Schedule,102% of WV Medicaid Rate,4617.6,165,,,Fee Schedule,165% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8038.46,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11024.11,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13808.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1052.05,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,193.99,14,,,percent of total billed charges,14% of total billed charges,193.99,13808.81,
27690- Transfer/transplt/low leg ten/spfc,3435091,CDM,510,RC,27690,HCPCS,Outpatient,,,1662.96,831.48,,1247.22,75,,,percent of total billed charges,75% of total billed charges,1247.22,75,,,percent of total billed charges,75% of total billed charges,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,2365.05,102,,,Fee Schedule,102% of WV Medicaid Rate,10261.1,165,,,Fee Schedule,165% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,17862.79,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,24497.4,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,30685.48,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,2318.68,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,232.81,14,,,percent of total billed charges,14% of total billed charges,232.81,30685.48,
27691- Transfer/transplt/low leg ten/deep,3435092,CDM,510,RC,27691,HCPCS,Outpatient,,,1936.23,968.12,,1452.17,75,,,percent of total billed charges,75% of total billed charges,1452.17,75,,,percent of total billed charges,75% of total billed charges,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,2365.05,102,,,Fee Schedule,102% of WV Medicaid Rate,10261.1,165,,,Fee Schedule,165% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,17862.79,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,24497.4,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,30685.48,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,2318.68,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,271.07,14,,,percent of total billed charges,14% of total billed charges,271.07,30685.48,
27692- Transfr/transplt/low leg ten/ea ad,3435093,CDM,510,RC,27692,HCPCS,Outpatient,,,268.64,134.32,,201.48,75,,,percent of total billed charges,75% of total billed charges,201.48,75,,,percent of total billed charges,75% of total billed charges,85.96,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.61,14,,,percent of total billed charges,14% of total billed charges,37.61,201.48,
27695- Rpr/primary/disrupt ligament/ankle,3435094,CDM,510,RC,27695,HCPCS,Outpatient,,,1242.47,621.24,,931.85,75,,,percent of total billed charges,75% of total billed charges,931.85,75,,,percent of total billed charges,75% of total billed charges,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,3094.4,102,,,Fee Schedule,102% of WV Medicaid Rate,10261.1,165,,,Fee Schedule,165% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,17862.79,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,24497.4,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,30685.48,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,3033.73,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,173.95,14,,,percent of total billed charges,14% of total billed charges,173.95,30685.48,
27696- Rpr/pri lig/ankle/both collat lig,3435095,CDM,510,RC,27696,HCPCS,Outpatient,,,1432.35,716.18,,1074.26,75,,,percent of total billed charges,75% of total billed charges,1074.26,75,,,percent of total billed charges,75% of total billed charges,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,3078.97,102,,,Fee Schedule,102% of WV Medicaid Rate,10261.1,165,,,Fee Schedule,165% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,17862.79,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,24497.4,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,30685.48,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,3018.6,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,200.53,14,,,percent of total billed charges,14% of total billed charges,200.53,30685.48,
27698- Rpr/secondary/disrupt lig/ankle,3435096,CDM,510,RC,27698,HCPCS,Outpatient,,,1663.78,831.89,,1247.84,75,,,percent of total billed charges,75% of total billed charges,1247.84,75,,,percent of total billed charges,75% of total billed charges,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,3078.29,102,,,Fee Schedule,102% of WV Medicaid Rate,10261.1,165,,,Fee Schedule,165% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,17862.79,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,24497.4,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,30685.48,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,3017.93,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,232.93,14,,,percent of total billed charges,14% of total billed charges,232.93,30685.48,
27705- Osteotomy/tibia,3435097,CDM,510,RC,27705,HCPCS,Outpatient,,,1986.95,993.48,,1490.21,75,,,percent of total billed charges,75% of total billed charges,1490.21,75,,,percent of total billed charges,75% of total billed charges,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,3072.53,102,,,Fee Schedule,102% of WV Medicaid Rate,10261.1,165,,,Fee Schedule,165% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,17862.79,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,24497.4,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,30685.48,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,3012.28,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,278.17,14,,,percent of total billed charges,14% of total billed charges,278.17,30685.48,
27720- Rpr/non/malunion/tibia w/o graft,3435098,CDM,510,RC,27720,HCPCS,Outpatient,,,2290.69,1145.35,,1718.02,75,,,percent of total billed charges,75% of total billed charges,1718.02,75,,,percent of total billed charges,75% of total billed charges,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,10261.1,165,,,Fee Schedule,165% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,17862.79,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,24497.4,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,30685.48,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,320.7,14,,,percent of total billed charges,14% of total billed charges,320.7,30685.48,
27726- Repair/fib/mal/nonunion/intern fix,3435099,CDM,510,RC,27726,HCPCS,Outpatient,,,2521.92,1260.96,,1891.44,75,,,percent of total billed charges,75% of total billed charges,1891.44,75,,,percent of total billed charges,75% of total billed charges,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,3192.97,102,,,Fee Schedule,102% of WV Medicaid Rate,10261.1,165,,,Fee Schedule,165% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,17862.79,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,24497.4,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,30685.48,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,3130.36,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,353.07,14,,,percent of total billed charges,14% of total billed charges,353.07,30685.48,
27750- Clsd tx/tibial shaft fx w/o manip,3435100,CDM,510,RC,27750,HCPCS,Outpatient,,,889.84,444.92,,667.38,75,,,percent of total billed charges,75% of total billed charges,667.38,75,,,percent of total billed charges,75% of total billed charges,194.62,100,,,Fee Schedule,100% of CMS OPPS Rate,84.13,102,,,Fee Schedule,102% of WV Medicaid Rate,321.11,165,,,Fee Schedule,165% of CMS OPPS Rate,201.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,559.02,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,766.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,960.32,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,82.48,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,194.62,100,,,Fee Schedule,100% of CMS OPPS Rate,201.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,124.58,14,,,percent of total billed charges,14% of total billed charges,82.48,960.32,
27752- Clsd tx/tibial shaft fx w/manip,3435101,CDM,510,RC,27752,HCPCS,Outpatient,,,1390.12,695.06,,1042.59,75,,,percent of total billed charges,75% of total billed charges,1042.59,75,,,percent of total billed charges,75% of total billed charges,1348.67,100,,,Fee Schedule,100% of CMS OPPS Rate,584.77,102,,,Fee Schedule,102% of WV Medicaid Rate,2225.32,165,,,Fee Schedule,165% of CMS OPPS Rate,1397.79,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,3873.91,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5312.76,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6654.78,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,573.3,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1348.67,100,,,Fee Schedule,100% of CMS OPPS Rate,1397.79,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,194.62,14,,,percent of total billed charges,14% of total billed charges,194.62,6654.78,
27758- Open tx/tib shaft fx/plate/screws,3435102,CDM,510,RC,27758,HCPCS,Outpatient,,,2347.97,1173.99,,1760.98,75,,,percent of total billed charges,75% of total billed charges,1760.98,75,,,percent of total billed charges,75% of total billed charges,12267.36,100,,,Fee Schedule,100% of CMS OPPS Rate,6696.95,102,,,Fee Schedule,102% of WV Medicaid Rate,20241.15,165,,,Fee Schedule,165% of CMS OPPS Rate,12714.07,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,35236.32,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,48323.81,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,60530.47,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,6565.64,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,12267.36,100,,,Fee Schedule,100% of CMS OPPS Rate,12714.07,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,328.72,14,,,percent of total billed charges,14% of total billed charges,328.72,60530.47,
27759- Tx/tib shaft fx/intramedul implant,3435103,CDM,510,RC,27759,HCPCS,Outpatient,,,2619.48,1309.74,,1964.61,75,,,percent of total billed charges,75% of total billed charges,1964.61,75,,,percent of total billed charges,75% of total billed charges,12267.36,100,,,Fee Schedule,100% of CMS OPPS Rate,6540.37,102,,,Fee Schedule,102% of WV Medicaid Rate,20241.15,165,,,Fee Schedule,165% of CMS OPPS Rate,12714.07,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,35236.32,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,48323.81,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,60530.47,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,6412.13,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,12267.36,100,,,Fee Schedule,100% of CMS OPPS Rate,12714.07,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,366.73,14,,,percent of total billed charges,14% of total billed charges,366.73,60530.47,
27760- Clsd tx/med malleolus fx w/o manip,3435104,CDM,510,RC,27760,HCPCS,Outpatient,,,849.4,424.7,,637.05,75,,,percent of total billed charges,75% of total billed charges,637.05,75,,,percent of total billed charges,75% of total billed charges,194.62,100,,,Fee Schedule,100% of CMS OPPS Rate,84.13,102,,,Fee Schedule,102% of WV Medicaid Rate,321.11,165,,,Fee Schedule,165% of CMS OPPS Rate,201.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,559.02,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,766.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,960.32,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,82.48,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,194.62,100,,,Fee Schedule,100% of CMS OPPS Rate,201.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,118.92,14,,,percent of total billed charges,14% of total billed charges,82.48,960.32,
27762- Clsd tx/med malleolus fx w/manip,3435105,CDM,510,RC,27762,HCPCS,Outpatient,,,1249.73,624.87,,937.3,75,,,percent of total billed charges,75% of total billed charges,937.3,75,,,percent of total billed charges,75% of total billed charges,1348.67,100,,,Fee Schedule,100% of CMS OPPS Rate,584.77,102,,,Fee Schedule,102% of WV Medicaid Rate,2225.32,165,,,Fee Schedule,165% of CMS OPPS Rate,1397.79,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,3873.91,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5312.76,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6654.78,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,573.3,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1348.67,100,,,Fee Schedule,100% of CMS OPPS Rate,1397.79,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,174.96,14,,,percent of total billed charges,14% of total billed charges,174.96,6654.78,
27766- Open tx/medial malleolus fx,3435106,CDM,510,RC,27766,HCPCS,Outpatient,,,1571.82,785.91,,1178.87,75,,,percent of total billed charges,75% of total billed charges,1178.87,75,,,percent of total billed charges,75% of total billed charges,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,2365.05,102,,,Fee Schedule,102% of WV Medicaid Rate,10261.1,165,,,Fee Schedule,165% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,17862.79,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,24497.4,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,30685.48,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,2318.68,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,220.05,14,,,percent of total billed charges,14% of total billed charges,220.05,30685.48,
27767- Clsd tx/post malleolus fx w/o mani,3435107,CDM,510,RC,27767,HCPCS,Outpatient,,,744.2,372.1,,558.15,75,,,percent of total billed charges,75% of total billed charges,558.15,75,,,percent of total billed charges,75% of total billed charges,194.62,100,,,Fee Schedule,100% of CMS OPPS Rate,84.13,102,,,Fee Schedule,102% of WV Medicaid Rate,321.11,165,,,Fee Schedule,165% of CMS OPPS Rate,201.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,559.02,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,766.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,960.32,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,82.48,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,194.62,100,,,Fee Schedule,100% of CMS OPPS Rate,201.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,104.19,14,,,percent of total billed charges,14% of total billed charges,82.48,960.32,
27769- Open tx/post malleolus fx,3435108,CDM,510,RC,27769,HCPCS,Outpatient,,,1906.65,953.33,,1429.99,75,,,percent of total billed charges,75% of total billed charges,1429.99,75,,,percent of total billed charges,75% of total billed charges,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,3078.97,102,,,Fee Schedule,102% of WV Medicaid Rate,10261.1,165,,,Fee Schedule,165% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,17862.79,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,24497.4,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,30685.48,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,3018.6,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,266.93,14,,,percent of total billed charges,14% of total billed charges,266.93,30685.48,
27780- Clsd tx/prox fib/shft fx w/o manip,3435109,CDM,510,RC,27780,HCPCS,Outpatient,,,791.19,395.6,,593.39,75,,,percent of total billed charges,75% of total billed charges,593.39,75,,,percent of total billed charges,75% of total billed charges,194.62,100,,,Fee Schedule,100% of CMS OPPS Rate,84.13,102,,,Fee Schedule,102% of WV Medicaid Rate,321.11,165,,,Fee Schedule,165% of CMS OPPS Rate,201.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,559.02,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,766.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,960.32,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,82.48,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,194.62,100,,,Fee Schedule,100% of CMS OPPS Rate,201.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,110.77,14,,,percent of total billed charges,14% of total billed charges,82.48,960.32,
27784- Open tx/prox fibula shaft fracture,3435110,CDM,510,RC,27784,HCPCS,Outpatient,,,1846.09,923.05,,1384.57,75,,,percent of total billed charges,75% of total billed charges,1384.57,75,,,percent of total billed charges,75% of total billed charges,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,2365.05,102,,,Fee Schedule,102% of WV Medicaid Rate,10261.1,165,,,Fee Schedule,165% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,17862.79,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,24497.4,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,30685.48,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,2318.68,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,258.45,14,,,percent of total billed charges,14% of total billed charges,258.45,30685.48,
27786- Clsd tx/dis fibular fx w/o manip,3435111,CDM,510,RC,27786,HCPCS,Outpatient,,,803.97,401.99,,602.98,75,,,percent of total billed charges,75% of total billed charges,602.98,75,,,percent of total billed charges,75% of total billed charges,194.62,100,,,Fee Schedule,100% of CMS OPPS Rate,84.13,102,,,Fee Schedule,102% of WV Medicaid Rate,321.11,165,,,Fee Schedule,165% of CMS OPPS Rate,201.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,559.02,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,766.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,960.32,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,82.48,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,194.62,100,,,Fee Schedule,100% of CMS OPPS Rate,201.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,112.56,14,,,percent of total billed charges,14% of total billed charges,82.48,960.32,
27792- Open tx/distal fibular fx,3435112,CDM,510,RC,27792,HCPCS,Outpatient,,,1682.18,841.09,,1261.64,75,,,percent of total billed charges,75% of total billed charges,1261.64,75,,,percent of total billed charges,75% of total billed charges,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,3159.12,102,,,Fee Schedule,102% of WV Medicaid Rate,10261.1,165,,,Fee Schedule,165% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,17862.79,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,24497.4,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,30685.48,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,3097.18,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,235.51,14,,,percent of total billed charges,14% of total billed charges,235.51,30685.48,
27808- Clsd tx/bimalleol ank fx w/o manip,3435113,CDM,510,RC,27808,HCPCS,Outpatient,,,854.95,427.48,,641.21,75,,,percent of total billed charges,75% of total billed charges,641.21,75,,,percent of total billed charges,75% of total billed charges,194.62,100,,,Fee Schedule,100% of CMS OPPS Rate,84.13,102,,,Fee Schedule,102% of WV Medicaid Rate,321.11,165,,,Fee Schedule,165% of CMS OPPS Rate,201.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,559.02,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,766.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,960.32,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,82.48,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,194.62,100,,,Fee Schedule,100% of CMS OPPS Rate,201.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,119.69,14,,,percent of total billed charges,14% of total billed charges,82.48,960.32,
27810- Clsd tx/bimalleol ankle fx w/manip,3435114,CDM,510,RC,27810,HCPCS,Outpatient,,,1221.55,610.78,,916.16,75,,,percent of total billed charges,75% of total billed charges,916.16,75,,,percent of total billed charges,75% of total billed charges,1348.67,100,,,Fee Schedule,100% of CMS OPPS Rate,584.77,102,,,Fee Schedule,102% of WV Medicaid Rate,2225.32,165,,,Fee Schedule,165% of CMS OPPS Rate,1397.79,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,3873.91,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5312.76,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6654.78,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,573.3,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1348.67,100,,,Fee Schedule,100% of CMS OPPS Rate,1397.79,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,171.02,14,,,percent of total billed charges,14% of total billed charges,171.02,6654.78,
27814- Open tx/bimalleolar ankle fracture,3435115,CDM,510,RC,27814,HCPCS,Outpatient,,,1998.51,999.26,,1498.88,75,,,percent of total billed charges,75% of total billed charges,1498.88,75,,,percent of total billed charges,75% of total billed charges,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,3176.85,102,,,Fee Schedule,102% of WV Medicaid Rate,10261.1,165,,,Fee Schedule,165% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,17862.79,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,24497.4,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,30685.48,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,3114.56,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,279.79,14,,,percent of total billed charges,14% of total billed charges,279.79,30685.48,
27822- Open tx/trimalleo ankle fx w/o fix,3435116,CDM,510,RC,27822,HCPCS,Outpatient,,,2280.8,1140.4,,1710.6,75,,,percent of total billed charges,75% of total billed charges,1710.6,75,,,percent of total billed charges,75% of total billed charges,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,3179.62,102,,,Fee Schedule,102% of WV Medicaid Rate,10261.1,165,,,Fee Schedule,165% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,17862.79,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,24497.4,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,30685.48,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,3117.27,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,319.31,14,,,percent of total billed charges,14% of total billed charges,319.31,30685.48,
27823- Open tx/trimalleo ankle fx w/fix,3435117,CDM,510,RC,27823,HCPCS,Outpatient,,,2572.13,1286.07,,1929.1,75,,,percent of total billed charges,75% of total billed charges,1929.1,75,,,percent of total billed charges,75% of total billed charges,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,3146.46,102,,,Fee Schedule,102% of WV Medicaid Rate,10261.1,165,,,Fee Schedule,165% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,17862.79,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,24497.4,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,30685.48,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,3084.76,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,360.1,14,,,percent of total billed charges,14% of total billed charges,360.1,30685.48,
27824- Clsd tx/dis tib/wt bear no manip,3435118,CDM,510,RC,27824,HCPCS,Outpatient,,,816.41,408.21,,612.31,75,,,percent of total billed charges,75% of total billed charges,612.31,75,,,percent of total billed charges,75% of total billed charges,194.62,100,,,Fee Schedule,100% of CMS OPPS Rate,84.13,102,,,Fee Schedule,102% of WV Medicaid Rate,321.11,165,,,Fee Schedule,165% of CMS OPPS Rate,201.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,559.02,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,766.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,960.32,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,82.48,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,194.62,100,,,Fee Schedule,100% of CMS OPPS Rate,201.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,114.3,14,,,percent of total billed charges,14% of total billed charges,82.48,960.32,
27825- Clsd tx/articulr/dis tib/traction,3435119,CDM,510,RC,27825,HCPCS,Outpatient,,,1412.96,706.48,,1059.72,75,,,percent of total billed charges,75% of total billed charges,1059.72,75,,,percent of total billed charges,75% of total billed charges,1348.67,100,,,Fee Schedule,100% of CMS OPPS Rate,584.77,102,,,Fee Schedule,102% of WV Medicaid Rate,2225.32,165,,,Fee Schedule,165% of CMS OPPS Rate,1397.79,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,3873.91,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5312.76,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6654.78,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,573.3,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1348.67,100,,,Fee Schedule,100% of CMS OPPS Rate,1397.79,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,197.81,14,,,percent of total billed charges,14% of total billed charges,197.81,6654.78,
27827- Open tx/artic dis tib/int fix tib,3435120,CDM,510,RC,27827,HCPCS,Outpatient,,,2923.06,1461.53,,2192.3,75,,,percent of total billed charges,75% of total billed charges,2192.3,75,,,percent of total billed charges,75% of total billed charges,12267.36,100,,,Fee Schedule,100% of CMS OPPS Rate,6749.63,102,,,Fee Schedule,102% of WV Medicaid Rate,20241.15,165,,,Fee Schedule,165% of CMS OPPS Rate,12714.07,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,35236.32,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,48323.81,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,60530.47,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,6617.28,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,12267.36,100,,,Fee Schedule,100% of CMS OPPS Rate,12714.07,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,409.23,14,,,percent of total billed charges,14% of total billed charges,409.23,60530.47,
27828- Open tx/ artic dis tib/fix tib/fib,3435121,CDM,510,RC,27828,HCPCS,Outpatient,,,3483.32,1741.66,,2612.49,75,,,percent of total billed charges,75% of total billed charges,2612.49,75,,,percent of total billed charges,75% of total billed charges,12267.36,100,,,Fee Schedule,100% of CMS OPPS Rate,6704.36,102,,,Fee Schedule,102% of WV Medicaid Rate,20241.15,165,,,Fee Schedule,165% of CMS OPPS Rate,12714.07,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,35236.32,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,48323.81,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,60530.47,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,6572.9,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,12267.36,100,,,Fee Schedule,100% of CMS OPPS Rate,12714.07,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,487.66,14,,,percent of total billed charges,14% of total billed charges,487.66,60530.47,
27829- Open tx/dist tibiofib jnt disrupt,3435122,CDM,510,RC,27829,HCPCS,Outpatient,,,1837.45,918.73,,1378.09,75,,,percent of total billed charges,75% of total billed charges,1378.09,75,,,percent of total billed charges,75% of total billed charges,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,3207.25,102,,,Fee Schedule,102% of WV Medicaid Rate,10261.1,165,,,Fee Schedule,165% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,17862.79,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,24497.4,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,30685.48,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,3144.36,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,257.24,14,,,percent of total billed charges,14% of total billed charges,257.24,30685.48,
27830- Clsd tx/tibiofib dislocat w/o anes,3435123,CDM,510,RC,27830,HCPCS,Outpatient,,,1006.32,503.16,,754.74,75,,,percent of total billed charges,75% of total billed charges,754.74,75,,,percent of total billed charges,75% of total billed charges,194.62,100,,,Fee Schedule,100% of CMS OPPS Rate,84.13,102,,,Fee Schedule,102% of WV Medicaid Rate,321.11,165,,,Fee Schedule,165% of CMS OPPS Rate,201.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,559.02,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,766.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,960.32,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,82.48,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,194.62,100,,,Fee Schedule,100% of CMS OPPS Rate,201.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,140.88,14,,,percent of total billed charges,14% of total billed charges,82.48,960.32,
27840- Clsd tx/ankle dislocate w/o anest,3435124,CDM,510,RC,27840,HCPCS,Outpatient,,,996.95,498.48,,747.71,75,,,percent of total billed charges,75% of total billed charges,747.71,75,,,percent of total billed charges,75% of total billed charges,194.62,100,,,Fee Schedule,100% of CMS OPPS Rate,84.13,102,,,Fee Schedule,102% of WV Medicaid Rate,321.11,165,,,Fee Schedule,165% of CMS OPPS Rate,201.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,559.02,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,766.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,960.32,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,82.48,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,194.62,100,,,Fee Schedule,100% of CMS OPPS Rate,201.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,139.57,14,,,percent of total billed charges,14% of total billed charges,82.48,960.32,
27842- Clsd tx/ankle dislocate/anesthesia,3435125,CDM,510,RC,27842,HCPCS,Outpatient,,,1295.31,647.66,,971.48,75,,,percent of total billed charges,75% of total billed charges,971.48,75,,,percent of total billed charges,75% of total billed charges,1348.67,100,,,Fee Schedule,100% of CMS OPPS Rate,775.02,102,,,Fee Schedule,102% of WV Medicaid Rate,2225.32,165,,,Fee Schedule,165% of CMS OPPS Rate,1397.79,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,3873.91,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5312.76,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6654.78,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,759.82,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1348.67,100,,,Fee Schedule,100% of CMS OPPS Rate,1397.79,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,181.34,14,,,percent of total billed charges,14% of total billed charges,181.34,6654.78,
27846- Open tx/ankle dislocate w/o repair/int fix,3435126,CDM,510,RC,27846,HCPCS,Outpatient,,,1893.49,946.75,,1420.12,75,,,percent of total billed charges,75% of total billed charges,1420.12,75,,,percent of total billed charges,75% of total billed charges,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,2365.05,102,,,Fee Schedule,102% of WV Medicaid Rate,10261.1,165,,,Fee Schedule,165% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,17862.79,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,24497.4,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,30685.48,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,2318.68,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,265.09,14,,,percent of total billed charges,14% of total billed charges,265.09,30685.48,
27870- Arthrodesis/ankle/open,3435127,CDM,510,RC,27870,HCPCS,Outpatient,,,2653.42,1326.71,,1990.07,75,,,percent of total billed charges,75% of total billed charges,1990.07,75,,,percent of total billed charges,75% of total billed charges,12267.36,100,,,Fee Schedule,100% of CMS OPPS Rate,7021.24,102,,,Fee Schedule,102% of WV Medicaid Rate,20241.15,165,,,Fee Schedule,165% of CMS OPPS Rate,12714.07,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,35236.32,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,48323.81,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,60530.47,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,6883.57,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,12267.36,100,,,Fee Schedule,100% of CMS OPPS Rate,12714.07,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,371.48,14,,,percent of total billed charges,14% of total billed charges,371.48,60530.47,
27871- Arthrodesis/tibiofib jnt/prox/dist,3435128,CDM,510,RC,27871,HCPCS,Outpatient,,,1802.23,901.12,,1351.67,75,,,percent of total billed charges,75% of total billed charges,1351.67,75,,,percent of total billed charges,75% of total billed charges,12267.36,100,,,Fee Schedule,100% of CMS OPPS Rate,7308.11,102,,,Fee Schedule,102% of WV Medicaid Rate,20241.15,165,,,Fee Schedule,165% of CMS OPPS Rate,12714.07,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,35236.32,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,48323.81,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,60530.47,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,7164.81,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,12267.36,100,,,Fee Schedule,100% of CMS OPPS Rate,12714.07,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,252.31,14,,,percent of total billed charges,14% of total billed charges,252.31,60530.47,
27884 - Amputate Leg thru Tibia/Fibula Sec Closure/Scar Rev,3899017,CDM,983,RC,27884,HCPCS,Outpatient,,,1533.77,766.89,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
27894- Decompr fasciot/leg/ant/lat/post,3435131,CDM,510,RC,27894,HCPCS,Outpatient,,,2167.89,1083.95,,1625.92,75,,,percent of total billed charges,75% of total billed charges,1625.92,75,,,percent of total billed charges,75% of total billed charges,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,1073.09,102,,,Fee Schedule,102% of WV Medicaid Rate,4617.6,165,,,Fee Schedule,165% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8038.46,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11024.11,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13808.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1052.05,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,303.5,14,,,percent of total billed charges,14% of total billed charges,303.5,13808.81,
28005- Incision/bone cortex/foot,3435136,CDM,510,RC,28005,HCPCS,Outpatient,,,1483.59,741.8,,1112.69,75,,,percent of total billed charges,75% of total billed charges,1112.69,75,,,percent of total billed charges,75% of total billed charges,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,1073.09,102,,,Fee Schedule,102% of WV Medicaid Rate,4617.6,165,,,Fee Schedule,165% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8038.46,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11024.11,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13808.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1052.05,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,207.7,14,,,percent of total billed charges,14% of total billed charges,207.7,13808.81,
28008- Fasciotomy/foot and/or toe,3435137,CDM,510,RC,28008,HCPCS,Outpatient,,,1073.25,536.63,,804.94,75,,,percent of total billed charges,75% of total billed charges,804.94,75,,,percent of total billed charges,75% of total billed charges,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,1073.09,102,,,Fee Schedule,102% of WV Medicaid Rate,4617.6,165,,,Fee Schedule,165% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8038.46,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11024.11,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13808.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1052.05,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,150.26,14,,,percent of total billed charges,14% of total billed charges,150.26,13808.81,
28010- Tenotomy/perc/toe/single tendon,3435138,CDM,510,RC,28010,HCPCS,Outpatient,,,587.53,293.77,,440.65,75,,,percent of total billed charges,75% of total billed charges,440.65,75,,,percent of total billed charges,75% of total billed charges,1348.67,100,,,Fee Schedule,100% of CMS OPPS Rate,99.1,102,,,Fee Schedule,102% of WV Medicaid Rate,2225.32,165,,,Fee Schedule,165% of CMS OPPS Rate,1397.79,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,3873.91,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5312.76,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6654.78,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,97.16,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1348.67,100,,,Fee Schedule,100% of CMS OPPS Rate,1397.79,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,82.25,14,,,percent of total billed charges,14% of total billed charges,82.25,6654.78,
28011- Tenotomy/perc/toe/mult tendons,3435139,CDM,510,RC,28011,HCPCS,Outpatient,,,798.83,399.42,,599.12,75,,,percent of total billed charges,75% of total billed charges,599.12,75,,,percent of total billed charges,75% of total billed charges,1348.67,100,,,Fee Schedule,100% of CMS OPPS Rate,584.77,102,,,Fee Schedule,102% of WV Medicaid Rate,2225.32,165,,,Fee Schedule,165% of CMS OPPS Rate,1397.79,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,3873.91,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5312.76,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6654.78,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,573.3,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1348.67,100,,,Fee Schedule,100% of CMS OPPS Rate,1397.79,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,111.84,14,,,percent of total billed charges,14% of total billed charges,111.84,6654.78,
28020- Arthrotomy/exp/intertar/tarsometat,3435140,CDM,510,RC,28020,HCPCS,Outpatient,,,1381.15,690.58,,1035.86,75,,,percent of total billed charges,75% of total billed charges,1035.86,75,,,percent of total billed charges,75% of total billed charges,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,1073.09,102,,,Fee Schedule,102% of WV Medicaid Rate,4617.6,165,,,Fee Schedule,165% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8038.46,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11024.11,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13808.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1052.05,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,193.36,14,,,percent of total billed charges,14% of total billed charges,193.36,13808.81,
28022- Arthrotomy/metatarsopalangeal jnt,3435141,CDM,510,RC,28022,HCPCS,Outpatient,,,1217.89,608.95,,913.42,75,,,percent of total billed charges,75% of total billed charges,913.42,75,,,percent of total billed charges,75% of total billed charges,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,1073.09,102,,,Fee Schedule,102% of WV Medicaid Rate,4617.6,165,,,Fee Schedule,165% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8038.46,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11024.11,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13808.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1052.05,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,170.5,14,,,percent of total billed charges,14% of total billed charges,170.5,13808.81,
28024- Arthrotomy/interphalangeal joint,3435142,CDM,510,RC,28024,HCPCS,Outpatient,,,1136.12,568.06,,852.09,75,,,percent of total billed charges,75% of total billed charges,852.09,75,,,percent of total billed charges,75% of total billed charges,1348.67,100,,,Fee Schedule,100% of CMS OPPS Rate,584.77,102,,,Fee Schedule,102% of WV Medicaid Rate,2225.32,165,,,Fee Schedule,165% of CMS OPPS Rate,1397.79,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,3873.91,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5312.76,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6654.78,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,573.3,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1348.67,100,,,Fee Schedule,100% of CMS OPPS Rate,1397.79,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,159.06,14,,,percent of total billed charges,14% of total billed charges,159.06,6654.78,
28035- Decompress posterior tibial nerve,3435143,CDM,510,RC,28035,HCPCS,Outpatient,,,1313.84,656.92,,985.38,75,,,percent of total billed charges,75% of total billed charges,985.38,75,,,percent of total billed charges,75% of total billed charges,1689.96,100,,,Fee Schedule,100% of CMS OPPS Rate,650.73,102,,,Fee Schedule,102% of WV Medicaid Rate,2788.43,165,,,Fee Schedule,165% of CMS OPPS Rate,1751.5,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4854.2,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,6657.14,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,8338.75,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,637.97,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1689.96,100,,,Fee Schedule,100% of CMS OPPS Rate,1751.5,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,183.94,14,,,percent of total billed charges,14% of total billed charges,183.94,8338.75,
28039- Exc SQ tumor/foot or toe < 1.5 cm,3435144,CDM,510,RC,28039,HCPCS,Outpatient,,,1243.34,621.67,,932.51,75,,,percent of total billed charges,75% of total billed charges,932.51,75,,,percent of total billed charges,75% of total billed charges,2428.67,100,,,Fee Schedule,100% of CMS OPPS Rate,803.83,102,,,Fee Schedule,102% of WV Medicaid Rate,4007.32,165,,,Fee Schedule,165% of CMS OPPS Rate,2517.11,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,6976.06,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,9567.11,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,11983.78,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,788.07,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2428.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2517.11,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,174.07,14,,,percent of total billed charges,14% of total billed charges,174.07,11983.78,
28045- Exc IM tumor/foot/toe < 1.5 cm,3435145,CDM,510,RC,28045,HCPCS,Outpatient,,,1202.42,601.21,,901.82,75,,,percent of total billed charges,75% of total billed charges,901.82,75,,,percent of total billed charges,75% of total billed charges,2428.67,100,,,Fee Schedule,100% of CMS OPPS Rate,803.83,102,,,Fee Schedule,102% of WV Medicaid Rate,4007.32,165,,,Fee Schedule,165% of CMS OPPS Rate,2517.11,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,6976.06,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,9567.11,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,11983.78,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,788.07,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2428.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2517.11,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,168.34,14,,,percent of total billed charges,14% of total billed charges,168.34,11983.78,
28046- Rad resec soft tis tum/ft/toe/<3cm,3435146,CDM,510,RC,28046,HCPCS,Outpatient,,,1860.91,930.46,,1395.68,75,,,percent of total billed charges,75% of total billed charges,1395.68,75,,,percent of total billed charges,75% of total billed charges,2428.67,100,,,Fee Schedule,100% of CMS OPPS Rate,803.83,102,,,Fee Schedule,102% of WV Medicaid Rate,4007.32,165,,,Fee Schedule,165% of CMS OPPS Rate,2517.11,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,6976.06,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,9567.11,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,11983.78,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,788.07,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2428.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2517.11,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,260.53,14,,,percent of total billed charges,14% of total billed charges,260.53,11983.78,
28052- Arthrotomy/bx metatarsophalang jnt,3435147,CDM,510,RC,28052,HCPCS,Outpatient,,,973.02,486.51,,729.77,75,,,percent of total billed charges,75% of total billed charges,729.77,75,,,percent of total billed charges,75% of total billed charges,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,1073.09,102,,,Fee Schedule,102% of WV Medicaid Rate,4617.6,165,,,Fee Schedule,165% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8038.46,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11024.11,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13808.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1052.05,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,136.22,14,,,percent of total billed charges,14% of total billed charges,136.22,13808.81,
28062- Fasciectomy/plantar fascia/radical,3435148,CDM,510,RC,28062,HCPCS,Outpatient,,,1433.53,716.77,,1075.15,75,,,percent of total billed charges,75% of total billed charges,1075.15,75,,,percent of total billed charges,75% of total billed charges,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,1073.09,102,,,Fee Schedule,102% of WV Medicaid Rate,4617.6,165,,,Fee Schedule,165% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8038.46,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11024.11,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13808.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1052.05,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,200.69,14,,,percent of total billed charges,14% of total billed charges,200.69,13808.81,
28072- Synovect/metatarsophalang jnt/ea,3435149,CDM,510,RC,28072,HCPCS,Outpatient,,,1226.19,613.1,,919.64,75,,,percent of total billed charges,75% of total billed charges,919.64,75,,,percent of total billed charges,75% of total billed charges,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,1073.09,102,,,Fee Schedule,102% of WV Medicaid Rate,4617.6,165,,,Fee Schedule,165% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8038.46,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11024.11,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13808.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1052.05,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,171.67,14,,,percent of total billed charges,14% of total billed charges,171.67,13808.81,
28080- Exc/interdigital neuroma/sng/ea,3435150,CDM,510,RC,28080,HCPCS,Outpatient,,,1322.46,661.23,,991.85,75,,,percent of total billed charges,75% of total billed charges,991.85,75,,,percent of total billed charges,75% of total billed charges,1348.67,100,,,Fee Schedule,100% of CMS OPPS Rate,584.77,102,,,Fee Schedule,102% of WV Medicaid Rate,2225.32,165,,,Fee Schedule,165% of CMS OPPS Rate,1397.79,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,3873.91,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5312.76,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6654.78,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,573.3,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1348.67,100,,,Fee Schedule,100% of CMS OPPS Rate,1397.79,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,185.14,14,,,percent of total billed charges,14% of total billed charges,185.14,6654.78,
28086- Synovect/tendon sheath/foot/flex,3435151,CDM,510,RC,28086,HCPCS,Outpatient,,,1342.32,671.16,,1006.74,75,,,percent of total billed charges,75% of total billed charges,1006.74,75,,,percent of total billed charges,75% of total billed charges,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,1073.09,102,,,Fee Schedule,102% of WV Medicaid Rate,4617.6,165,,,Fee Schedule,165% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8038.46,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11024.11,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13808.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1052.05,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,187.92,14,,,percent of total billed charges,14% of total billed charges,187.92,13808.81,
28090- Exc/lesion/ten/sheath/capsule/foot,3435152,CDM,510,RC,28090,HCPCS,Outpatient,,,1158.29,579.15,,868.72,75,,,percent of total billed charges,75% of total billed charges,868.72,75,,,percent of total billed charges,75% of total billed charges,1348.67,100,,,Fee Schedule,100% of CMS OPPS Rate,584.77,102,,,Fee Schedule,102% of WV Medicaid Rate,2225.32,165,,,Fee Schedule,165% of CMS OPPS Rate,1397.79,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,3873.91,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5312.76,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6654.78,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,573.3,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1348.67,100,,,Fee Schedule,100% of CMS OPPS Rate,1397.79,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,162.16,14,,,percent of total billed charges,14% of total billed charges,162.16,6654.78,
28092- Exc toe les/tendon/sheath/caps/ea,3435153,CDM,510,RC,28092,HCPCS,Outpatient,,,1038.37,519.19,,778.78,75,,,percent of total billed charges,75% of total billed charges,778.78,75,,,percent of total billed charges,75% of total billed charges,1348.67,100,,,Fee Schedule,100% of CMS OPPS Rate,584.77,102,,,Fee Schedule,102% of WV Medicaid Rate,2225.32,165,,,Fee Schedule,165% of CMS OPPS Rate,1397.79,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,3873.91,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5312.76,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6654.78,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,573.3,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1348.67,100,,,Fee Schedule,100% of CMS OPPS Rate,1397.79,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,145.37,14,,,percent of total billed charges,14% of total billed charges,145.37,6654.78,
28104- Exc bone cyst/bgn tum/tarsal/meta,3435154,CDM,510,RC,28104,HCPCS,Outpatient,,,1311.42,655.71,,983.57,75,,,percent of total billed charges,75% of total billed charges,983.57,75,,,percent of total billed charges,75% of total billed charges,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,1073.09,102,,,Fee Schedule,102% of WV Medicaid Rate,4617.6,165,,,Fee Schedule,165% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8038.46,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11024.11,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13808.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1052.05,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,183.6,14,,,percent of total billed charges,14% of total billed charges,183.6,13808.81,
"28108- Excision/Curettage Bone Cyst or Benign Tumor, Phalanges",3435155,CDM,510,RC,28108,HCPCS,Outpatient,,,1081.79,540.9,,811.34,75,,,percent of total billed charges,75% of total billed charges,811.34,75,,,percent of total billed charges,75% of total billed charges,1348.67,100,,,Fee Schedule,100% of CMS OPPS Rate,584.77,102,,,Fee Schedule,102% of WV Medicaid Rate,2225.32,165,,,Fee Schedule,165% of CMS OPPS Rate,1397.79,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,3873.91,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5312.76,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6654.78,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,573.3,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1348.67,100,,,Fee Schedule,100% of CMS OPPS Rate,1397.79,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,151.45,14,,,percent of total billed charges,14% of total billed charges,151.45,6654.78,
28110- Ostectomy/part/5th metatar head,3435156,CDM,510,RC,28110,HCPCS,Outpatient,,,1141.39,570.7,,856.04,75,,,percent of total billed charges,75% of total billed charges,856.04,75,,,percent of total billed charges,75% of total billed charges,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,1073.09,102,,,Fee Schedule,102% of WV Medicaid Rate,4617.6,165,,,Fee Schedule,165% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8038.46,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11024.11,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13808.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1052.05,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,159.79,14,,,percent of total billed charges,14% of total billed charges,159.79,13808.81,
"28112- Ostectomy/comp/2,3,4 metatar head",3435157,CDM,510,RC,28112,HCPCS,Outpatient,,,1205.92,602.96,,904.44,75,,,percent of total billed charges,75% of total billed charges,904.44,75,,,percent of total billed charges,75% of total billed charges,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,1073.09,102,,,Fee Schedule,102% of WV Medicaid Rate,4617.6,165,,,Fee Schedule,165% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8038.46,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11024.11,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13808.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1052.05,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,168.83,14,,,percent of total billed charges,14% of total billed charges,168.83,13808.81,
28116- Ostectromy/exc tarsal coalition,3435158,CDM,510,RC,28116,HCPCS,Outpatient,,,1960,980,,1470,75,,,percent of total billed charges,75% of total billed charges,1470,75,,,percent of total billed charges,75% of total billed charges,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,1073.09,102,,,Fee Schedule,102% of WV Medicaid Rate,4617.6,165,,,Fee Schedule,165% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8038.46,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11024.11,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13808.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1052.05,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,274.4,14,,,percent of total billed charges,14% of total billed charges,274.4,13808.81,
28118- Ostectomy/calcaneus,3435159,CDM,510,RC,28118,HCPCS,Outpatient,,,1516.33,758.17,,1137.25,75,,,percent of total billed charges,75% of total billed charges,1137.25,75,,,percent of total billed charges,75% of total billed charges,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,1073.09,102,,,Fee Schedule,102% of WV Medicaid Rate,4617.6,165,,,Fee Schedule,165% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8038.46,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11024.11,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13808.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1052.05,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,212.29,14,,,percent of total billed charges,14% of total billed charges,212.29,13808.81,
28119- Ostectomy/calcaneus/for spur,3435160,CDM,510,RC,28119,HCPCS,Outpatient,,,1318.34,659.17,,988.76,75,,,percent of total billed charges,75% of total billed charges,988.76,75,,,percent of total billed charges,75% of total billed charges,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,1073.09,102,,,Fee Schedule,102% of WV Medicaid Rate,4617.6,165,,,Fee Schedule,165% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8038.46,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11024.11,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13808.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1052.05,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,184.57,14,,,percent of total billed charges,14% of total billed charges,184.57,13808.81,
28120- Part excision bone/talus/calcaneus,3435161,CDM,510,RC,28120,HCPCS,Outpatient,,,1701.46,850.73,,1276.1,75,,,percent of total billed charges,75% of total billed charges,1276.1,75,,,percent of total billed charges,75% of total billed charges,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,1073.09,102,,,Fee Schedule,102% of WV Medicaid Rate,4617.6,165,,,Fee Schedule,165% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8038.46,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11024.11,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13808.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1052.05,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,238.2,14,,,percent of total billed charges,14% of total billed charges,238.2,13808.81,
28124- Part excision/bone/phalanx of toe,3435163,CDM,510,RC,28124,HCPCS,Outpatient,,,1188.5,594.25,,891.38,75,,,percent of total billed charges,75% of total billed charges,891.38,75,,,percent of total billed charges,75% of total billed charges,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,235.05,102,,,Fee Schedule,102% of WV Medicaid Rate,4617.6,165,,,Fee Schedule,165% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8038.46,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11024.11,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13808.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,230.44,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,166.39,14,,,percent of total billed charges,14% of total billed charges,166.39,13808.81,
28130- Talectomy,3435164,CDM,510,RC,28130,HCPCS,Outpatient,,,1591.21,795.61,,1193.41,75,,,percent of total billed charges,75% of total billed charges,1193.41,75,,,percent of total billed charges,75% of total billed charges,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,3147.6,102,,,Fee Schedule,102% of WV Medicaid Rate,10261.1,165,,,Fee Schedule,165% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,17862.79,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,24497.4,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,30685.48,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,3085.88,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,222.77,14,,,percent of total billed charges,14% of total billed charges,222.77,30685.48,
28200- Rpr/tendon/flexor/foot/ea tendon,3435168,CDM,510,RC,28200,HCPCS,Outpatient,,,1240.21,620.11,,930.16,75,,,percent of total billed charges,75% of total billed charges,930.16,75,,,percent of total billed charges,75% of total billed charges,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,1073.09,102,,,Fee Schedule,102% of WV Medicaid Rate,4617.6,165,,,Fee Schedule,165% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8038.46,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11024.11,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13808.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1052.05,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,173.63,14,,,percent of total billed charges,14% of total billed charges,173.63,13808.81,
28202- Rpr flx tend ft/secondary/free gft,3435169,CDM,510,RC,28202,HCPCS,Outpatient,,,1501.81,750.91,,1126.36,75,,,percent of total billed charges,75% of total billed charges,1126.36,75,,,percent of total billed charges,75% of total billed charges,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,3062.62,102,,,Fee Schedule,102% of WV Medicaid Rate,10261.1,165,,,Fee Schedule,165% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,17862.79,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,24497.4,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,30685.48,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,3002.57,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,210.25,14,,,percent of total billed charges,14% of total billed charges,210.25,30685.48,
28208- Rpr/tendon/extension/foot/ea tendon,3435170,CDM,510,RC,28208,HCPCS,Outpatient,,,1205.6,602.8,,904.2,75,,,percent of total billed charges,75% of total billed charges,904.2,75,,,percent of total billed charges,75% of total billed charges,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,1073.09,102,,,Fee Schedule,102% of WV Medicaid Rate,4617.6,165,,,Fee Schedule,165% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8038.46,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11024.11,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13808.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1052.05,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,168.78,14,,,percent of total billed charges,14% of total billed charges,168.78,13808.81,
28220- Tenolysis/flexor/foot/sng tendon,3435171,CDM,510,RC,28220,HCPCS,Outpatient,,,1124.66,562.33,,843.5,75,,,percent of total billed charges,75% of total billed charges,843.5,75,,,percent of total billed charges,75% of total billed charges,1348.67,100,,,Fee Schedule,100% of CMS OPPS Rate,223.85,102,,,Fee Schedule,102% of WV Medicaid Rate,2225.32,165,,,Fee Schedule,165% of CMS OPPS Rate,1397.79,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,3873.91,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5312.76,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6654.78,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,219.46,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1348.67,100,,,Fee Schedule,100% of CMS OPPS Rate,1397.79,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,157.45,14,,,percent of total billed charges,14% of total billed charges,157.45,6654.78,
28225- Tenolysis/extensor/foot/sng tendon,3435172,CDM,510,RC,28225,HCPCS,Outpatient,,,1031.07,515.54,,773.3,75,,,percent of total billed charges,75% of total billed charges,773.3,75,,,percent of total billed charges,75% of total billed charges,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,1073.09,102,,,Fee Schedule,102% of WV Medicaid Rate,4617.6,165,,,Fee Schedule,165% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8038.46,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11024.11,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13808.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1052.05,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,144.35,14,,,percent of total billed charges,14% of total billed charges,144.35,13808.81,
28230- Tenotomy/open/flex/foot/sng/multi,3435173,CDM,510,RC,28230,HCPCS,Outpatient,,,1078.94,539.47,,809.21,75,,,percent of total billed charges,75% of total billed charges,809.21,75,,,percent of total billed charges,75% of total billed charges,1348.67,100,,,Fee Schedule,100% of CMS OPPS Rate,218.67,102,,,Fee Schedule,102% of WV Medicaid Rate,2225.32,165,,,Fee Schedule,165% of CMS OPPS Rate,1397.79,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,3873.91,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5312.76,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6654.78,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,214.38,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1348.67,100,,,Fee Schedule,100% of CMS OPPS Rate,1397.79,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,151.05,14,,,percent of total billed charges,14% of total billed charges,151.05,6654.78,
28232- Tenotomy/open/tendon flex/toe/sng,3435174,CDM,510,RC,28232,HCPCS,Outpatient,,,939.46,469.73,,704.6,75,,,percent of total billed charges,75% of total billed charges,704.6,75,,,percent of total billed charges,75% of total billed charges,1348.67,100,,,Fee Schedule,100% of CMS OPPS Rate,200.91,102,,,Fee Schedule,102% of WV Medicaid Rate,2225.32,165,,,Fee Schedule,165% of CMS OPPS Rate,1397.79,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,3873.91,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5312.76,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6654.78,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,196.97,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1348.67,100,,,Fee Schedule,100% of CMS OPPS Rate,1397.79,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,131.52,14,,,percent of total billed charges,14% of total billed charges,131.52,6654.78,
28234- Tenotomy/open/extensor/ft/toe/each,3435175,CDM,510,RC,28234,HCPCS,Outpatient,,,1009.16,504.58,,756.87,75,,,percent of total billed charges,75% of total billed charges,756.87,75,,,percent of total billed charges,75% of total billed charges,1348.67,100,,,Fee Schedule,100% of CMS OPPS Rate,584.77,102,,,Fee Schedule,102% of WV Medicaid Rate,2225.32,165,,,Fee Schedule,165% of CMS OPPS Rate,1397.79,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,3873.91,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5312.76,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6654.78,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,573.3,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1348.67,100,,,Fee Schedule,100% of CMS OPPS Rate,1397.79,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,141.28,14,,,percent of total billed charges,14% of total billed charges,141.28,6654.78,
28238- Revise post tib ten/exc navic bone,3435176,CDM,510,RC,28238,HCPCS,Outpatient,,,1698.78,849.39,,1274.09,75,,,percent of total billed charges,75% of total billed charges,1274.09,75,,,percent of total billed charges,75% of total billed charges,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,2365.05,102,,,Fee Schedule,102% of WV Medicaid Rate,10261.1,165,,,Fee Schedule,165% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,17862.79,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,24497.4,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,30685.48,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,2318.68,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,237.83,14,,,percent of total billed charges,14% of total billed charges,237.83,30685.48,
28250- Division of plantar fascia/muscle,3435177,CDM,510,RC,28250,HCPCS,Outpatient,,,1459.05,729.53,,1094.29,75,,,percent of total billed charges,75% of total billed charges,1094.29,75,,,percent of total billed charges,75% of total billed charges,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,1073.09,102,,,Fee Schedule,102% of WV Medicaid Rate,4617.6,165,,,Fee Schedule,165% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8038.46,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11024.11,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13808.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1052.05,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,204.27,14,,,percent of total billed charges,14% of total billed charges,204.27,13808.81,
28270- Capsulotomy/metaphalang jnt/ea jnt,3435178,CDM,510,RC,28270,HCPCS,Outpatient,,,1215.52,607.76,,911.64,75,,,percent of total billed charges,75% of total billed charges,911.64,75,,,percent of total billed charges,75% of total billed charges,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,1073.09,102,,,Fee Schedule,102% of WV Medicaid Rate,4617.6,165,,,Fee Schedule,165% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8038.46,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11024.11,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13808.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1052.05,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,170.17,14,,,percent of total billed charges,14% of total billed charges,170.17,13808.81,
28272- Capsulotomy/interphalan jnt/ea jnt,3435179,CDM,510,RC,28272,HCPCS,Outpatient,,,955.88,477.94,,716.91,75,,,percent of total billed charges,75% of total billed charges,716.91,75,,,percent of total billed charges,75% of total billed charges,1348.67,100,,,Fee Schedule,100% of CMS OPPS Rate,193.56,102,,,Fee Schedule,102% of WV Medicaid Rate,2225.32,165,,,Fee Schedule,165% of CMS OPPS Rate,1397.79,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,3873.91,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5312.76,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6654.78,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,189.76,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1348.67,100,,,Fee Schedule,100% of CMS OPPS Rate,1397.79,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,133.82,14,,,percent of total billed charges,14% of total billed charges,133.82,6654.78,
28280- Syndactylization/toes,3435180,CDM,510,RC,28280,HCPCS,Outpatient,,,1280.6,640.3,,960.45,75,,,percent of total billed charges,75% of total billed charges,960.45,75,,,percent of total billed charges,75% of total billed charges,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,1073.09,102,,,Fee Schedule,102% of WV Medicaid Rate,4617.6,165,,,Fee Schedule,165% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8038.46,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11024.11,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13808.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1052.05,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,179.28,14,,,percent of total billed charges,14% of total billed charges,179.28,13808.81,
28285- Correction/hammertoe,3435181,CDM,510,RC,28285,HCPCS,Outpatient,,,1344.53,672.27,,1008.4,75,,,percent of total billed charges,75% of total billed charges,1008.4,75,,,percent of total billed charges,75% of total billed charges,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,1073.09,102,,,Fee Schedule,102% of WV Medicaid Rate,4617.6,165,,,Fee Schedule,165% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8038.46,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11024.11,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13808.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1052.05,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,188.23,14,,,percent of total billed charges,14% of total billed charges,188.23,13808.81,
28286- Correct cock-up 5th toe/plast clos,3435182,CDM,510,RC,28286,HCPCS,Outpatient,,,1104.39,552.2,,828.29,75,,,percent of total billed charges,75% of total billed charges,828.29,75,,,percent of total billed charges,75% of total billed charges,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,1073.09,102,,,Fee Schedule,102% of WV Medicaid Rate,4617.6,165,,,Fee Schedule,165% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8038.46,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11024.11,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13808.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1052.05,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,154.61,14,,,percent of total billed charges,14% of total billed charges,154.61,13808.81,
28288- Ostectomy/part/ea metatarsal head,3435183,CDM,510,RC,28288,HCPCS,Outpatient,,,1510.65,755.33,,1132.99,75,,,percent of total billed charges,75% of total billed charges,1132.99,75,,,percent of total billed charges,75% of total billed charges,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,1073.09,102,,,Fee Schedule,102% of WV Medicaid Rate,4617.6,165,,,Fee Schedule,165% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8038.46,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11024.11,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13808.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1052.05,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,211.49,14,,,percent of total billed charges,14% of total billed charges,211.49,13808.81,
28289- Correction of hallux rigidus,3435184,CDM,510,RC,28289,HCPCS,Outpatient,,,1720.95,860.48,,1290.71,75,,,percent of total billed charges,75% of total billed charges,1290.71,75,,,percent of total billed charges,75% of total billed charges,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,1073.09,102,,,Fee Schedule,102% of WV Medicaid Rate,4617.6,165,,,Fee Schedule,165% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8038.46,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11024.11,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13808.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1052.05,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,240.93,14,,,percent of total billed charges,14% of total billed charges,240.93,13808.81,
28292-Cor hlx vlgs rsc prx phlx bs,3435186,CDM,510,RC,28292,HCPCS,Outpatient,,,1739.57,869.79,,1304.68,75,,,percent of total billed charges,75% of total billed charges,1304.68,75,,,percent of total billed charges,75% of total billed charges,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,1073.09,102,,,Fee Schedule,102% of WV Medicaid Rate,4617.6,165,,,Fee Schedule,165% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8038.46,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11024.11,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13808.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1052.05,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,243.54,14,,,percent of total billed charges,14% of total billed charges,243.54,13808.81,
28296- Cor hlx vlgs dstl mtar osteo,3435187,CDM,510,RC,28296,HCPCS,Outpatient,,,2214.9,1107.45,,1661.18,75,,,percent of total billed charges,75% of total billed charges,1661.18,75,,,percent of total billed charges,75% of total billed charges,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,1073.09,102,,,Fee Schedule,102% of WV Medicaid Rate,4617.6,165,,,Fee Schedule,165% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8038.46,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11024.11,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13808.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1052.05,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,310.09,14,,,percent of total billed charges,14% of total billed charges,310.09,13808.81,
28297- Cor hlx vlgs jt arthrd,3435188,CDM,510,RC,28297,HCPCS,Outpatient,,,2591.28,1295.64,,1943.46,75,,,percent of total billed charges,75% of total billed charges,1943.46,75,,,percent of total billed charges,75% of total billed charges,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,3459.42,102,,,Fee Schedule,102% of WV Medicaid Rate,10261.1,165,,,Fee Schedule,165% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,17862.79,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,24497.4,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,30685.48,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,3391.59,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,362.78,14,,,percent of total billed charges,14% of total billed charges,362.78,30685.48,
28299- Cor hlx vlgs double osteot,3435189,CDM,510,RC,28299,HCPCS,Outpatient,,,2512.67,1256.34,,1884.5,75,,,percent of total billed charges,75% of total billed charges,1884.5,75,,,percent of total billed charges,75% of total billed charges,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,3088.88,102,,,Fee Schedule,102% of WV Medicaid Rate,10261.1,165,,,Fee Schedule,165% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,17862.79,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,24497.4,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,30685.48,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,3028.31,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,351.77,14,,,percent of total billed charges,14% of total billed charges,351.77,30685.48,
28300- Osteotomy/calcaneus w/w/o int fix,3435190,CDM,510,RC,28300,HCPCS,Outpatient,,,1694.07,847.04,,1270.55,75,,,percent of total billed charges,75% of total billed charges,1270.55,75,,,percent of total billed charges,75% of total billed charges,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,3335.52,102,,,Fee Schedule,102% of WV Medicaid Rate,10261.1,165,,,Fee Schedule,165% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,17862.79,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,24497.4,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,30685.48,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,3270.12,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,237.17,14,,,percent of total billed charges,14% of total billed charges,237.17,30685.48,
28304- Osteotomy/tarsal bones,3435191,CDM,510,RC,28304,HCPCS,Outpatient,,,2099.28,1049.64,,1574.46,75,,,percent of total billed charges,75% of total billed charges,1574.46,75,,,percent of total billed charges,75% of total billed charges,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,2365.05,102,,,Fee Schedule,102% of WV Medicaid Rate,10261.1,165,,,Fee Schedule,165% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,17862.79,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,24497.4,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,30685.48,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,2318.68,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,293.9,14,,,percent of total billed charges,14% of total billed charges,293.9,30685.48,
28306- Osteotomy/first metatarsal,3435192,CDM,510,RC,28306,HCPCS,Outpatient,,,1517.81,758.91,,1138.36,75,,,percent of total billed charges,75% of total billed charges,1138.36,75,,,percent of total billed charges,75% of total billed charges,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,2365.05,102,,,Fee Schedule,102% of WV Medicaid Rate,10261.1,165,,,Fee Schedule,165% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,17862.79,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,24497.4,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,30685.48,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,2318.68,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,212.49,14,,,percent of total billed charges,14% of total billed charges,212.49,30685.48,
28308- Osteotomy/not first metatarsal/ea,3435193,CDM,510,RC,28308,HCPCS,Outpatient,,,1423.25,711.63,,1067.44,75,,,percent of total billed charges,75% of total billed charges,1067.44,75,,,percent of total billed charges,75% of total billed charges,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,1073.09,102,,,Fee Schedule,102% of WV Medicaid Rate,4617.6,165,,,Fee Schedule,165% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8038.46,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11024.11,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13808.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1052.05,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,199.26,14,,,percent of total billed charges,14% of total billed charges,199.26,13808.81,
28309- Osteotomy/multiple metatarsal,3435194,CDM,510,RC,28309,HCPCS,Outpatient,,,2333.56,1166.78,,1750.17,75,,,percent of total billed charges,75% of total billed charges,1750.17,75,,,percent of total billed charges,75% of total billed charges,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,3209.32,102,,,Fee Schedule,102% of WV Medicaid Rate,10261.1,165,,,Fee Schedule,165% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,17862.79,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,24497.4,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,30685.48,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,3146.39,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,326.7,14,,,percent of total billed charges,14% of total billed charges,326.7,30685.48,
28310- Osteot/shorten/prox phalan/1st toe,3435195,CDM,510,RC,28310,HCPCS,Outpatient,,,1364.26,682.13,,1023.2,75,,,percent of total billed charges,75% of total billed charges,1023.2,75,,,percent of total billed charges,75% of total billed charges,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,2365.05,102,,,Fee Schedule,102% of WV Medicaid Rate,10261.1,165,,,Fee Schedule,165% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,17862.79,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,24497.4,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,30685.48,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,2318.68,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,191,14,,,percent of total billed charges,14% of total billed charges,191,30685.48,
28313- Repair/deformity/toe/soft tis only,3435196,CDM,510,RC,28313,HCPCS,Outpatient,,,1320.55,660.28,,990.41,75,,,percent of total billed charges,75% of total billed charges,990.41,75,,,percent of total billed charges,75% of total billed charges,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,1073.09,102,,,Fee Schedule,102% of WV Medicaid Rate,4617.6,165,,,Fee Schedule,165% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8038.46,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11024.11,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13808.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1052.05,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,184.88,14,,,percent of total billed charges,14% of total billed charges,184.88,13808.81,
28322- Repair metatarsal,3435197,CDM,510,RC,28322,HCPCS,Outpatient,,,1987.69,993.85,,1490.77,75,,,percent of total billed charges,75% of total billed charges,1490.77,75,,,percent of total billed charges,75% of total billed charges,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,3290.16,102,,,Fee Schedule,102% of WV Medicaid Rate,10261.1,165,,,Fee Schedule,165% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,17862.79,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,24497.4,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,30685.48,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,3225.65,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,278.28,14,,,percent of total billed charges,14% of total billed charges,278.28,30685.48,
28400- Clsd tx/calcaneal fx w/o manip,3435198,CDM,510,RC,28400,HCPCS,Outpatient,,,625.28,312.64,,468.96,75,,,percent of total billed charges,75% of total billed charges,468.96,75,,,percent of total billed charges,75% of total billed charges,194.62,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,321.11,165,,,Fee Schedule,165% of CMS OPPS Rate,201.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,559.02,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,766.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,960.32,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,194.62,100,,,Fee Schedule,100% of CMS OPPS Rate,201.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,87.54,14,,,percent of total billed charges,14% of total billed charges,87.54,960.32,
28406- Perc skel fix/calcaneal fx/manip,3435199,CDM,510,RC,28406,HCPCS,Outpatient,,,1453.77,726.89,,1090.33,75,,,percent of total billed charges,75% of total billed charges,1090.33,75,,,percent of total billed charges,75% of total billed charges,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,10261.1,165,,,Fee Schedule,165% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,17862.79,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,24497.4,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,30685.48,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,203.53,14,,,percent of total billed charges,14% of total billed charges,203.53,30685.48,
28415- Open tx/calcaneal fracture,3435200,CDM,510,RC,28415,HCPCS,Outpatient,,,2937.63,1468.82,,2203.22,75,,,percent of total billed charges,75% of total billed charges,2203.22,75,,,percent of total billed charges,75% of total billed charges,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,3334.6,102,,,Fee Schedule,102% of WV Medicaid Rate,10261.1,165,,,Fee Schedule,165% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,17862.79,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,24497.4,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,30685.48,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,3269.22,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,411.27,14,,,percent of total billed charges,14% of total billed charges,411.27,30685.48,
28430- Clsd tx talus ankle fx w/o manip,3435201,CDM,510,RC,28430,HCPCS,Outpatient,,,607.68,303.84,,455.76,75,,,percent of total billed charges,75% of total billed charges,455.76,75,,,percent of total billed charges,75% of total billed charges,194.62,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,321.11,165,,,Fee Schedule,165% of CMS OPPS Rate,201.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,559.02,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,766.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,960.32,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,194.62,100,,,Fee Schedule,100% of CMS OPPS Rate,201.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,85.08,14,,,percent of total billed charges,14% of total billed charges,85.08,960.32,
28445- Open tx/talus fracture,3435202,CDM,510,RC,28445,HCPCS,Outpatient,,,2675.13,1337.57,,2006.35,75,,,percent of total billed charges,75% of total billed charges,2006.35,75,,,percent of total billed charges,75% of total billed charges,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,3314.8,102,,,Fee Schedule,102% of WV Medicaid Rate,10261.1,165,,,Fee Schedule,165% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,17862.79,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,24497.4,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,30685.48,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,3249.8,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,374.52,14,,,percent of total billed charges,14% of total billed charges,374.52,30685.48,
28450- Tx tarsal bone fx w/o manip,3435203,CDM,510,RC,28450,HCPCS,Outpatient,,,533.54,266.77,,400.16,75,,,percent of total billed charges,75% of total billed charges,400.16,75,,,percent of total billed charges,75% of total billed charges,194.62,100,,,Fee Schedule,100% of CMS OPPS Rate,84.13,102,,,Fee Schedule,102% of WV Medicaid Rate,321.11,165,,,Fee Schedule,165% of CMS OPPS Rate,201.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,559.02,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,766.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,960.32,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,82.48,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,194.62,100,,,Fee Schedule,100% of CMS OPPS Rate,201.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,74.7,14,,,percent of total billed charges,14% of total billed charges,74.7,960.32,
28465- Open tx/tarsal fx/internal fix/ea,3435204,CDM,510,RC,28465,HCPCS,Outpatient,,,1646.32,823.16,,1234.74,75,,,percent of total billed charges,75% of total billed charges,1234.74,75,,,percent of total billed charges,75% of total billed charges,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,3127.34,102,,,Fee Schedule,102% of WV Medicaid Rate,10261.1,165,,,Fee Schedule,165% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,17862.79,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,24497.4,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,30685.48,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,3066.02,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,230.48,14,,,percent of total billed charges,14% of total billed charges,230.48,30685.48,
28470- Clsd tx/metatarsal fx w/o manip,3435205,CDM,510,RC,28470,HCPCS,Outpatient,,,549.63,274.82,,412.22,75,,,percent of total billed charges,75% of total billed charges,412.22,75,,,percent of total billed charges,75% of total billed charges,194.62,100,,,Fee Schedule,100% of CMS OPPS Rate,84.13,102,,,Fee Schedule,102% of WV Medicaid Rate,321.11,165,,,Fee Schedule,165% of CMS OPPS Rate,201.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,559.02,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,766.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,960.32,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,82.48,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,194.62,100,,,Fee Schedule,100% of CMS OPPS Rate,201.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,76.95,14,,,percent of total billed charges,14% of total billed charges,76.95,960.32,
28476- Perc skel fix/metatar fx/manip/ea,3435206,CDM,510,RC,28476,HCPCS,Outpatient,,,982.41,491.21,,736.81,75,,,percent of total billed charges,75% of total billed charges,736.81,75,,,percent of total billed charges,75% of total billed charges,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,1073.09,102,,,Fee Schedule,102% of WV Medicaid Rate,4617.6,165,,,Fee Schedule,165% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8038.46,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11024.11,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13808.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1052.05,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,137.54,14,,,percent of total billed charges,14% of total billed charges,137.54,13808.81,
28485- Open tx/metatarsal fx/int fix/each,3435207,CDM,510,RC,28485,HCPCS,Outpatient,,,1441.97,720.99,,1081.48,75,,,percent of total billed charges,75% of total billed charges,1081.48,75,,,percent of total billed charges,75% of total billed charges,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,3182.15,102,,,Fee Schedule,102% of WV Medicaid Rate,10261.1,165,,,Fee Schedule,165% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,17862.79,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,24497.4,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,30685.48,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,3119.75,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,201.88,14,,,percent of total billed charges,14% of total billed charges,201.88,30685.48,
28490- Clsd tx/fx grt toe/phalanx/phalang,3435208,CDM,510,RC,28490,HCPCS,Outpatient,,,352.26,176.13,,264.2,75,,,percent of total billed charges,75% of total billed charges,264.2,75,,,percent of total billed charges,75% of total billed charges,194.62,100,,,Fee Schedule,100% of CMS OPPS Rate,78.07,102,,,Fee Schedule,102% of WV Medicaid Rate,321.11,165,,,Fee Schedule,165% of CMS OPPS Rate,201.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,559.02,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,766.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,960.32,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,76.54,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,194.62,100,,,Fee Schedule,100% of CMS OPPS Rate,201.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,49.32,14,,,percent of total billed charges,14% of total billed charges,49.32,960.32,
28495- Clsd tx/fx great toe/manipulation,3435209,CDM,510,RC,28495,HCPCS,Outpatient,,,447.48,223.74,,335.61,75,,,percent of total billed charges,75% of total billed charges,335.61,75,,,percent of total billed charges,75% of total billed charges,194.62,100,,,Fee Schedule,100% of CMS OPPS Rate,84.13,102,,,Fee Schedule,102% of WV Medicaid Rate,321.11,165,,,Fee Schedule,165% of CMS OPPS Rate,201.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,559.02,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,766.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,960.32,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,82.48,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,194.62,100,,,Fee Schedule,100% of CMS OPPS Rate,201.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,62.65,14,,,percent of total billed charges,14% of total billed charges,62.65,960.32,
28505- Open tx/great toe/phalanx/phalange,3435210,CDM,510,RC,28505,HCPCS,Outpatient,,,1670.32,835.16,,1252.74,75,,,percent of total billed charges,75% of total billed charges,1252.74,75,,,percent of total billed charges,75% of total billed charges,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,1073.09,102,,,Fee Schedule,102% of WV Medicaid Rate,4617.6,165,,,Fee Schedule,165% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8038.46,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11024.11,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13808.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1052.05,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,233.84,14,,,percent of total billed charges,14% of total billed charges,233.84,13808.81,
28510- Clsd tx/phalanges fx w/o manip,3435211,CDM,510,RC,28510,HCPCS,Outpatient,,,300.16,150.08,,225.12,75,,,percent of total billed charges,75% of total billed charges,225.12,75,,,percent of total billed charges,75% of total billed charges,194.62,100,,,Fee Schedule,100% of CMS OPPS Rate,61.98,102,,,Fee Schedule,102% of WV Medicaid Rate,321.11,165,,,Fee Schedule,165% of CMS OPPS Rate,201.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,559.02,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,766.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,960.32,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,60.76,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,194.62,100,,,Fee Schedule,100% of CMS OPPS Rate,201.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,42.02,14,,,percent of total billed charges,14% of total billed charges,42.02,960.32,
28515- Clsd tx/fx/phalanx/phalang/manip,3435212,CDM,510,RC,28515,HCPCS,Outpatient,,,408.98,204.49,,306.74,75,,,percent of total billed charges,75% of total billed charges,306.74,75,,,percent of total billed charges,75% of total billed charges,194.62,100,,,Fee Schedule,100% of CMS OPPS Rate,84.13,102,,,Fee Schedule,102% of WV Medicaid Rate,321.11,165,,,Fee Schedule,165% of CMS OPPS Rate,201.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,559.02,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,766.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,960.32,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,82.48,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,194.62,100,,,Fee Schedule,100% of CMS OPPS Rate,201.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,57.26,14,,,percent of total billed charges,14% of total billed charges,57.26,960.32,
28525- Opn tx/fx/phalanx/phalang/int fix,3435213,CDM,510,RC,28525,HCPCS,Outpatient,,,1426.62,713.31,,1069.97,75,,,percent of total billed charges,75% of total billed charges,1069.97,75,,,percent of total billed charges,75% of total billed charges,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,1073.09,102,,,Fee Schedule,102% of WV Medicaid Rate,4617.6,165,,,Fee Schedule,165% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8038.46,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11024.11,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13808.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1052.05,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,199.73,14,,,percent of total billed charges,14% of total billed charges,199.73,13808.81,
28530- Clsd tx/sesamoid fracture,3435214,CDM,510,RC,28530,HCPCS,Outpatient,,,282.96,141.48,,212.22,75,,,percent of total billed charges,75% of total billed charges,212.22,75,,,percent of total billed charges,75% of total billed charges,194.62,100,,,Fee Schedule,100% of CMS OPPS Rate,58.69,102,,,Fee Schedule,102% of WV Medicaid Rate,321.11,165,,,Fee Schedule,165% of CMS OPPS Rate,201.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,559.02,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,766.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,960.32,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,57.54,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,194.62,100,,,Fee Schedule,100% of CMS OPPS Rate,201.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,39.61,14,,,percent of total billed charges,14% of total billed charges,39.61,960.32,
28555- Open tx/tarsal bone dislocateate,3435216,CDM,510,RC,28555,HCPCS,Outpatient,,,2189.08,1094.54,,1641.81,75,,,percent of total billed charges,75% of total billed charges,1641.81,75,,,percent of total billed charges,75% of total billed charges,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,3135.63,102,,,Fee Schedule,102% of WV Medicaid Rate,10261.1,165,,,Fee Schedule,165% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,17862.79,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,24497.4,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,30685.48,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,3074.15,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,306.47,14,,,percent of total billed charges,14% of total billed charges,306.47,30685.48,
28575- Clsd tx/talotarsal dislocat/anes,3435217,CDM,510,RC,28575,HCPCS,Outpatient,,,963.08,481.54,,722.31,75,,,percent of total billed charges,75% of total billed charges,722.31,75,,,percent of total billed charges,75% of total billed charges,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,1073.09,102,,,Fee Schedule,102% of WV Medicaid Rate,4617.6,165,,,Fee Schedule,165% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8038.46,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11024.11,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13808.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1052.05,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,134.83,14,,,percent of total billed charges,14% of total billed charges,134.83,13808.81,
28585- Open tx/talotarsal dislocateation,3435218,CDM,510,RC,28585,HCPCS,Outpatient,,,2255.99,1128,,1691.99,75,,,percent of total billed charges,75% of total billed charges,1691.99,75,,,percent of total billed charges,75% of total billed charges,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,3388.03,102,,,Fee Schedule,102% of WV Medicaid Rate,10261.1,165,,,Fee Schedule,165% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,17862.79,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,24497.4,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,30685.48,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,3321.6,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,315.84,14,,,percent of total billed charges,14% of total billed charges,315.84,30685.48,
28615- Open tx/tarsometatar jnt dislocateate,3435219,CDM,510,RC,28615,HCPCS,Outpatient,,,2134.02,1067.01,,1600.52,75,,,percent of total billed charges,75% of total billed charges,1600.52,75,,,percent of total billed charges,75% of total billed charges,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,3236.74,102,,,Fee Schedule,102% of WV Medicaid Rate,10261.1,165,,,Fee Schedule,165% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,17862.79,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,24497.4,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,30685.48,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,3173.27,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,298.76,14,,,percent of total billed charges,14% of total billed charges,298.76,30685.48,
28630- Clsd tx/interphalang jnt dislocate,3435220,CDM,510,RC,28630,HCPCS,Outpatient,,,389.96,194.98,,292.47,75,,,percent of total billed charges,75% of total billed charges,292.47,75,,,percent of total billed charges,75% of total billed charges,194.62,100,,,Fee Schedule,100% of CMS OPPS Rate,69.62,102,,,Fee Schedule,102% of WV Medicaid Rate,321.11,165,,,Fee Schedule,165% of CMS OPPS Rate,201.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,559.02,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,766.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,960.32,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,68.25,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,194.62,100,,,Fee Schedule,100% of CMS OPPS Rate,201.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,54.59,14,,,percent of total billed charges,14% of total billed charges,54.59,960.32,
28645- Open tx/metatarsophalan jnt dislocate,3435221,CDM,510,RC,28645,HCPCS,Outpatient,,,1643.66,821.83,,1232.75,75,,,percent of total billed charges,75% of total billed charges,1232.75,75,,,percent of total billed charges,75% of total billed charges,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,1073.09,102,,,Fee Schedule,102% of WV Medicaid Rate,4617.6,165,,,Fee Schedule,165% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8038.46,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11024.11,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13808.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1052.05,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,230.11,14,,,percent of total billed charges,14% of total billed charges,230.11,13808.81,
28665- Clsd tx/interphal jnt disloc/anest,3435222,CDM,510,RC,28665,HCPCS,Outpatient,,,383.37,191.69,,287.53,75,,,percent of total billed charges,75% of total billed charges,287.53,75,,,percent of total billed charges,75% of total billed charges,225.55,100,,,Fee Schedule,100% of CMS OPPS Rate,98.46,102,,,Fee Schedule,102% of WV Medicaid Rate,372.16,165,,,Fee Schedule,165% of CMS OPPS Rate,233.76,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,647.87,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,888.5,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1112.94,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,96.53,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,225.55,100,,,Fee Schedule,100% of CMS OPPS Rate,233.76,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,53.67,14,,,percent of total billed charges,14% of total billed charges,53.67,1112.94,
28675- Open tx/interphalang jnt dislocateat,3435223,CDM,510,RC,28675,HCPCS,Outpatient,,,1445.74,722.87,,1084.31,75,,,percent of total billed charges,75% of total billed charges,1084.31,75,,,percent of total billed charges,75% of total billed charges,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,1073.09,102,,,Fee Schedule,102% of WV Medicaid Rate,4617.6,165,,,Fee Schedule,165% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8038.46,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11024.11,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13808.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1052.05,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,202.4,14,,,percent of total billed charges,14% of total billed charges,202.4,13808.81,
28715- Arthrodesis/pantalar/triple,3435224,CDM,510,RC,28715,HCPCS,Outpatient,,,2445.94,1222.97,,1834.46,75,,,percent of total billed charges,75% of total billed charges,1834.46,75,,,percent of total billed charges,75% of total billed charges,12267.36,100,,,Fee Schedule,100% of CMS OPPS Rate,7247.59,102,,,Fee Schedule,102% of WV Medicaid Rate,20241.15,165,,,Fee Schedule,165% of CMS OPPS Rate,12714.07,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,35236.32,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,48323.81,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,60530.47,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,7105.48,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,12267.36,100,,,Fee Schedule,100% of CMS OPPS Rate,12714.07,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,342.43,14,,,percent of total billed charges,14% of total billed charges,342.43,60530.47,
28725- Arthrodesis/pantalar/subtalar,3435225,CDM,510,RC,28725,HCPCS,Outpatient,,,2021.09,1010.55,,1515.82,75,,,percent of total billed charges,75% of total billed charges,1515.82,75,,,percent of total billed charges,75% of total billed charges,12267.36,100,,,Fee Schedule,100% of CMS OPPS Rate,6856.33,102,,,Fee Schedule,102% of WV Medicaid Rate,20241.15,165,,,Fee Schedule,165% of CMS OPPS Rate,12714.07,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,35236.32,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,48323.81,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,60530.47,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,6721.89,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,12267.36,100,,,Fee Schedule,100% of CMS OPPS Rate,12714.07,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,282.95,14,,,percent of total billed charges,14% of total billed charges,282.95,60530.47,
28730- Arthrodesis/mid/tarsometatarsal,3435226,CDM,510,RC,28730,HCPCS,Outpatient,,,1901.77,950.89,,1426.33,75,,,percent of total billed charges,75% of total billed charges,1426.33,75,,,percent of total billed charges,75% of total billed charges,12267.36,100,,,Fee Schedule,100% of CMS OPPS Rate,7279.01,102,,,Fee Schedule,102% of WV Medicaid Rate,20241.15,165,,,Fee Schedule,165% of CMS OPPS Rate,12714.07,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,35236.32,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,48323.81,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,60530.47,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,7136.28,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,12267.36,100,,,Fee Schedule,100% of CMS OPPS Rate,12714.07,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,266.25,14,,,percent of total billed charges,14% of total billed charges,266.25,60530.47,
28735- Arthrodesis/mid/tarsometatarsal/mult/transv/osteotomy,3435227,CDM,510,RC,28735,HCPCS,Outpatient,,,2043.61,1021.81,,1532.71,75,,,percent of total billed charges,75% of total billed charges,1532.71,75,,,percent of total billed charges,75% of total billed charges,12267.36,100,,,Fee Schedule,100% of CMS OPPS Rate,7400.96,102,,,Fee Schedule,102% of WV Medicaid Rate,20241.15,165,,,Fee Schedule,165% of CMS OPPS Rate,12714.07,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,35236.32,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,48323.81,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,60530.47,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,7255.84,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,12267.36,100,,,Fee Schedule,100% of CMS OPPS Rate,12714.07,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,286.11,14,,,percent of total billed charges,14% of total billed charges,286.11,60530.47,
28740- Arthrodes/mid/tarsometatar/sng jnt,3435228,CDM,510,RC,28740,HCPCS,Outpatient,,,2099.78,1049.89,,1574.84,75,,,percent of total billed charges,75% of total billed charges,1574.84,75,,,percent of total billed charges,75% of total billed charges,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,3549.94,102,,,Fee Schedule,102% of WV Medicaid Rate,10261.1,165,,,Fee Schedule,165% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,17862.79,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,24497.4,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,30685.48,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,3480.33,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,293.97,14,,,percent of total billed charges,14% of total billed charges,293.97,30685.48,
28750- Arthrodes/grt toe/metatarsophalan,3435229,CDM,510,RC,28750,HCPCS,Outpatient,,,1985.56,992.78,,1489.17,75,,,percent of total billed charges,75% of total billed charges,1489.17,75,,,percent of total billed charges,75% of total billed charges,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,3423.04,102,,,Fee Schedule,102% of WV Medicaid Rate,10261.1,165,,,Fee Schedule,165% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,17862.79,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,24497.4,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,30685.48,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,3355.92,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,277.98,14,,,percent of total billed charges,14% of total billed charges,277.98,30685.48,
28755- Arthrodes/grt toe/interphalangeal,3435230,CDM,510,RC,28755,HCPCS,Outpatient,,,1267.6,633.8,,950.7,75,,,percent of total billed charges,75% of total billed charges,950.7,75,,,percent of total billed charges,75% of total billed charges,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,2365.05,102,,,Fee Schedule,102% of WV Medicaid Rate,10261.1,165,,,Fee Schedule,165% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,17862.79,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,24497.4,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,30685.48,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,2318.68,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,177.46,14,,,percent of total billed charges,14% of total billed charges,177.46,30685.48,
28825- Amputation/toe/interphalangeal jnt,3435233,CDM,510,RC,28825,HCPCS,Outpatient,,,747.98,373.99,,560.99,75,,,percent of total billed charges,75% of total billed charges,560.99,75,,,percent of total billed charges,75% of total billed charges,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,1073.09,102,,,Fee Schedule,102% of WV Medicaid Rate,4617.6,165,,,Fee Schedule,165% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8038.46,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11024.11,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13808.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1052.05,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,104.72,14,,,percent of total billed charges,14% of total billed charges,104.72,13808.81,
29065- Apply figure 8 cast/shoulder/hand,3435235,CDM,510,RC,29065,HCPCS,Outpatient,,,240.45,120.23,,180.34,75,,,percent of total billed charges,75% of total billed charges,180.34,75,,,percent of total billed charges,75% of total billed charges,225.55,100,,,Fee Schedule,100% of CMS OPPS Rate,48.59,102,,,Fee Schedule,102% of WV Medicaid Rate,372.16,165,,,Fee Schedule,165% of CMS OPPS Rate,233.76,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,647.87,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,888.5,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1112.94,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,47.64,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,225.55,100,,,Fee Schedule,100% of CMS OPPS Rate,233.76,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,33.66,14,,,percent of total billed charges,14% of total billed charges,33.66,1112.94,
29075- Apply figure 8 cast/elbow/finger,3435236,CDM,510,RC,29075,HCPCS,Outpatient,,,215,107.5,,161.25,75,,,percent of total billed charges,75% of total billed charges,161.25,75,,,percent of total billed charges,75% of total billed charges,225.55,100,,,Fee Schedule,100% of CMS OPPS Rate,44.49,102,,,Fee Schedule,102% of WV Medicaid Rate,372.16,165,,,Fee Schedule,165% of CMS OPPS Rate,233.76,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,647.87,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,888.5,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1112.94,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,43.62,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,225.55,100,,,Fee Schedule,100% of CMS OPPS Rate,233.76,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,30.1,14,,,percent of total billed charges,14% of total billed charges,30.1,1112.94,
29085- Apply fig 8 cast/hand/low forearm,3435237,CDM,510,RC,29085,HCPCS,Outpatient,,,237.77,118.89,,178.33,75,,,percent of total billed charges,75% of total billed charges,178.33,75,,,percent of total billed charges,75% of total billed charges,137.03,100,,,Fee Schedule,100% of CMS OPPS Rate,48.05,102,,,Fee Schedule,102% of WV Medicaid Rate,226.1,165,,,Fee Schedule,165% of CMS OPPS Rate,142.02,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,393.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,539.8,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,676.18,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,47.11,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,137.03,100,,,Fee Schedule,100% of CMS OPPS Rate,142.02,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,33.29,14,,,percent of total billed charges,14% of total billed charges,33.29,676.18,
29105- Application long arm splint,3435238,CDM,510,RC,29105,HCPCS,Outpatient,,,203.54,101.77,,152.66,75,,,percent of total billed charges,75% of total billed charges,152.66,75,,,percent of total billed charges,75% of total billed charges,137.03,100,,,Fee Schedule,100% of CMS OPPS Rate,39.59,102,,,Fee Schedule,102% of WV Medicaid Rate,226.1,165,,,Fee Schedule,165% of CMS OPPS Rate,142.02,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,393.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,539.8,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,676.18,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,38.81,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,137.03,100,,,Fee Schedule,100% of CMS OPPS Rate,142.02,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,28.5,14,,,percent of total billed charges,14% of total billed charges,28.5,676.18,
App Long Arm Splint,3428386,CDM,981,RC,29105,HCPCS,Outpatient,,,203.54,101.77,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
29125- App of short arm splint/static,3435239,CDM,510,RC,29125,HCPCS,Outpatient,,,160.97,80.49,,120.73,75,,,percent of total billed charges,75% of total billed charges,120.73,75,,,percent of total billed charges,75% of total billed charges,109.16,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,180.11,165,,,Fee Schedule,165% of CMS OPPS Rate,113.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,313.55,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,430.01,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,538.63,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,109.16,100,,,Fee Schedule,100% of CMS OPPS Rate,113.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,22.54,14,,,percent of total billed charges,14% of total billed charges,22.54,538.63,
App Short Arm Splnt;Statc,3428388,CDM,981,RC,29125,HCPCS,Outpatient,,,160.97,80.49,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
29126- Apply short arm splint/dynamic,3435240,CDM,510,RC,29126,HCPCS,Outpatient,,,190.46,95.23,,142.85,75,,,percent of total billed charges,75% of total billed charges,142.85,75,,,percent of total billed charges,75% of total billed charges,109.16,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,180.11,165,,,Fee Schedule,165% of CMS OPPS Rate,113.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,313.55,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,430.01,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,538.63,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,109.16,100,,,Fee Schedule,100% of CMS OPPS Rate,113.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,26.66,14,,,percent of total billed charges,14% of total billed charges,26.66,538.63,
29130- Application finger splint/static,3435241,CDM,510,RC,29130,HCPCS,Outpatient,,,104.89,52.45,,78.67,75,,,percent of total billed charges,75% of total billed charges,78.67,75,,,percent of total billed charges,75% of total billed charges,109.16,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,180.11,165,,,Fee Schedule,165% of CMS OPPS Rate,113.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,313.55,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,430.01,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,538.63,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,109.16,100,,,Fee Schedule,100% of CMS OPPS Rate,113.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,14.68,14,,,percent of total billed charges,14% of total billed charges,14.68,538.63,
APPLICATION SPLINT STATIC FINGER CUSTOM,3428390,CDM,981,RC,29130,HCPCS,Outpatient,,,104.89,52.45,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
29260 Strapping Elbow/Wrist,4305638,CDM,761,RC,29260,HCPCS,Outpatient,,,317.28,158.64,,237.96,75,,,percent of total billed charges,75% of total billed charges,237.96,75,,,percent of total billed charges,75% of total billed charges,54.04,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,89.16,165,,,Fee Schedule,165% of CMS OPPS Rate,56,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,155.22,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,212.87,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,266.65,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,54.04,100,,,Fee Schedule,100% of CMS OPPS Rate,56,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,44.42,14,,,percent of total billed charges,14% of total billed charges,44.42,266.65,
29280 Strapping Hand/Finger,4305639,CDM,761,RC,29280,HCPCS,Outpatient,,,318.51,159.26,,238.88,75,,,percent of total billed charges,75% of total billed charges,238.88,75,,,percent of total billed charges,75% of total billed charges,54.04,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,89.16,165,,,Fee Schedule,165% of CMS OPPS Rate,56,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,155.22,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,212.87,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,266.65,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,54.04,100,,,Fee Schedule,100% of CMS OPPS Rate,56,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,44.59,14,,,percent of total billed charges,14% of total billed charges,44.59,266.65,
29280- Strapping/hand or finger,3435242,CDM,510,RC,29280,HCPCS,Outpatient,,,350.16,175.08,,262.62,75,,,percent of total billed charges,75% of total billed charges,262.62,75,,,percent of total billed charges,75% of total billed charges,54.04,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,89.16,165,,,Fee Schedule,165% of CMS OPPS Rate,56,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,155.22,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,212.87,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,266.65,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,54.04,100,,,Fee Schedule,100% of CMS OPPS Rate,56,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,49.02,14,,,percent of total billed charges,14% of total billed charges,49.02,266.65,
29305- Application hip spica cast/1 leg,3435243,CDM,510,RC,29305,HCPCS,Outpatient,,,608.66,304.33,,456.5,75,,,percent of total billed charges,75% of total billed charges,456.5,75,,,percent of total billed charges,75% of total billed charges,225.55,100,,,Fee Schedule,100% of CMS OPPS Rate,98.46,102,,,Fee Schedule,102% of WV Medicaid Rate,372.16,165,,,Fee Schedule,165% of CMS OPPS Rate,233.76,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,647.87,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,888.5,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1112.94,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,96.53,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,225.55,100,,,Fee Schedule,100% of CMS OPPS Rate,233.76,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,85.21,14,,,percent of total billed charges,14% of total billed charges,85.21,1112.94,
29325- Apply hip spica cast/both legs,3435244,CDM,510,RC,29325,HCPCS,Outpatient,,,674.35,337.18,,505.76,75,,,percent of total billed charges,75% of total billed charges,505.76,75,,,percent of total billed charges,75% of total billed charges,225.55,100,,,Fee Schedule,100% of CMS OPPS Rate,98.46,102,,,Fee Schedule,102% of WV Medicaid Rate,372.16,165,,,Fee Schedule,165% of CMS OPPS Rate,233.76,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,647.87,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,888.5,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1112.94,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,96.53,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,225.55,100,,,Fee Schedule,100% of CMS OPPS Rate,233.76,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,94.41,14,,,percent of total billed charges,14% of total billed charges,94.41,1112.94,
29345- Apply long leg cast/thigh/toes,3435245,CDM,510,RC,29345,HCPCS,Outpatient,,,340.21,170.11,,255.16,75,,,percent of total billed charges,75% of total billed charges,255.16,75,,,percent of total billed charges,75% of total billed charges,225.55,100,,,Fee Schedule,100% of CMS OPPS Rate,62.78,102,,,Fee Schedule,102% of WV Medicaid Rate,372.16,165,,,Fee Schedule,165% of CMS OPPS Rate,233.76,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,647.87,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,888.5,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1112.94,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,61.55,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,225.55,100,,,Fee Schedule,100% of CMS OPPS Rate,233.76,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,47.63,14,,,percent of total billed charges,14% of total billed charges,47.63,1112.94,
29355- Apply long leg cast/ambulatory,3435246,CDM,510,RC,29355,HCPCS,Outpatient,,,357.55,178.78,,268.16,75,,,percent of total billed charges,75% of total billed charges,268.16,75,,,percent of total billed charges,75% of total billed charges,225.55,100,,,Fee Schedule,100% of CMS OPPS Rate,63.88,102,,,Fee Schedule,102% of WV Medicaid Rate,372.16,165,,,Fee Schedule,165% of CMS OPPS Rate,233.76,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,647.87,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,888.5,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1112.94,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,62.63,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,225.55,100,,,Fee Schedule,100% of CMS OPPS Rate,233.76,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,50.06,14,,,percent of total billed charges,14% of total billed charges,50.06,1112.94,
29365- Apply cylinder cast/thigh/ankle,3435247,CDM,510,RC,29365,HCPCS,Outpatient,,,307.18,153.59,,230.39,75,,,percent of total billed charges,75% of total billed charges,230.39,75,,,percent of total billed charges,75% of total billed charges,225.55,100,,,Fee Schedule,100% of CMS OPPS Rate,59.52,102,,,Fee Schedule,102% of WV Medicaid Rate,372.16,165,,,Fee Schedule,165% of CMS OPPS Rate,233.76,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,647.87,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,888.5,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1112.94,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,58.35,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,225.55,100,,,Fee Schedule,100% of CMS OPPS Rate,233.76,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,43.01,14,,,percent of total billed charges,14% of total billed charges,43.01,1112.94,
29405 Application Short Leg Cast Below Knee-Toe,3436035,CDM,761,RC,29405,HCPCS,Outpatient,,,198.2,99.1,,148.65,75,,,percent of total billed charges,75% of total billed charges,148.65,75,,,percent of total billed charges,75% of total billed charges,225.55,100,,,Fee Schedule,100% of CMS OPPS Rate,38.49,102,,,Fee Schedule,102% of WV Medicaid Rate,372.16,165,,,Fee Schedule,165% of CMS OPPS Rate,233.76,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,647.87,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,888.5,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1112.94,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,37.74,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,225.55,100,,,Fee Schedule,100% of CMS OPPS Rate,233.76,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,27.75,14,,,percent of total billed charges,14% of total billed charges,27.75,1112.94,
29405- Apply short leg cast/below knee/to,3435248,CDM,510,RC,29405,HCPCS,Outpatient,,,1473.99,737,,1105.49,75,,,percent of total billed charges,75% of total billed charges,1105.49,75,,,percent of total billed charges,75% of total billed charges,225.55,100,,,Fee Schedule,100% of CMS OPPS Rate,38.49,102,,,Fee Schedule,102% of WV Medicaid Rate,372.16,165,,,Fee Schedule,165% of CMS OPPS Rate,233.76,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,647.87,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,888.5,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1112.94,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,37.74,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,225.55,100,,,Fee Schedule,100% of CMS OPPS Rate,233.76,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,206.36,14,,,percent of total billed charges,14% of total billed charges,37.74,1112.94,
29425 Application Short Leg Cast Walking/Ambulatory,3549204,CDM,761,RC,29425,HCPCS,Outpatient,,,187.29,93.65,,140.47,75,,,percent of total billed charges,75% of total billed charges,140.47,75,,,percent of total billed charges,75% of total billed charges,225.55,100,,,Fee Schedule,100% of CMS OPPS Rate,35.49,102,,,Fee Schedule,102% of WV Medicaid Rate,372.16,165,,,Fee Schedule,165% of CMS OPPS Rate,233.76,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,647.87,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,888.5,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1112.94,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,34.79,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,225.55,100,,,Fee Schedule,100% of CMS OPPS Rate,233.76,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,26.22,14,,,percent of total billed charges,14% of total billed charges,26.22,1112.94,
29425- Apply short leg cast/ambulatory,3435249,CDM,510,RC,29425,HCPCS,Outpatient,,,1464.62,732.31,,1098.47,75,,,percent of total billed charges,75% of total billed charges,1098.47,75,,,percent of total billed charges,75% of total billed charges,225.55,100,,,Fee Schedule,100% of CMS OPPS Rate,35.49,102,,,Fee Schedule,102% of WV Medicaid Rate,372.16,165,,,Fee Schedule,165% of CMS OPPS Rate,233.76,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,647.87,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,888.5,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1112.94,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,34.79,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,225.55,100,,,Fee Schedule,100% of CMS OPPS Rate,233.76,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,205.05,14,,,percent of total billed charges,14% of total billed charges,34.79,1112.94,
29445 Application Rigid Total Contact Leg Cast,3436037,CDM,761,RC,29445,HCPCS,Outpatient,,,327.2,163.6,,245.4,75,,,percent of total billed charges,75% of total billed charges,245.4,75,,,percent of total billed charges,75% of total billed charges,225.55,100,,,Fee Schedule,100% of CMS OPPS Rate,48.87,102,,,Fee Schedule,102% of WV Medicaid Rate,372.16,165,,,Fee Schedule,165% of CMS OPPS Rate,233.76,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,647.87,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,888.5,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1112.94,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,47.91,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,225.55,100,,,Fee Schedule,100% of CMS OPPS Rate,233.76,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,45.81,14,,,percent of total billed charges,14% of total billed charges,45.81,1112.94,
29450- Apply clubfoot cast/long or short,3435250,CDM,510,RC,29450,HCPCS,Outpatient,,,372.97,186.49,,279.73,75,,,percent of total billed charges,75% of total billed charges,279.73,75,,,percent of total billed charges,75% of total billed charges,137.03,100,,,Fee Schedule,100% of CMS OPPS Rate,53.23,102,,,Fee Schedule,102% of WV Medicaid Rate,226.1,165,,,Fee Schedule,165% of CMS OPPS Rate,142.02,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,393.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,539.8,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,676.18,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,52.19,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,137.03,100,,,Fee Schedule,100% of CMS OPPS Rate,142.02,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,52.22,14,,,percent of total billed charges,14% of total billed charges,52.19,676.18,
29505- Application long leg splint,3435251,CDM,510,RC,29505,HCPCS,Outpatient,,,213.81,106.91,,160.36,75,,,percent of total billed charges,75% of total billed charges,160.36,75,,,percent of total billed charges,75% of total billed charges,137.03,100,,,Fee Schedule,100% of CMS OPPS Rate,47.78,102,,,Fee Schedule,102% of WV Medicaid Rate,226.1,165,,,Fee Schedule,165% of CMS OPPS Rate,142.02,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,393.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,539.8,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,676.18,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,46.84,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,137.03,100,,,Fee Schedule,100% of CMS OPPS Rate,142.02,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,29.93,14,,,percent of total billed charges,14% of total billed charges,29.93,676.18,
App Long Leg Splint,3428387,CDM,981,RC,29505,HCPCS,Outpatient,,,213.81,106.91,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
29515- Apply short leg splint/calf/foot,3435252,CDM,510,RC,29515,HCPCS,Outpatient,,,177.21,88.61,,132.91,75,,,percent of total billed charges,75% of total billed charges,132.91,75,,,percent of total billed charges,75% of total billed charges,137.03,100,,,Fee Schedule,100% of CMS OPPS Rate,33.84,102,,,Fee Schedule,102% of WV Medicaid Rate,226.1,165,,,Fee Schedule,165% of CMS OPPS Rate,142.02,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,393.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,539.8,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,676.18,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,33.18,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,137.03,100,,,Fee Schedule,100% of CMS OPPS Rate,142.02,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,24.81,14,,,percent of total billed charges,14% of total billed charges,24.81,676.18,
App Short Leg Splint,3428389,CDM,981,RC,29515,HCPCS,Outpatient,,,177.21,88.61,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
29540 Strapping Ankle &/Foot,3436039,CDM,761,RC,29540,HCPCS,Outpatient,,,71.12,35.56,,53.34,75,,,percent of total billed charges,75% of total billed charges,53.34,75,,,percent of total billed charges,75% of total billed charges,137.03,100,,,Fee Schedule,100% of CMS OPPS Rate,10.65,102,,,Fee Schedule,102% of WV Medicaid Rate,226.1,165,,,Fee Schedule,165% of CMS OPPS Rate,142.02,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,393.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,539.8,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,676.18,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,10.44,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,137.03,100,,,Fee Schedule,100% of CMS OPPS Rate,142.02,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,9.96,14,,,percent of total billed charges,14% of total billed charges,9.96,676.18,
29540- Strapping/ankle and/or foot,3435253,CDM,510,RC,29540,HCPCS,Outpatient,,,830.92,415.46,,623.19,75,,,percent of total billed charges,75% of total billed charges,623.19,75,,,percent of total billed charges,75% of total billed charges,137.03,100,,,Fee Schedule,100% of CMS OPPS Rate,10.65,102,,,Fee Schedule,102% of WV Medicaid Rate,226.1,165,,,Fee Schedule,165% of CMS OPPS Rate,142.02,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,393.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,539.8,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,676.18,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,10.44,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,137.03,100,,,Fee Schedule,100% of CMS OPPS Rate,142.02,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,116.33,14,,,percent of total billed charges,14% of total billed charges,10.44,676.18,
29550- Strapping/toes,3435254,CDM,510,RC,29550,HCPCS,Outpatient,,,48.1,24.05,,36.08,75,,,percent of total billed charges,75% of total billed charges,36.08,75,,,percent of total billed charges,75% of total billed charges,54.04,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,89.16,165,,,Fee Schedule,165% of CMS OPPS Rate,56,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,155.22,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,212.87,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,266.65,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,54.04,100,,,Fee Schedule,100% of CMS OPPS Rate,56,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,6.73,14,,,percent of total billed charges,14% of total billed charges,6.73,266.65,
29580 Application of Paste Boot,3436042,CDM,761,RC,29580,HCPCS,Outpatient,,,159.71,79.86,,119.78,75,,,percent of total billed charges,75% of total billed charges,119.78,75,,,percent of total billed charges,75% of total billed charges,137.03,100,,,Fee Schedule,100% of CMS OPPS Rate,34.67,102,,,Fee Schedule,102% of WV Medicaid Rate,226.1,165,,,Fee Schedule,165% of CMS OPPS Rate,142.02,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,393.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,539.8,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,676.18,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,33.99,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,137.03,100,,,Fee Schedule,100% of CMS OPPS Rate,142.02,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,22.36,14,,,percent of total billed charges,14% of total billed charges,22.36,676.18,
29580 Application of Paste Boot - Bilateral,3436041,CDM,761,RC,29580,HCPCS,Outpatient,,,319.43,159.72,,239.57,75,,,percent of total billed charges,75% of total billed charges,239.57,75,,,percent of total billed charges,75% of total billed charges,137.03,100,,,Fee Schedule,100% of CMS OPPS Rate,34.67,102,,,Fee Schedule,102% of WV Medicaid Rate,226.1,165,,,Fee Schedule,165% of CMS OPPS Rate,142.02,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,393.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,539.8,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,676.18,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,33.99,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,137.03,100,,,Fee Schedule,100% of CMS OPPS Rate,142.02,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,44.72,14,,,percent of total billed charges,14% of total billed charges,33.99,676.18,
29580 Application of Unna Boot,4135334,CDM,510,RC,29580,HCPCS,Outpatient,,,849.92,424.96,,637.44,75,,,percent of total billed charges,75% of total billed charges,637.44,75,,,percent of total billed charges,75% of total billed charges,137.03,100,,,Fee Schedule,100% of CMS OPPS Rate,34.67,102,,,Fee Schedule,102% of WV Medicaid Rate,226.1,165,,,Fee Schedule,165% of CMS OPPS Rate,142.02,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,393.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,539.8,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,676.18,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,33.99,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,137.03,100,,,Fee Schedule,100% of CMS OPPS Rate,142.02,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,118.99,14,,,percent of total billed charges,14% of total billed charges,33.99,676.18,
29581 Appl Mltlayr Compres Leg Below Knee W/Ankle Foot,3436046,CDM,761,RC,29581,HCPCS,Outpatient,,,757.44,378.72,,568.08,75,,,percent of total billed charges,75% of total billed charges,568.08,75,,,percent of total billed charges,75% of total billed charges,137.03,100,,,Fee Schedule,100% of CMS OPPS Rate,55.69,102,,,Fee Schedule,102% of WV Medicaid Rate,226.1,165,,,Fee Schedule,165% of CMS OPPS Rate,142.02,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,393.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,539.8,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,676.18,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,54.6,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,137.03,100,,,Fee Schedule,100% of CMS OPPS Rate,142.02,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,106.04,14,,,percent of total billed charges,14% of total billed charges,54.6,676.18,
29581 Appl Mltlayr Compres Leg Below Knee W/Ankle Foot - Bil,3436045,CDM,761,RC,29581,HCPCS,Outpatient,,,1136.17,568.09,,852.13,75,,,percent of total billed charges,75% of total billed charges,852.13,75,,,percent of total billed charges,75% of total billed charges,137.03,100,,,Fee Schedule,100% of CMS OPPS Rate,55.69,102,,,Fee Schedule,102% of WV Medicaid Rate,226.1,165,,,Fee Schedule,165% of CMS OPPS Rate,142.02,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,393.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,539.8,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,676.18,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,54.6,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,137.03,100,,,Fee Schedule,100% of CMS OPPS Rate,142.02,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,159.06,14,,,percent of total billed charges,14% of total billed charges,54.6,852.13,
29581- Apply multi-lay compres/lower leg,3436044,CDM,761,RC,29581,HCPCS,Outpatient,,,757.44,378.72,,568.08,75,,,percent of total billed charges,75% of total billed charges,568.08,75,,,percent of total billed charges,75% of total billed charges,137.03,100,,,Fee Schedule,100% of CMS OPPS Rate,55.69,102,,,Fee Schedule,102% of WV Medicaid Rate,226.1,165,,,Fee Schedule,165% of CMS OPPS Rate,142.02,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,393.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,539.8,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,676.18,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,54.6,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,137.03,100,,,Fee Schedule,100% of CMS OPPS Rate,142.02,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,106.04,14,,,percent of total billed charges,14% of total billed charges,54.6,676.18,
29584 Appl Mltlayr Compres Sys Uparm Lwarm Hand&Fing,4305637,CDM,761,RC,29584,HCPCS,Outpatient,,,735.16,367.58,,551.37,75,,,percent of total billed charges,75% of total billed charges,551.37,75,,,percent of total billed charges,75% of total billed charges,137.03,100,,,Fee Schedule,100% of CMS OPPS Rate,57.33,102,,,Fee Schedule,102% of WV Medicaid Rate,226.1,165,,,Fee Schedule,165% of CMS OPPS Rate,142.02,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,393.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,539.8,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,676.18,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,56.21,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,137.03,100,,,Fee Schedule,100% of CMS OPPS Rate,142.02,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,102.92,14,,,percent of total billed charges,14% of total billed charges,56.21,676.18,
29705- Rmv/bivalve cast/full arm/full leg,3435255,CDM,510,RC,29705,HCPCS,Outpatient,,,159.46,79.73,,119.6,75,,,percent of total billed charges,75% of total billed charges,119.6,75,,,percent of total billed charges,75% of total billed charges,225.55,100,,,Fee Schedule,100% of CMS OPPS Rate,26.75,102,,,Fee Schedule,102% of WV Medicaid Rate,372.16,165,,,Fee Schedule,165% of CMS OPPS Rate,233.76,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,647.87,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,888.5,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1112.94,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,26.23,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,225.55,100,,,Fee Schedule,100% of CMS OPPS Rate,233.76,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,22.32,14,,,percent of total billed charges,14% of total billed charges,22.32,1112.94,
29805- Arthroscopy/shoulder/diagnostic,3435257,CDM,510,RC,29805,HCPCS,Outpatient,,,1218.02,609.01,,913.52,75,,,percent of total billed charges,75% of total billed charges,913.52,75,,,percent of total billed charges,75% of total billed charges,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,1073.09,102,,,Fee Schedule,102% of WV Medicaid Rate,4617.6,165,,,Fee Schedule,165% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8038.46,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11024.11,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13808.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1052.05,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,170.52,14,,,percent of total billed charges,14% of total billed charges,170.52,13808.81,
29806- Arthroscopy/shoulder/surgical,3435258,CDM,510,RC,29806,HCPCS,Outpatient,,,2774.88,1387.44,,2081.16,75,,,percent of total billed charges,75% of total billed charges,2081.16,75,,,percent of total billed charges,75% of total billed charges,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,2365.05,102,,,Fee Schedule,102% of WV Medicaid Rate,10261.1,165,,,Fee Schedule,165% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,17862.79,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,24497.4,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,30685.48,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,2318.68,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,388.48,14,,,percent of total billed charges,14% of total billed charges,388.48,30685.48,
29807- Arthroscop/shoulder/rpr SLAP les,3435259,CDM,510,RC,29807,HCPCS,Outpatient,,,2704.8,1352.4,,2028.6,75,,,percent of total billed charges,75% of total billed charges,2028.6,75,,,percent of total billed charges,75% of total billed charges,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,2365.05,102,,,Fee Schedule,102% of WV Medicaid Rate,10261.1,165,,,Fee Schedule,165% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,17862.79,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,24497.4,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,30685.48,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,2318.68,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,378.67,14,,,percent of total billed charges,14% of total billed charges,378.67,30685.48,
29819- Arthroscopy/shoulder/rmv loose/FB,3435260,CDM,510,RC,29819,HCPCS,Outpatient,,,1530.23,765.12,,1147.67,75,,,percent of total billed charges,75% of total billed charges,1147.67,75,,,percent of total billed charges,75% of total billed charges,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,1073.09,102,,,Fee Schedule,102% of WV Medicaid Rate,4617.6,165,,,Fee Schedule,165% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8038.46,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11024.11,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13808.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1052.05,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,214.23,14,,,percent of total billed charges,14% of total billed charges,214.23,13808.81,
29820-  Shoulder arthroscopy/surgery,3435261,CDM,510,RC,29820,HCPCS,Outpatient,,,1399.81,699.91,,1049.86,75,,,percent of total billed charges,75% of total billed charges,1049.86,75,,,percent of total billed charges,75% of total billed charges,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,2365.05,102,,,Fee Schedule,102% of WV Medicaid Rate,10261.1,165,,,Fee Schedule,165% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,17862.79,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,24497.4,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,30685.48,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,2318.68,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,195.97,14,,,percent of total billed charges,14% of total billed charges,195.97,30685.48,
29821- Arthroscopy/shoulder/synovect/comp,3435262,CDM,510,RC,29821,HCPCS,Outpatient,,,1550.62,775.31,,1162.97,75,,,percent of total billed charges,75% of total billed charges,1162.97,75,,,percent of total billed charges,75% of total billed charges,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,1073.09,102,,,Fee Schedule,102% of WV Medicaid Rate,4617.6,165,,,Fee Schedule,165% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8038.46,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11024.11,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13808.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1052.05,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,217.09,14,,,percent of total billed charges,14% of total billed charges,217.09,13808.81,
29822- Arthroscop/shoulder/debrid/ltd,3435263,CDM,510,RC,29822,HCPCS,Outpatient,,,1408.54,704.27,,1056.41,75,,,percent of total billed charges,75% of total billed charges,1056.41,75,,,percent of total billed charges,75% of total billed charges,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,1073.09,102,,,Fee Schedule,102% of WV Medicaid Rate,4617.6,165,,,Fee Schedule,165% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8038.46,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11024.11,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13808.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1052.05,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,197.2,14,,,percent of total billed charges,14% of total billed charges,197.2,13808.81,
29823- Arthroscop/shoulder/debrid/ext,3435264,CDM,510,RC,29823,HCPCS,Outpatient,,,1546.3,773.15,,1159.73,75,,,percent of total billed charges,75% of total billed charges,1159.73,75,,,percent of total billed charges,75% of total billed charges,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,1073.09,102,,,Fee Schedule,102% of WV Medicaid Rate,4617.6,165,,,Fee Schedule,165% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8038.46,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11024.11,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13808.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1052.05,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,216.48,14,,,percent of total billed charges,14% of total billed charges,216.48,13808.81,
29824- Arthro/shoulder/dis claviculectomy,3435265,CDM,510,RC,29824,HCPCS,Outpatient,,,1764.12,882.06,,1323.09,75,,,percent of total billed charges,75% of total billed charges,1323.09,75,,,percent of total billed charges,75% of total billed charges,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,1073.09,102,,,Fee Schedule,102% of WV Medicaid Rate,4617.6,165,,,Fee Schedule,165% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8038.46,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11024.11,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13808.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1052.05,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,246.98,14,,,percent of total billed charges,14% of total billed charges,246.98,13808.81,
29825- Arthroscop/shoulder/resect adhes,3435266,CDM,510,RC,29825,HCPCS,Outpatient,,,1529.91,764.96,,1147.43,75,,,percent of total billed charges,75% of total billed charges,1147.43,75,,,percent of total billed charges,75% of total billed charges,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,1073.09,102,,,Fee Schedule,102% of WV Medicaid Rate,4617.6,165,,,Fee Schedule,165% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8038.46,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11024.11,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13808.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1052.05,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,214.19,14,,,percent of total billed charges,14% of total billed charges,214.19,13808.81,
29826- Arthroscop/shoulder/decomp/subacro,3435267,CDM,510,RC,29826,HCPCS,Outpatient,,,460.68,230.34,,345.51,75,,,percent of total billed charges,75% of total billed charges,345.51,75,,,percent of total billed charges,75% of total billed charges,147.42,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.5,14,,,percent of total billed charges,14% of total billed charges,64.5,345.51,
29827- Arthroscop/shoulder/rotat cuff rpr,3435268,CDM,510,RC,29827,HCPCS,Outpatient,,,2803.34,1401.67,,2102.51,75,,,percent of total billed charges,75% of total billed charges,2102.51,75,,,percent of total billed charges,75% of total billed charges,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,2365.05,102,,,Fee Schedule,102% of WV Medicaid Rate,10261.1,165,,,Fee Schedule,165% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,17862.79,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,24497.4,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,30685.48,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,2318.68,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,392.47,14,,,percent of total billed charges,14% of total billed charges,392.47,30685.48,
29828- Arthroscop/shoulder/biceps tenodes,3435269,CDM,510,RC,29828,HCPCS,Outpatient,,,2402.97,1201.49,,1802.23,75,,,percent of total billed charges,75% of total billed charges,1802.23,75,,,percent of total billed charges,75% of total billed charges,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,2365.05,102,,,Fee Schedule,102% of WV Medicaid Rate,10261.1,165,,,Fee Schedule,165% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,17862.79,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,24497.4,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,30685.48,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,2318.68,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,336.42,14,,,percent of total billed charges,14% of total billed charges,336.42,30685.48,
29834- Arthroscopy/elbow/surg/remove FB,3435270,CDM,510,RC,29834,HCPCS,Outpatient,,,1280.28,640.14,,960.21,75,,,percent of total billed charges,75% of total billed charges,960.21,75,,,percent of total billed charges,75% of total billed charges,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,1073.09,102,,,Fee Schedule,102% of WV Medicaid Rate,4617.6,165,,,Fee Schedule,165% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8038.46,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11024.11,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13808.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1052.05,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,179.24,14,,,percent of total billed charges,14% of total billed charges,179.24,13808.81,
29837- Arthroscopy/elbow/surg/debride/lmt,3435271,CDM,510,RC,29837,HCPCS,Outpatient,,,1379.37,689.69,,1034.53,75,,,percent of total billed charges,75% of total billed charges,1034.53,75,,,percent of total billed charges,75% of total billed charges,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,1073.09,102,,,Fee Schedule,102% of WV Medicaid Rate,4617.6,165,,,Fee Schedule,165% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8038.46,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11024.11,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13808.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1052.05,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,193.11,14,,,percent of total billed charges,14% of total billed charges,193.11,13808.81,
29838- Arthroscopy/elbow/surg/debride/ext,3435272,CDM,510,RC,29838,HCPCS,Outpatient,,,1545.78,772.89,,1159.34,75,,,percent of total billed charges,75% of total billed charges,1159.34,75,,,percent of total billed charges,75% of total billed charges,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,1073.09,102,,,Fee Schedule,102% of WV Medicaid Rate,4617.6,165,,,Fee Schedule,165% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8038.46,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11024.11,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13808.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1052.05,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,216.41,14,,,percent of total billed charges,14% of total billed charges,216.41,13808.81,
29840- Arthroscopy/wrist/diagnostic,3435273,CDM,510,RC,29840,HCPCS,Outpatient,,,1165.8,582.9,,874.35,75,,,percent of total billed charges,75% of total billed charges,874.35,75,,,percent of total billed charges,75% of total billed charges,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,1073.09,102,,,Fee Schedule,102% of WV Medicaid Rate,4617.6,165,,,Fee Schedule,165% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8038.46,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11024.11,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13808.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1052.05,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,163.21,14,,,percent of total billed charges,14% of total billed charges,163.21,13808.81,
29844- Arthrosc/wrist/surg/synovect/part,3435274,CDM,510,RC,29844,HCPCS,Outpatient,,,1295.35,647.68,,971.51,75,,,percent of total billed charges,75% of total billed charges,971.51,75,,,percent of total billed charges,75% of total billed charges,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,1073.09,102,,,Fee Schedule,102% of WV Medicaid Rate,4617.6,165,,,Fee Schedule,165% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8038.46,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11024.11,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13808.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1052.05,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,181.35,14,,,percent of total billed charges,14% of total billed charges,181.35,13808.81,
29846- Arthrosc/wrist/surg/joint debrid,3435275,CDM,510,RC,29846,HCPCS,Outpatient,,,1357.14,678.57,,1017.86,75,,,percent of total billed charges,75% of total billed charges,1017.86,75,,,percent of total billed charges,75% of total billed charges,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,1073.09,102,,,Fee Schedule,102% of WV Medicaid Rate,4617.6,165,,,Fee Schedule,165% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8038.46,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11024.11,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13808.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1052.05,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,190,14,,,percent of total billed charges,14% of total billed charges,190,13808.81,
29848- Endoscopy/wrist/surgical,3435276,CDM,510,RC,29848,HCPCS,Outpatient,,,1321.26,660.63,,990.95,75,,,percent of total billed charges,75% of total billed charges,990.95,75,,,percent of total billed charges,75% of total billed charges,1348.67,100,,,Fee Schedule,100% of CMS OPPS Rate,584.77,102,,,Fee Schedule,102% of WV Medicaid Rate,2225.32,165,,,Fee Schedule,165% of CMS OPPS Rate,1397.79,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,3873.91,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5312.76,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6654.78,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,573.3,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1348.67,100,,,Fee Schedule,100% of CMS OPPS Rate,1397.79,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,184.98,14,,,percent of total billed charges,14% of total billed charges,184.98,6654.78,
29850- Arthroscope/intercond spine w/o fi,3435277,CDM,510,RC,29850,HCPCS,Outpatient,,,1626.79,813.4,,1220.09,75,,,percent of total billed charges,75% of total billed charges,1220.09,75,,,percent of total billed charges,75% of total billed charges,1348.67,100,,,Fee Schedule,100% of CMS OPPS Rate,584.77,102,,,Fee Schedule,102% of WV Medicaid Rate,2225.32,165,,,Fee Schedule,165% of CMS OPPS Rate,1397.79,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,3873.91,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5312.76,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6654.78,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,573.3,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1348.67,100,,,Fee Schedule,100% of CMS OPPS Rate,1397.79,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,227.75,14,,,percent of total billed charges,14% of total billed charges,227.75,6654.78,
29851- Arthroscope/intercond spine w/fix,3435278,CDM,510,RC,29851,HCPCS,Outpatient,,,2436.13,1218.07,,1827.1,75,,,percent of total billed charges,75% of total billed charges,1827.1,75,,,percent of total billed charges,75% of total billed charges,1348.67,100,,,Fee Schedule,100% of CMS OPPS Rate,584.77,102,,,Fee Schedule,102% of WV Medicaid Rate,2225.32,165,,,Fee Schedule,165% of CMS OPPS Rate,1397.79,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,3873.91,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5312.76,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6654.78,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,573.3,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1348.67,100,,,Fee Schedule,100% of CMS OPPS Rate,1397.79,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,341.06,14,,,percent of total billed charges,14% of total billed charges,341.06,6654.78,
29855- Arthrosc/knee/surg/drill/bone gft,3435279,CDM,510,RC,29855,HCPCS,Outpatient,,,2041.99,1021,,1531.49,75,,,percent of total billed charges,75% of total billed charges,1531.49,75,,,percent of total billed charges,75% of total billed charges,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,3581.03,102,,,Fee Schedule,102% of WV Medicaid Rate,10261.1,165,,,Fee Schedule,165% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,17862.79,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,24497.4,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,30685.48,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,3510.81,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,285.88,14,,,percent of total billed charges,14% of total billed charges,285.88,30685.48,
29856- Arthrosc/knee/surg/drill/lesion,3435280,CDM,510,RC,29856,HCPCS,Outpatient,,,2605.11,1302.56,,1953.83,75,,,percent of total billed charges,75% of total billed charges,1953.83,75,,,percent of total billed charges,75% of total billed charges,12267.36,100,,,Fee Schedule,100% of CMS OPPS Rate,6550.53,102,,,Fee Schedule,102% of WV Medicaid Rate,20241.15,165,,,Fee Schedule,165% of CMS OPPS Rate,12714.07,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,35236.32,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,48323.81,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,60530.47,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,6422.09,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,12267.36,100,,,Fee Schedule,100% of CMS OPPS Rate,12714.07,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,364.72,14,,,percent of total billed charges,14% of total billed charges,364.72,60530.47,
29862- Arthroscop/hip/debrid/chondroplast,3435281,CDM,510,RC,29862,HCPCS,Outpatient,,,2127.09,1063.55,,1595.32,75,,,percent of total billed charges,75% of total billed charges,1595.32,75,,,percent of total billed charges,75% of total billed charges,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,2365.05,102,,,Fee Schedule,102% of WV Medicaid Rate,10261.1,165,,,Fee Schedule,165% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,17862.79,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,24497.4,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,30685.48,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,2318.68,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,297.79,14,,,percent of total billed charges,14% of total billed charges,297.79,30685.48,
29866- Arthroscop/knee/osteochon autogft,3435282,CDM,510,RC,29866,HCPCS,Outpatient,,,2752.16,1376.08,,2064.12,75,,,percent of total billed charges,75% of total billed charges,2064.12,75,,,percent of total billed charges,75% of total billed charges,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,10261.1,165,,,Fee Schedule,165% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,17862.79,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,24497.4,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,30685.48,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,385.3,14,,,percent of total billed charges,14% of total billed charges,385.3,30685.48,
29867- Arthroscop/knee/osteochon allogft,3435283,CDM,510,RC,29867,HCPCS,Outpatient,,,3351.55,1675.78,,2513.66,75,,,percent of total billed charges,75% of total billed charges,2513.66,75,,,percent of total billed charges,75% of total billed charges,12267.36,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,20241.15,165,,,Fee Schedule,165% of CMS OPPS Rate,12714.07,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,35236.32,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,48323.81,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,60530.47,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,12267.36,100,,,Fee Schedule,100% of CMS OPPS Rate,12714.07,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,469.22,14,,,percent of total billed charges,14% of total billed charges,469.22,60530.47,
29870- Arthroscopy/knee w/w/o synovial bx,3435284,CDM,510,RC,29870,HCPCS,Outpatient,,,1402.45,701.23,,1051.84,75,,,percent of total billed charges,75% of total billed charges,1051.84,75,,,percent of total billed charges,75% of total billed charges,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,1073.09,102,,,Fee Schedule,102% of WV Medicaid Rate,4617.6,165,,,Fee Schedule,165% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8038.46,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11024.11,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13808.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1052.05,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,196.34,14,,,percent of total billed charges,14% of total billed charges,196.34,13808.81,
29871- Arthroscopy/knee/surg/lavage/infec,3435285,CDM,510,RC,29871,HCPCS,Outpatient,,,1339.06,669.53,,1004.3,75,,,percent of total billed charges,75% of total billed charges,1004.3,75,,,percent of total billed charges,75% of total billed charges,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,1073.09,102,,,Fee Schedule,102% of WV Medicaid Rate,4617.6,165,,,Fee Schedule,165% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8038.46,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11024.11,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13808.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1052.05,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,187.47,14,,,percent of total billed charges,14% of total billed charges,187.47,13808.81,
29873- Arthroscopy/knee/surg/lat release,3435286,CDM,510,RC,29873,HCPCS,Outpatient,,,1386.26,693.13,,1039.7,75,,,percent of total billed charges,75% of total billed charges,1039.7,75,,,percent of total billed charges,75% of total billed charges,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,1073.09,102,,,Fee Schedule,102% of WV Medicaid Rate,4617.6,165,,,Fee Schedule,165% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8038.46,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11024.11,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13808.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1052.05,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,194.08,14,,,percent of total billed charges,14% of total billed charges,194.08,13808.81,
29874- Arthroscopy/knee/surg/rmv loose/FB,3435287,CDM,510,RC,29874,HCPCS,Outpatient,,,1398.62,699.31,,1048.97,75,,,percent of total billed charges,75% of total billed charges,1048.97,75,,,percent of total billed charges,75% of total billed charges,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,1073.09,102,,,Fee Schedule,102% of WV Medicaid Rate,4617.6,165,,,Fee Schedule,165% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8038.46,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11024.11,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13808.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1052.05,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,195.81,14,,,percent of total billed charges,14% of total billed charges,195.81,13808.81,
29875- Arthroscopy/knee/surg/synovectomy,3435288,CDM,510,RC,29875,HCPCS,Outpatient,,,1291.68,645.84,,968.76,75,,,percent of total billed charges,75% of total billed charges,968.76,75,,,percent of total billed charges,75% of total billed charges,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,1073.09,102,,,Fee Schedule,102% of WV Medicaid Rate,4617.6,165,,,Fee Schedule,165% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8038.46,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11024.11,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13808.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1052.05,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,180.84,14,,,percent of total billed charges,14% of total billed charges,180.84,13808.81,
29876- Knee artho/synovectomy/2or> comp,3431443,CDM,510,RC,29876,HCPCS,Outpatient,,,1705.83,852.92,,1279.37,75,,,percent of total billed charges,75% of total billed charges,1279.37,75,,,percent of total billed charges,75% of total billed charges,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,1073.09,102,,,Fee Schedule,102% of WV Medicaid Rate,4617.6,165,,,Fee Schedule,165% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8038.46,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11024.11,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13808.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1052.05,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,238.82,14,,,percent of total billed charges,14% of total billed charges,238.82,13808.81,
29877- Arthroscopy/knee/chondroplasty,3435289,CDM,510,RC,29877,HCPCS,Outpatient,,,1621.02,810.51,,1215.77,75,,,percent of total billed charges,75% of total billed charges,1215.77,75,,,percent of total billed charges,75% of total billed charges,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,1073.09,102,,,Fee Schedule,102% of WV Medicaid Rate,4617.6,165,,,Fee Schedule,165% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8038.46,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11024.11,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13808.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1052.05,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,226.94,14,,,percent of total billed charges,14% of total billed charges,226.94,13808.81,
29879- Arthroscopy/knee/abras arthroplast,3435290,CDM,510,RC,29879,HCPCS,Outpatient,,,1727.6,863.8,,1295.7,75,,,percent of total billed charges,75% of total billed charges,1295.7,75,,,percent of total billed charges,75% of total billed charges,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,1073.09,102,,,Fee Schedule,102% of WV Medicaid Rate,4617.6,165,,,Fee Schedule,165% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8038.46,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11024.11,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13808.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1052.05,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,241.86,14,,,percent of total billed charges,14% of total billed charges,241.86,13808.81,
29880- Arthroscopy/knee/meniscect/med/lat,3435291,CDM,510,RC,29880,HCPCS,Outpatient,,,1463.91,731.96,,1097.93,75,,,percent of total billed charges,75% of total billed charges,1097.93,75,,,percent of total billed charges,75% of total billed charges,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,1073.09,102,,,Fee Schedule,102% of WV Medicaid Rate,4617.6,165,,,Fee Schedule,165% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8038.46,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11024.11,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13808.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1052.05,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,204.95,14,,,percent of total billed charges,14% of total billed charges,204.95,13808.81,
29881- Arthroscopy/knee/menisc/med or lat,3435292,CDM,510,RC,29881,HCPCS,Outpatient,,,1408.82,704.41,,1056.62,75,,,percent of total billed charges,75% of total billed charges,1056.62,75,,,percent of total billed charges,75% of total billed charges,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,1073.09,102,,,Fee Schedule,102% of WV Medicaid Rate,4617.6,165,,,Fee Schedule,165% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8038.46,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11024.11,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13808.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1052.05,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,197.23,14,,,percent of total billed charges,14% of total billed charges,197.23,13808.81,
29882- Arthroscopy/knee w/meniscus repair,3435293,CDM,510,RC,29882,HCPCS,Outpatient,,,1800.31,900.16,,1350.23,75,,,percent of total billed charges,75% of total billed charges,1350.23,75,,,percent of total billed charges,75% of total billed charges,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,1073.09,102,,,Fee Schedule,102% of WV Medicaid Rate,4617.6,165,,,Fee Schedule,165% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8038.46,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11024.11,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13808.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1052.05,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,252.04,14,,,percent of total billed charges,14% of total billed charges,252.04,13808.81,
29883- Arthroscopy/knee/meniscus repair,3435294,CDM,510,RC,29883,HCPCS,Outpatient,,,2199.92,1099.96,,1649.94,75,,,percent of total billed charges,75% of total billed charges,1649.94,75,,,percent of total billed charges,75% of total billed charges,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,1073.09,102,,,Fee Schedule,102% of WV Medicaid Rate,4617.6,165,,,Fee Schedule,165% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8038.46,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11024.11,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13808.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1052.05,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,307.99,14,,,percent of total billed charges,14% of total billed charges,307.99,13808.81,
29887- Arthroscopy/knee/surg/drill for intact osteochondritis dissecans les,3435295,CDM,510,RC,29887,HCPCS,Outpatient,,,1966.12,983.06,,1474.59,75,,,percent of total billed charges,75% of total billed charges,1474.59,75,,,percent of total billed charges,75% of total billed charges,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,2365.05,102,,,Fee Schedule,102% of WV Medicaid Rate,10261.1,165,,,Fee Schedule,165% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,17862.79,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,24497.4,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,30685.48,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,2318.68,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,275.26,14,,,percent of total billed charges,14% of total billed charges,275.26,30685.48,
29888- Arthroscope/ant cruciate lig rpr,3435296,CDM,510,RC,29888,HCPCS,Outpatient,,,2563.57,1281.79,,1922.68,75,,,percent of total billed charges,75% of total billed charges,1922.68,75,,,percent of total billed charges,75% of total billed charges,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,3253.99,102,,,Fee Schedule,102% of WV Medicaid Rate,10261.1,165,,,Fee Schedule,165% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,17862.79,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,24497.4,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,30685.48,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,3190.19,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,358.9,14,,,percent of total billed charges,14% of total billed charges,358.9,30685.48,
29889- Arthroscope/post cruciate lig rpr,3435297,CDM,510,RC,29889,HCPCS,Outpatient,,,3207.23,1603.62,,2405.42,75,,,percent of total billed charges,75% of total billed charges,2405.42,75,,,percent of total billed charges,75% of total billed charges,12267.36,100,,,Fee Schedule,100% of CMS OPPS Rate,6509.87,102,,,Fee Schedule,102% of WV Medicaid Rate,20241.15,165,,,Fee Schedule,165% of CMS OPPS Rate,12714.07,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,35236.32,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,48323.81,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,60530.47,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,6382.23,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,12267.36,100,,,Fee Schedule,100% of CMS OPPS Rate,12714.07,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,449.01,14,,,percent of total billed charges,14% of total billed charges,449.01,60530.47,
29891- Arthros/ankle/exc osteochon defect,3435298,CDM,510,RC,29891,HCPCS,Outpatient,,,1743.83,871.92,,1307.87,75,,,percent of total billed charges,75% of total billed charges,1307.87,75,,,percent of total billed charges,75% of total billed charges,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,1073.09,102,,,Fee Schedule,102% of WV Medicaid Rate,4617.6,165,,,Fee Schedule,165% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8038.46,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11024.11,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13808.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1052.05,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,244.14,14,,,percent of total billed charges,14% of total billed charges,244.14,13808.81,
29893- Endoscopic/plantar fasciotomy,3435299,CDM,510,RC,29893,HCPCS,Outpatient,,,1656.92,828.46,,1242.69,75,,,percent of total billed charges,75% of total billed charges,1242.69,75,,,percent of total billed charges,75% of total billed charges,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,1073.09,102,,,Fee Schedule,102% of WV Medicaid Rate,4617.6,165,,,Fee Schedule,165% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8038.46,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11024.11,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13808.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1052.05,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,231.97,14,,,percent of total billed charges,14% of total billed charges,231.97,13808.81,
29894- Arthroscop/ankle/rmv loose/FB,3435300,CDM,510,RC,29894,HCPCS,Outpatient,,,1314.24,657.12,,985.68,75,,,percent of total billed charges,75% of total billed charges,985.68,75,,,percent of total billed charges,75% of total billed charges,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,1073.09,102,,,Fee Schedule,102% of WV Medicaid Rate,4617.6,165,,,Fee Schedule,165% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8038.46,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11024.11,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13808.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1052.05,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,183.99,14,,,percent of total billed charges,14% of total billed charges,183.99,13808.81,
29897- Arthros/ankle/debridement/limited,3435301,CDM,510,RC,29897,HCPCS,Outpatient,,,1282.44,641.22,,961.83,75,,,percent of total billed charges,75% of total billed charges,961.83,75,,,percent of total billed charges,75% of total billed charges,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,1073.09,102,,,Fee Schedule,102% of WV Medicaid Rate,4617.6,165,,,Fee Schedule,165% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8038.46,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11024.11,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13808.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1052.05,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,179.54,14,,,percent of total billed charges,14% of total billed charges,179.54,13808.81,
29898- Arthroscopy/ankle/debridement/ext,3435302,CDM,510,RC,29898,HCPCS,Outpatient,,,1463.51,731.76,,1097.63,75,,,percent of total billed charges,75% of total billed charges,1097.63,75,,,percent of total billed charges,75% of total billed charges,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,1073.09,102,,,Fee Schedule,102% of WV Medicaid Rate,4617.6,165,,,Fee Schedule,165% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8038.46,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11024.11,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13808.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1052.05,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,204.89,14,,,percent of total billed charges,14% of total billed charges,204.89,13808.81,
29899- Arthroscopy/ankle w/arthrodesis,3435303,CDM,510,RC,29899,HCPCS,Outpatient,,,2666.19,1333.1,,1999.64,75,,,percent of total billed charges,75% of total billed charges,1999.64,75,,,percent of total billed charges,75% of total billed charges,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,3159.81,102,,,Fee Schedule,102% of WV Medicaid Rate,10261.1,165,,,Fee Schedule,165% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,17862.79,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,24497.4,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,30685.48,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,3097.85,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,373.27,14,,,percent of total billed charges,14% of total billed charges,373.27,30685.48,
29902- Arthrosc/metacarpophalangeal joint,3435304,CDM,510,RC,29902,HCPCS,Outpatient,,,1487.45,743.73,,1115.59,75,,,percent of total billed charges,75% of total billed charges,1115.59,75,,,percent of total billed charges,75% of total billed charges,1348.67,100,,,Fee Schedule,100% of CMS OPPS Rate,584.77,102,,,Fee Schedule,102% of WV Medicaid Rate,2225.32,165,,,Fee Schedule,165% of CMS OPPS Rate,1397.79,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,3873.91,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5312.76,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6654.78,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,573.3,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1348.67,100,,,Fee Schedule,100% of CMS OPPS Rate,1397.79,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,208.24,14,,,percent of total billed charges,14% of total billed charges,208.24,6654.78,
29906- Arthroscop/subtal jnt/surg/debrid,3435305,CDM,510,RC,29906,HCPCS,Outpatient,,,1701.88,850.94,,1276.41,75,,,percent of total billed charges,75% of total billed charges,1276.41,75,,,percent of total billed charges,75% of total billed charges,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,1073.09,102,,,Fee Schedule,102% of WV Medicaid Rate,4617.6,165,,,Fee Schedule,165% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8038.46,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11024.11,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13808.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1052.05,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2798.55,100,,,Fee Schedule,100% of CMS OPPS Rate,2900.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,238.26,14,,,percent of total billed charges,14% of total billed charges,238.26,13808.81,
29914- Arthroscopy/hip/femoroplasty,3435306,CDM,510,RC,29914,HCPCS,Outpatient,,,2618.93,1309.47,,1964.2,75,,,percent of total billed charges,75% of total billed charges,1964.2,75,,,percent of total billed charges,75% of total billed charges,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,2365.05,102,,,Fee Schedule,102% of WV Medicaid Rate,10261.1,165,,,Fee Schedule,165% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,17862.79,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,24497.4,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,30685.48,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,2318.68,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,366.65,14,,,percent of total billed charges,14% of total billed charges,366.65,30685.48,
29915- Arthroscopy/hip/acetabuloplasty,3435307,CDM,510,RC,29915,HCPCS,Outpatient,,,2696.45,1348.23,,2022.34,75,,,percent of total billed charges,75% of total billed charges,2022.34,75,,,percent of total billed charges,75% of total billed charges,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,2365.05,102,,,Fee Schedule,102% of WV Medicaid Rate,10261.1,165,,,Fee Schedule,165% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,17862.79,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,24497.4,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,30685.48,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,2318.68,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,377.5,14,,,percent of total billed charges,14% of total billed charges,377.5,30685.48,
29916- Arthroscopy/hip/labral repair,3435308,CDM,510,RC,29916,HCPCS,Outpatient,,,2679.12,1339.56,,2009.34,75,,,percent of total billed charges,75% of total billed charges,2009.34,75,,,percent of total billed charges,75% of total billed charges,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,2365.05,102,,,Fee Schedule,102% of WV Medicaid Rate,10261.1,165,,,Fee Schedule,165% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,17862.79,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,24497.4,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,30685.48,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,2318.68,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,375.08,14,,,percent of total billed charges,14% of total billed charges,375.08,30685.48,
30110- Excision/nasal polyps/simple,3435860,CDM,510,RC,30110,HCPCS,Outpatient,,,620.87,310.44,,465.65,75,,,percent of total billed charges,75% of total billed charges,465.65,75,,,percent of total billed charges,75% of total billed charges,1305.07,100,,,Fee Schedule,100% of CMS OPPS Rate,152.06,102,,,Fee Schedule,102% of WV Medicaid Rate,2153.38,165,,,Fee Schedule,165% of CMS OPPS Rate,1352.6,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,3748.66,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5141,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6439.62,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,149.08,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1305.07,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,86.92,14,,,percent of total billed charges,14% of total billed charges,86.92,6439.62,
30220 Insert nasal septal button,3584866,CDM,960,RC,30220,HCPCS,Outpatient,,,759.95,379.98,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
30300- Rmv foreign body/nose/office proc,3435861,CDM,510,RC,30300,HCPCS,Outpatient,,,519.23,259.62,,389.42,75,,,percent of total billed charges,75% of total billed charges,389.42,75,,,percent of total billed charges,75% of total billed charges,109.16,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,180.11,165,,,Fee Schedule,165% of CMS OPPS Rate,113.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,313.55,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,430.01,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,538.63,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,109.16,100,,,Fee Schedule,100% of CMS OPPS Rate,113.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,72.69,14,,,percent of total billed charges,14% of total billed charges,72.69,538.63,
PHY-REMOVAL FOREIGN BODY INTRANASAL,3428511,CDM,981,RC,30300,HCPCS,Outpatient,,,519.23,259.62,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
30310 Remove nasal foreign body,3584867,CDM,960,RC,30310,HCPCS,Outpatient,,,530.11,265.06,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
30465- Repair/nasal vestibular stenosis,3435862,CDM,510,RC,30465,HCPCS,Outpatient,,,2657.92,1328.96,,1993.44,75,,,percent of total billed charges,75% of total billed charges,1993.44,75,,,percent of total billed charges,75% of total billed charges,5020.17,100,,,Fee Schedule,100% of CMS OPPS Rate,1926.95,102,,,Fee Schedule,102% of WV Medicaid Rate,8283.28,165,,,Fee Schedule,165% of CMS OPPS Rate,5202.97,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,14419.76,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,19775.56,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,24770.9,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1889.17,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,5020.17,100,,,Fee Schedule,100% of CMS OPPS Rate,5202.97,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,372.11,14,,,percent of total billed charges,14% of total billed charges,372.11,24770.9,
30901- Control nosebleed/anterior/simple,3435863,CDM,510,RC,30901,HCPCS,Outpatient,,,396.2,198.1,,297.15,75,,,percent of total billed charges,75% of total billed charges,297.15,75,,,percent of total billed charges,75% of total billed charges,109.16,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,180.11,165,,,Fee Schedule,165% of CMS OPPS Rate,113.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,313.55,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,430.01,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,538.63,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,109.16,100,,,Fee Schedule,100% of CMS OPPS Rate,113.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,55.47,14,,,percent of total billed charges,14% of total billed charges,55.47,538.63,
30903 Control of nosebleed,3584868,CDM,960,RC,30903,HCPCS,Outpatient,,,616.22,308.11,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
PHY-CONTROL NASAL HEMORRHAGE POSTR W/PACK INITIAL,3428507,CDM,981,RC,30905,HCPCS,Outpatient,,,878.11,439.06,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
30906- Control nosebleed/post/subsequent,3435864,CDM,510,RC,30906,HCPCS,Outpatient,,,927.79,463.9,,695.84,75,,,percent of total billed charges,75% of total billed charges,695.84,75,,,percent of total billed charges,75% of total billed charges,195.39,100,,,Fee Schedule,100% of CMS OPPS Rate,86.35,102,,,Fee Schedule,102% of WV Medicaid Rate,322.39,165,,,Fee Schedule,165% of CMS OPPS Rate,202.5,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,561.23,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,769.7,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,964.12,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,84.66,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,195.39,100,,,Fee Schedule,100% of CMS OPPS Rate,202.5,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,129.89,14,,,percent of total billed charges,14% of total billed charges,84.66,964.12,
31030 - Exporation Maxillary Sinus,4189303,CDM,960,RC,31030,HCPCS,Outpatient,,,1434.42,717.21,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
31087- Sinusotomy/nonob/osteo flp/cor inc,3435865,CDM,510,RC,31087,HCPCS,Outpatient,,,2908.75,1454.38,,2181.56,75,,,percent of total billed charges,75% of total billed charges,2181.56,75,,,percent of total billed charges,75% of total billed charges,5020.17,100,,,Fee Schedule,100% of CMS OPPS Rate,1926.95,102,,,Fee Schedule,102% of WV Medicaid Rate,8283.28,165,,,Fee Schedule,165% of CMS OPPS Rate,5202.97,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,14419.76,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,19775.56,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,24770.9,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1889.17,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,5020.17,100,,,Fee Schedule,100% of CMS OPPS Rate,5202.97,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,407.23,14,,,percent of total billed charges,14% of total billed charges,407.23,24770.9,
31231- Nasal endoscopy dx,3431300,CDM,510,RC,31231,HCPCS,Outpatient,,,1131.52,565.76,,848.64,75,,,percent of total billed charges,75% of total billed charges,848.64,75,,,percent of total billed charges,75% of total billed charges,168.05,100,,,Fee Schedule,100% of CMS OPPS Rate,67.2,102,,,Fee Schedule,102% of WV Medicaid Rate,277.27,165,,,Fee Schedule,165% of CMS OPPS Rate,174.17,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,482.7,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,661.99,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,829.22,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,65.88,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,168.05,100,,,Fee Schedule,100% of CMS OPPS Rate,174.17,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,158.41,14,,,percent of total billed charges,14% of total billed charges,65.88,848.64,
31231-OCC Nasal endoscopy dx,3536973,CDM,510,RC,31231,HCPCS,Outpatient,,,1131.52,565.76,,848.64,75,,,percent of total billed charges,75% of total billed charges,848.64,75,,,percent of total billed charges,75% of total billed charges,168.05,100,,,Fee Schedule,100% of CMS OPPS Rate,67.2,102,,,Fee Schedule,102% of WV Medicaid Rate,277.27,165,,,Fee Schedule,165% of CMS OPPS Rate,174.17,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,482.7,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,661.99,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,829.22,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,65.88,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,168.05,100,,,Fee Schedule,100% of CMS OPPS Rate,174.17,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,158.41,14,,,percent of total billed charges,14% of total billed charges,65.88,848.64,
Endoscopy,3428425,CDM,490,RC,31231,HCPCS,Outpatient,,,465.68,232.84,,349.26,75,,,percent of total billed charges,75% of total billed charges,349.26,75,,,percent of total billed charges,75% of total billed charges,168.05,100,,,Fee Schedule,100% of CMS OPPS Rate,67.2,102,,,Fee Schedule,102% of WV Medicaid Rate,277.27,165,,,Fee Schedule,165% of CMS OPPS Rate,174.17,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,482.7,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,661.99,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,829.22,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,65.88,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,168.05,100,,,Fee Schedule,100% of CMS OPPS Rate,174.17,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,65.2,14,,,percent of total billed charges,14% of total billed charges,65.2,829.22,
31237 - Nasal/Sinus Endoscopy Surg,4189304,CDM,960,RC,31237,HCPCS,Outpatient,,,578.59,289.3,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
"Hemorrhage Repair ? Eyes, Ears, Nose, Throat (EENT)",3428461,CDM,981,RC,31238,HCPCS,Outpatient,,,636.27,318.14,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
31239- Nasal/sinus endoscopy/surgical,3431301,CDM,510,RC,31239,HCPCS,Outpatient,,,1560.47,780.24,,1170.35,75,,,percent of total billed charges,75% of total billed charges,1170.35,75,,,percent of total billed charges,75% of total billed charges,3134.18,100,,,Fee Schedule,100% of CMS OPPS Rate,1047.42,102,,,Fee Schedule,102% of WV Medicaid Rate,5171.39,165,,,Fee Schedule,165% of CMS OPPS Rate,3248.31,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,9002.51,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,12346.23,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,15464.9,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1026.88,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,3134.18,100,,,Fee Schedule,100% of CMS OPPS Rate,3248.31,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,218.47,14,,,percent of total billed charges,14% of total billed charges,218.47,15464.9,
INCISION OF WINDPIPE,3527827,CDM,981,RC,31605,HCPCS,Outpatient,,,900.37,450.19,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
36410 - Non-routine bl draw 3/> yrs,4241827,CDM,960,RC,36410,HCPCS,Outpatient,,,57.43,28.72,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
36415 Venipuncture,3435565,CDM,300,RC,36415,HCPCS,Outpatient,,,14.63,7.32,,10.97,75,,,percent of total billed charges,75% of total billed charges,10.97,75,,,percent of total billed charges,75% of total billed charges,8.57,100,,,Fee Schedule,100% of CMS OPPS Rate,3,100,,,Fee Schedule,100% of WV Medicaid Rate,8.57,100,,,Fee Schedule,100% of CMS OPPS Rate,3,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,30.38,354.54,,,Fee Schedule,354.54% of CMS OPPS Fee Schedule Rate,36.73,428.7,,,Fee Schedule,428.7% of CMS OPPS Fee Schedule Rate,38.63,450.81,,,Fee Schedule,450.81% of CMS OPPS Fee Schedule Rate,3,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,8.57,100,,,Fee Schedule,100% of CMS OPPS Rate,3,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,2.05,14,,,percent of total billed charges,14% of total billed charges,2.05,38.63,
36416 - Collection of Capillary Blood Specimen,4315464,CDM,983,RC,36416,HCPCS,Outpatient,,,45.42,22.71,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
36460- Transfusion/intrauterine/fetal,3430713,CDM,510,RC,36460,HCPCS,Outpatient,,,920.12,460.06,,690.09,75,,,percent of total billed charges,75% of total billed charges,690.09,75,,,percent of total billed charges,75% of total billed charges,383.34,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,632.52,165,,,Fee Schedule,165% of CMS OPPS Rate,397.31,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1101.11,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1510.1,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1891.56,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,383.34,100,,,Fee Schedule,100% of CMS OPPS Rate,397.31,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,128.82,14,,,percent of total billed charges,14% of total billed charges,128.82,1891.56,
36465 NJX Noncmpnd Sclerosant Single Incmptnt Vein,3436048,CDM,761,RC,36465,HCPCS,Outpatient,,,3257.89,1628.95,,2443.42,75,,,percent of total billed charges,75% of total billed charges,2443.42,75,,,percent of total billed charges,75% of total billed charges,1622.59,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,2677.27,165,,,Fee Schedule,165% of CMS OPPS Rate,1681.67,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4660.68,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,6391.75,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,8006.31,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,1622.59,100,,,Fee Schedule,100% of CMS OPPS Rate,1681.67,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,456.1,14,,,percent of total billed charges,14% of total billed charges,456.1,8006.31,
36466 NJX Noncmpnd Sclerosant Multiple Incmptnt Veins,3436049,CDM,761,RC,36466,HCPCS,Outpatient,,,3609.18,1804.59,,2706.89,75,,,percent of total billed charges,75% of total billed charges,2706.89,75,,,percent of total billed charges,75% of total billed charges,1622.59,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,2677.27,165,,,Fee Schedule,165% of CMS OPPS Rate,1681.67,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4660.68,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,6391.75,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,8006.31,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,1622.59,100,,,Fee Schedule,100% of CMS OPPS Rate,1681.67,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,505.29,14,,,percent of total billed charges,14% of total billed charges,505.29,8006.31,
36468 Tx of symptomatic spider veins sclerotherapy,4117375,CDM,761,RC,36468,HCPCS,Outpatient,,,380.64,190.32,,285.48,75,,,percent of total billed charges,75% of total billed charges,285.48,75,,,percent of total billed charges,75% of total billed charges,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,578.73,165,,,Fee Schedule,165% of CMS OPPS Rate,363.52,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1007.47,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1381.67,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1730.68,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,363.52,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,53.29,14,,,percent of total billed charges,14% of total billed charges,53.29,1730.68,
36470 Injection Sclerosant Single Incmptnt Vein,3436050,CDM,761,RC,36470,HCPCS,Outpatient,,,285.8,142.9,,214.35,75,,,percent of total billed charges,75% of total billed charges,214.35,75,,,percent of total billed charges,75% of total billed charges,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,69.62,102,,,Fee Schedule,102% of WV Medicaid Rate,578.72,165,,,Fee Schedule,165% of CMS OPPS Rate,363.51,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1007.47,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1381.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1730.67,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,68.25,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,363.51,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,40.01,14,,,percent of total billed charges,14% of total billed charges,40.01,1730.67,
36471 Injection Sclerosant Multiple Incmptnt Veins,3436052,CDM,761,RC,36471,HCPCS,Outpatient,,,500.57,250.29,,375.43,75,,,percent of total billed charges,75% of total billed charges,375.43,75,,,percent of total billed charges,75% of total billed charges,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,114.66,102,,,Fee Schedule,102% of WV Medicaid Rate,578.72,165,,,Fee Schedule,165% of CMS OPPS Rate,363.51,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1007.47,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1381.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1730.67,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,112.41,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,363.51,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,70.08,14,,,percent of total billed charges,14% of total billed charges,70.08,1730.67,
36475 - Radiofrequency ablation vein,4023140,CDM,761,RC,36475,HCPCS,Outpatient,,,2739.73,1369.87,,2054.8,75,,,percent of total billed charges,75% of total billed charges,2054.8,75,,,percent of total billed charges,75% of total billed charges,2800.71,100,,,Fee Schedule,100% of CMS OPPS Rate,1102.62,102,,,Fee Schedule,102% of WV Medicaid Rate,4621.18,165,,,Fee Schedule,165% of CMS OPPS Rate,2902.7,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8044.7,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11032.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13819.53,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1081,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2800.71,100,,,Fee Schedule,100% of CMS OPPS Rate,2902.7,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,383.56,14,,,percent of total billed charges,14% of total billed charges,383.56,13819.53,
36475- Endo abl/incom vein/ext/rad fre/#1,3430716,CDM,761,RC,36475,HCPCS,Outpatient,,,16672.2,8336.1,,12504.15,75,,,percent of total billed charges,75% of total billed charges,12504.15,75,,,percent of total billed charges,75% of total billed charges,2800.71,100,,,Fee Schedule,100% of CMS OPPS Rate,1102.62,102,,,Fee Schedule,102% of WV Medicaid Rate,4621.18,165,,,Fee Schedule,165% of CMS OPPS Rate,2902.7,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8044.7,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11032.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13819.53,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1081,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2800.71,100,,,Fee Schedule,100% of CMS OPPS Rate,2902.7,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,2334.11,14,,,percent of total billed charges,14% of total billed charges,1081,13819.53,
36478 Endoven AbltJ Incmptnt Vein XTR Laser 1st Vein,3436053,CDM,761,RC,36478,HCPCS,Outpatient,,,2505.7,1252.85,,1879.28,75,,,percent of total billed charges,75% of total billed charges,1879.28,75,,,percent of total billed charges,75% of total billed charges,2800.71,100,,,Fee Schedule,100% of CMS OPPS Rate,1102.62,102,,,Fee Schedule,102% of WV Medicaid Rate,4621.18,165,,,Fee Schedule,165% of CMS OPPS Rate,2902.7,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8044.7,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11032.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13819.53,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1081,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2800.71,100,,,Fee Schedule,100% of CMS OPPS Rate,2902.7,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,350.8,14,,,percent of total billed charges,14% of total billed charges,350.8,13819.53,
36482 Endoven Ablti Ther Chem Adhesive 1st Vein,3549208,CDM,761,RC,36482,HCPCS,Outpatient,,,4161.61,2080.81,,3121.21,75,,,percent of total billed charges,75% of total billed charges,3121.21,75,,,percent of total billed charges,75% of total billed charges,4832.22,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,7973.16,165,,,Fee Schedule,165% of CMS OPPS Rate,5008.18,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,13879.91,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,19035.18,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,23843.51,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,4832.22,100,,,Fee Schedule,100% of CMS OPPS Rate,5008.18,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,582.63,14,,,percent of total billed charges,14% of total billed charges,582.63,23843.51,
36483 Endoven Ablti Ther Chem Adhesive Sbsq Vein,3549209,CDM,761,RC,36483,HCPCS,Outpatient,,,357.23,178.62,,267.92,75,,,percent of total billed charges,75% of total billed charges,267.92,75,,,percent of total billed charges,75% of total billed charges,114.31,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50.01,14,,,percent of total billed charges,14% of total billed charges,50.01,267.92,
36558 - Hero Graft Placement- add-on,4233191,CDM,481,RC,36558,HCPCS,Outpatient,,,1613.4,806.7,,1210.05,75,,,percent of total billed charges,75% of total billed charges,1210.05,75,,,percent of total billed charges,75% of total billed charges,2800.71,100,,,Fee Schedule,100% of CMS OPPS Rate,1102.62,102,,,Fee Schedule,102% of WV Medicaid Rate,4621.18,165,,,Fee Schedule,165% of CMS OPPS Rate,2902.7,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8044.7,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11032.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13819.53,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1081,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2800.71,100,,,Fee Schedule,100% of CMS OPPS Rate,2902.7,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,225.88,14,,,percent of total billed charges,14% of total billed charges,225.88,13819.53,
36558 - PF Hero Graft Placement- add-on,4233189,CDM,960,RC,36558,HCPCS,Outpatient,,,1613.4,806.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
Hero Graft Placement- add-on,,,761,RC,36558,HCPCS,Outpatient,,,1613.4,806.7,,1210.05,75,,,percent of total billed charges,75% of total billed charges,1210.05,75,,,percent of total billed charges,75% of total billed charges,2800.71,100,,,Fee Schedule,100% of CMS OPPS Rate,1102.62,102,,,Fee Schedule,102% of WV Medicaid Rate,4621.18,165,,,Fee Schedule,165% of CMS OPPS Rate,2902.7,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8044.7,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11032.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13819.53,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1081,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2800.71,100,,,Fee Schedule,100% of CMS OPPS Rate,2902.7,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,225.88,14,,,percent of total billed charges,14% of total billed charges,225.88,13819.53,
36591 Draw blood of venous device,3428321,CDM,301,RC,36591,HCPCS,Outpatient,,,62.69,31.35,,47.02,75,,,percent of total billed charges,75% of total billed charges,47.02,75,,,percent of total billed charges,75% of total billed charges,109.16,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,180.11,165,,,Fee Schedule,165% of CMS OPPS Rate,113.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,313.55,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,430.01,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,538.63,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,109.16,100,,,Fee Schedule,100% of CMS OPPS Rate,113.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8.78,14,,,percent of total billed charges,14% of total billed charges,8.78,538.63,
"36592- Collect bld, cen/per cath vein NOS",3430726,CDM,300,RC,36592,HCPCS,Outpatient,,,69.81,34.91,,52.36,75,,,percent of total billed charges,75% of total billed charges,52.36,75,,,percent of total billed charges,75% of total billed charges,109.16,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,180.11,165,,,Fee Schedule,165% of CMS OPPS Rate,113.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,313.55,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,430.01,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,538.63,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,109.16,100,,,Fee Schedule,100% of CMS OPPS Rate,113.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,9.77,14,,,percent of total billed charges,14% of total billed charges,9.77,538.63,
36600- Arterial puncture/blood draw,3430727,CDM,300,RC,36600,HCPCS,Outpatient,,,72.55,36.28,,54.41,75,,,percent of total billed charges,75% of total billed charges,54.41,75,,,percent of total billed charges,75% of total billed charges,109.16,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,180.11,165,,,Fee Schedule,165% of CMS OPPS Rate,113.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,313.55,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,430.01,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,538.63,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,109.16,100,,,Fee Schedule,100% of CMS OPPS Rate,113.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,10.16,14,,,percent of total billed charges,14% of total billed charges,10.16,538.63,
36660- Umbilical artery cath/newborn,3430729,CDM,510,RC,36660,HCPCS,Outpatient,,,179.83,89.92,,134.87,75,,,percent of total billed charges,75% of total billed charges,134.87,75,,,percent of total billed charges,75% of total billed charges,179.83,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,179.83,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,179.83,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,179.83,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,179.83,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,179.83,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,179.83,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,179.83,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,25.18,14,,,percent of total billed charges,14% of total billed charges,25.18,179.83,
37226 - REVSC OPN/PRQ FEM/POP W/STNT/ANGIOP SM VSL,4037523,CDM,481,RC,37226,HCPCS,Outpatient,,,53259.29,26629.65,,39944.47,75,,,percent of total billed charges,75% of total billed charges,39944.47,75,,,percent of total billed charges,75% of total billed charges,9980.15,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,16467.25,165,,,Fee Schedule,165% of CMS OPPS Rate,10343.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,28666.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,39314,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,49244.77,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,9980.15,100,,,Fee Schedule,100% of CMS OPPS Rate,10343.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,7456.3,14,,,percent of total billed charges,14% of total billed charges,7456.3,49244.77,
37231 - REVSC OPN/PRQ TIB/PERO W/STNT/ATHR/ANGIOP SM VSL,4037542,CDM,481,RC,37231,HCPCS,Outpatient,,,84934.9,42467.45,,63701.18,75,,,percent of total billed charges,75% of total billed charges,63701.18,75,,,percent of total billed charges,75% of total billed charges,16149.79,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,26647.16,165,,,Fee Schedule,165% of CMS OPPS Rate,16737.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,46388.09,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,63617.56,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,79687.45,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,16149.79,100,,,Fee Schedule,100% of CMS OPPS Rate,16737.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,11890.89,14,,,percent of total billed charges,14% of total billed charges,11890.89,79687.45,
Clinic Adjustment Gastric Band - S2083,4311851,CDM,510,RC,43999,HCPCS,Outpatient,,,4497.48,2248.74,,3373.11,75,,,percent of total billed charges,75% of total billed charges,3373.11,75,,,percent of total billed charges,75% of total billed charges,776.11,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1280.58,165,,,Fee Schedule,165% of CMS OPPS Rate,804.37,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,2229.28,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,3057.28,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,3829.56,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,776.11,100,,,Fee Schedule,100% of CMS OPPS Rate,804.37,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,629.65,14,,,percent of total billed charges,14% of total billed charges,629.65,3829.56,
44144- Colectomy/w colostomy or ileostomy,3431222,CDM,510,RC,44144,HCPCS,Outpatient,,,3743.67,1871.84,,2807.75,75,,,percent of total billed charges,75% of total billed charges,2807.75,75,,,percent of total billed charges,75% of total billed charges,3743.67,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,3743.67,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3743.67,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3743.67,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3743.67,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3743.67,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,3743.67,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3743.67,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,524.11,14,,,percent of total billed charges,14% of total billed charges,524.11,3743.67,
46083-Incise external hemorrhoid,3431258,CDM,510,RC,46083,HCPCS,Outpatient,,,1384.71,692.36,,1038.53,75,,,percent of total billed charges,75% of total billed charges,1038.53,75,,,percent of total billed charges,75% of total billed charges,202.01,100,,,Fee Schedule,100% of CMS OPPS Rate,108.62,102,,,Fee Schedule,102% of WV Medicaid Rate,333.31,165,,,Fee Schedule,165% of CMS OPPS Rate,209.36,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,580.25,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,795.77,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,996.78,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,106.49,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,202.01,100,,,Fee Schedule,100% of CMS OPPS Rate,209.36,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,193.86,14,,,percent of total billed charges,14% of total billed charges,106.49,1038.53,
46220-HKBT EXC PERIANAL SKIN TAG,3435933,CDM,510,RC,46220,HCPCS,Outpatient,,,4803.77,2401.89,,3602.83,75,,,percent of total billed charges,75% of total billed charges,3602.83,75,,,percent of total billed charges,75% of total billed charges,1018.11,100,,,Fee Schedule,100% of CMS OPPS Rate,423.26,102,,,Fee Schedule,102% of WV Medicaid Rate,1679.88,165,,,Fee Schedule,165% of CMS OPPS Rate,1055.19,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,2924.39,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,4010.57,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,5023.64,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,414.96,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1018.11,100,,,Fee Schedule,100% of CMS OPPS Rate,1055.19,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,672.53,14,,,percent of total billed charges,14% of total billed charges,414.96,5023.64,
46916 - Cryosurgery Anal Les,4327324,CDM,510,RC,46916,HCPCS,Outpatient,,,1292.57,646.29,,969.43,75,,,percent of total billed charges,75% of total billed charges,969.43,75,,,percent of total billed charges,75% of total billed charges,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,73.31,102,,,Fee Schedule,102% of WV Medicaid Rate,280.12,165,,,Fee Schedule,165% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,487.65,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,668.77,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,837.71,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,71.87,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,180.96,14,,,percent of total billed charges,14% of total billed charges,71.87,969.43,
"49329-MA UNLISTED LAP ABD, PERIT, OMENT",3430022,CDM,510,RC,49329,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4900.27,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,8085.46,165,,,Fee Schedule,165% of CMS OPPS Rate,5078.72,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,14075.4,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,19303.29,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,24179.33,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,4900.27,100,,,Fee Schedule,100% of CMS OPPS Rate,5078.72,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,4900.27,24179.33,
51700- Bladder irrigate/lavage/instill,3435948,CDM,510,RC,51700,HCPCS,Outpatient,,,1230.47,615.24,,922.85,75,,,percent of total billed charges,75% of total billed charges,922.85,75,,,percent of total billed charges,75% of total billed charges,202.01,100,,,Fee Schedule,100% of CMS OPPS Rate,43.68,102,,,Fee Schedule,102% of WV Medicaid Rate,333.31,165,,,Fee Schedule,165% of CMS OPPS Rate,209.36,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,580.25,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,795.77,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,996.78,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,42.82,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,202.01,100,,,Fee Schedule,100% of CMS OPPS Rate,209.36,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,172.27,14,,,percent of total billed charges,14% of total billed charges,42.82,996.78,
AMB alprostidil Admin Charge:Admin alprostadil Charge 51700,3444221,CDM,510,RC,51700,HCPCS,Outpatient,,,1230.47,615.24,,922.85,75,,,percent of total billed charges,75% of total billed charges,922.85,75,,,percent of total billed charges,75% of total billed charges,202.01,100,,,Fee Schedule,100% of CMS OPPS Rate,43.68,102,,,Fee Schedule,102% of WV Medicaid Rate,333.31,165,,,Fee Schedule,165% of CMS OPPS Rate,209.36,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,580.25,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,795.77,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,996.78,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,42.82,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,202.01,100,,,Fee Schedule,100% of CMS OPPS Rate,209.36,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,172.27,14,,,percent of total billed charges,14% of total billed charges,42.82,996.78,
AMB Bladder Irrigation Charge:Bladder Irrigation- 51700,3444232,CDM,510,RC,51700,HCPCS,Outpatient,,,1230.47,615.24,,922.85,75,,,percent of total billed charges,75% of total billed charges,922.85,75,,,percent of total billed charges,75% of total billed charges,202.01,100,,,Fee Schedule,100% of CMS OPPS Rate,43.68,102,,,Fee Schedule,102% of WV Medicaid Rate,333.31,165,,,Fee Schedule,165% of CMS OPPS Rate,209.36,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,580.25,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,795.77,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,996.78,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,42.82,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,202.01,100,,,Fee Schedule,100% of CMS OPPS Rate,209.36,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,172.27,14,,,percent of total billed charges,14% of total billed charges,42.82,996.78,
51701- Insert/non-indwelling bladder cath,3435949,CDM,510,RC,51701,HCPCS,Outpatient,,,686.4,343.2,,514.8,75,,,percent of total billed charges,75% of total billed charges,514.8,75,,,percent of total billed charges,75% of total billed charges,109.16,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,180.11,165,,,Fee Schedule,165% of CMS OPPS Rate,113.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,313.55,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,430.01,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,538.63,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,109.16,100,,,Fee Schedule,100% of CMS OPPS Rate,113.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,96.1,14,,,percent of total billed charges,14% of total billed charges,96.1,538.63,
CATH INSERT STRAIGHT,3428402,CDM,981,RC,51701,HCPCS,Outpatient,,,59.82,29.91,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
AMB Bladder Instill/Anticarcin:Bladder Instill/Anticarcin-51720,3444225,CDM,510,RC,51720,HCPCS,Outpatient,,,3477.25,1738.63,,2607.94,75,,,percent of total billed charges,75% of total billed charges,2607.94,75,,,percent of total billed charges,75% of total billed charges,587.91,100,,,Fee Schedule,100% of CMS OPPS Rate,44.22,102,,,Fee Schedule,102% of WV Medicaid Rate,970.06,165,,,Fee Schedule,165% of CMS OPPS Rate,609.32,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1688.72,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2315.94,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,2900.97,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,43.35,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,587.91,100,,,Fee Schedule,100% of CMS OPPS Rate,609.32,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,486.82,14,,,percent of total billed charges,14% of total billed charges,43.35,2900.97,
Clinic Cystometrogram Simple,3550630,CDM,510,RC,51725,HCPCS,Outpatient,,,1657.45,828.73,,1243.09,75,,,percent of total billed charges,75% of total billed charges,1243.09,75,,,percent of total billed charges,75% of total billed charges,202.01,100,,,Fee Schedule,100% of CMS OPPS Rate,108.62,102,,,Fee Schedule,102% of WV Medicaid Rate,333.31,165,,,Fee Schedule,165% of CMS OPPS Rate,209.36,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,580.25,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,795.77,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,996.78,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,106.49,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,202.01,100,,,Fee Schedule,100% of CMS OPPS Rate,209.36,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,232.04,14,,,percent of total billed charges,14% of total billed charges,106.49,1243.09,
Clinic Cystometrogram Complex,3550631,CDM,510,RC,51726,HCPCS,Outpatient,,,1810.53,905.27,,1357.9,75,,,percent of total billed charges,75% of total billed charges,1357.9,75,,,percent of total billed charges,75% of total billed charges,202.01,100,,,Fee Schedule,100% of CMS OPPS Rate,108.62,102,,,Fee Schedule,102% of WV Medicaid Rate,333.31,165,,,Fee Schedule,165% of CMS OPPS Rate,209.36,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,580.25,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,795.77,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,996.78,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,106.49,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,202.01,100,,,Fee Schedule,100% of CMS OPPS Rate,209.36,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,253.47,14,,,percent of total billed charges,14% of total billed charges,106.49,1357.9,
Clinic Compl Cystometrogram Void Press Stu - 51728,4305354,CDM,510,RC,51728,HCPCS,Outpatient,,,3227.64,1613.82,,2420.73,75,,,percent of total billed charges,75% of total billed charges,2420.73,75,,,percent of total billed charges,75% of total billed charges,587.91,100,,,Fee Schedule,100% of CMS OPPS Rate,219.47,102,,,Fee Schedule,102% of WV Medicaid Rate,970.06,165,,,Fee Schedule,165% of CMS OPPS Rate,609.32,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1688.72,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2315.94,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,2900.97,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,215.17,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,587.91,100,,,Fee Schedule,100% of CMS OPPS Rate,609.32,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,451.87,14,,,percent of total billed charges,14% of total billed charges,215.17,2900.97,
Clinic Complex Uroflometry - 51741,4305355,CDM,510,RC,51741,HCPCS,Outpatient,,,718.46,359.23,,538.85,75,,,percent of total billed charges,75% of total billed charges,538.85,75,,,percent of total billed charges,75% of total billed charges,136.72,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,225.6,165,,,Fee Schedule,165% of CMS OPPS Rate,141.7,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,392.73,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,538.6,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,674.65,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,136.72,100,,,Fee Schedule,100% of CMS OPPS Rate,141.7,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,100.58,14,,,percent of total billed charges,14% of total billed charges,100.58,674.65,
Clinic EMG stds Anal/Urtl Sphnctr Other/Thn Ndl -51784,4305356,CDM,510,RC,51784,HCPCS,Outpatient,,,777.65,388.83,,583.24,75,,,percent of total billed charges,75% of total billed charges,583.24,75,,,percent of total billed charges,75% of total billed charges,136.72,100,,,Fee Schedule,100% of CMS OPPS Rate,21.84,102,,,Fee Schedule,102% of WV Medicaid Rate,225.58,165,,,Fee Schedule,165% of CMS OPPS Rate,141.69,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,392.72,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,538.59,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,674.64,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,21.41,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,136.72,100,,,Fee Schedule,100% of CMS OPPS Rate,141.69,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,108.87,14,,,percent of total billed charges,14% of total billed charges,21.41,674.64,
Clinic Cystoscopy,3550628,CDM,510,RC,52000,HCPCS,Outpatient,,,3561.37,1780.69,,2671.03,75,,,percent of total billed charges,75% of total billed charges,2671.03,75,,,percent of total billed charges,75% of total billed charges,587.91,100,,,Fee Schedule,100% of CMS OPPS Rate,234.83,102,,,Fee Schedule,102% of WV Medicaid Rate,970.06,165,,,Fee Schedule,165% of CMS OPPS Rate,609.32,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1688.72,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2315.94,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,2900.97,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,230.23,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,587.91,100,,,Fee Schedule,100% of CMS OPPS Rate,609.32,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,498.59,14,,,percent of total billed charges,14% of total billed charges,230.23,2900.97,
Clinic Cystoscopy w/stent removal,3550633,CDM,510,RC,52310,HCPCS,Outpatient,,,10359.33,5179.67,,7769.5,75,,,percent of total billed charges,75% of total billed charges,7769.5,75,,,percent of total billed charges,75% of total billed charges,1743.88,100,,,Fee Schedule,100% of CMS OPPS Rate,643.69,102,,,Fee Schedule,102% of WV Medicaid Rate,2877.42,165,,,Fee Schedule,165% of CMS OPPS Rate,1807.39,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,5009.09,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,6869.58,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,8604.84,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,631.07,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1743.88,100,,,Fee Schedule,100% of CMS OPPS Rate,1807.39,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1450.31,14,,,percent of total billed charges,14% of total billed charges,631.07,8604.84,
54056- Cryosurgery/penis lesion(s),3431644,CDM,510,RC,54056,HCPCS,Outpatient,,,1154.1,577.05,,865.58,75,,,percent of total billed charges,75% of total billed charges,865.58,75,,,percent of total billed charges,75% of total billed charges,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,280.12,165,,,Fee Schedule,165% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,487.65,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,668.78,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,837.71,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,161.57,14,,,percent of total billed charges,14% of total billed charges,161.57,865.58,
Clinic Vasectomy,3550629,CDM,510,RC,55250,HCPCS,Outpatient,,,9402.54,4701.27,,7051.91,75,,,percent of total billed charges,75% of total billed charges,7051.91,75,,,percent of total billed charges,75% of total billed charges,1743.88,100,,,Fee Schedule,100% of CMS OPPS Rate,643.69,102,,,Fee Schedule,102% of WV Medicaid Rate,2877.42,165,,,Fee Schedule,165% of CMS OPPS Rate,1807.39,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,5009.09,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,6869.58,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,8604.84,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,631.07,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1743.88,100,,,Fee Schedule,100% of CMS OPPS Rate,1807.39,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1316.36,14,,,percent of total billed charges,14% of total billed charges,631.07,8604.84,
56420- Bartholin's gland abscess/I & D,3431353,CDM,510,RC,56420,HCPCS,Outpatient,,,1217.47,608.74,,913.1,75,,,percent of total billed charges,75% of total billed charges,913.1,75,,,percent of total billed charges,75% of total billed charges,167.47,100,,,Fee Schedule,100% of CMS OPPS Rate,69.54,102,,,Fee Schedule,102% of WV Medicaid Rate,276.31,165,,,Fee Schedule,165% of CMS OPPS Rate,173.56,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,481.04,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,659.7,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,826.34,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,68.18,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,167.47,100,,,Fee Schedule,100% of CMS OPPS Rate,173.56,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,170.45,14,,,percent of total billed charges,14% of total billed charges,68.18,913.1,
"56501-MA DESTROY, VULVA LESIONS",3430122,CDM,510,RC,56501,HCPCS,Outpatient,,,9474.23,4737.12,,7105.67,75,,,percent of total billed charges,75% of total billed charges,7105.67,75,,,percent of total billed charges,75% of total billed charges,1622.59,100,,,Fee Schedule,100% of CMS OPPS Rate,109.48,102,,,Fee Schedule,102% of WV Medicaid Rate,2677.27,165,,,Fee Schedule,165% of CMS OPPS Rate,1681.67,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4660.68,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,6391.75,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,8006.31,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,107.33,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1622.59,100,,,Fee Schedule,100% of CMS OPPS Rate,1681.67,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1326.39,14,,,percent of total billed charges,14% of total billed charges,107.33,8006.31,
57061-MA DESTROY VAG LESIONS,3430142,CDM,510,RC,57061,HCPCS,Outpatient,,,16016.57,8008.29,,12012.43,75,,,percent of total billed charges,75% of total billed charges,12012.43,75,,,percent of total billed charges,75% of total billed charges,2658.26,100,,,Fee Schedule,100% of CMS OPPS Rate,97.45,102,,,Fee Schedule,102% of WV Medicaid Rate,4386.13,165,,,Fee Schedule,165% of CMS OPPS Rate,2755.05,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,7635.49,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,10471.46,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13116.58,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,95.54,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2658.26,100,,,Fee Schedule,100% of CMS OPPS Rate,2755.05,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,2242.32,14,,,percent of total billed charges,14% of total billed charges,95.54,13116.58,
57100 - Bx vaginal mucosa; simple,3431363,CDM,360,RC,57100,HCPCS,Outpatient,,,266.73,133.37,,200.05,75,,,percent of total billed charges,75% of total billed charges,200.05,75,,,percent of total billed charges,75% of total billed charges,661.37,100,,,Fee Schedule,100% of CMS OPPS Rate,46.41,102,,,Fee Schedule,102% of WV Medicaid Rate,1091.26,165,,,Fee Schedule,165% of CMS OPPS Rate,685.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1899.71,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2605.3,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,3263.41,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,45.5,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,661.37,100,,,Fee Schedule,100% of CMS OPPS Rate,685.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,37.34,14,,,percent of total billed charges,14% of total billed charges,37.34,3263.41,
57454- Colposcopy/cervix/biopsy/curettage,3431388,CDM,510,RC,57454,HCPCS,Outpatient,,,1887.88,943.94,,1415.91,75,,,percent of total billed charges,75% of total billed charges,1415.91,75,,,percent of total billed charges,75% of total billed charges,274.47,100,,,Fee Schedule,100% of CMS OPPS Rate,64.15,102,,,Fee Schedule,102% of WV Medicaid Rate,452.9,165,,,Fee Schedule,165% of CMS OPPS Rate,284.48,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,788.43,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1081.27,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1354.41,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,62.89,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,274.47,100,,,Fee Schedule,100% of CMS OPPS Rate,284.48,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,264.3,14,,,percent of total billed charges,14% of total billed charges,62.89,1415.91,
57500- Biopsy/cervix/single/multiple,3431393,CDM,514,RC,57500,HCPCS,Outpatient,,,3563.5,1781.75,,2672.63,75,,,percent of total billed charges,75% of total billed charges,2672.63,75,,,percent of total billed charges,75% of total billed charges,661.37,100,,,Fee Schedule,100% of CMS OPPS Rate,90.09,102,,,Fee Schedule,102% of WV Medicaid Rate,1091.26,165,,,Fee Schedule,165% of CMS OPPS Rate,685.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1899.71,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2605.3,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,3263.41,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,88.32,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,661.37,100,,,Fee Schedule,100% of CMS OPPS Rate,685.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,498.89,14,,,percent of total billed charges,14% of total billed charges,88.32,3263.41,
58110- EMB w/colposcopy,3431399,CDM,510,RC,58110,HCPCS,Outpatient,,,370.53,185.27,,277.9,75,,,percent of total billed charges,75% of total billed charges,277.9,75,,,percent of total billed charges,75% of total billed charges,118.57,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.87,14,,,percent of total billed charges,14% of total billed charges,51.87,277.9,
Clinic Artificial Insemination/Intrauterine-58322,4311235,CDM,983,RC,58322,HCPCS,Outpatient,,,981.16,490.58,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
58340- Cath/saline/contrast/SIS/hysteosal,3431413,CDM,510,RC,58340,HCPCS,Outpatient,,,304.09,152.05,,228.07,75,,,percent of total billed charges,75% of total billed charges,228.07,75,,,percent of total billed charges,75% of total billed charges,97.31,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.57,14,,,percent of total billed charges,14% of total billed charges,42.57,228.07,
58679-MA AST LAPARO PROC OVIDUCT-OVARY,3430266,CDM,510,RC,58679,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4900.27,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,8085.46,165,,,Fee Schedule,165% of CMS OPPS Rate,5078.72,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,14075.4,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,19303.29,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,24179.33,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,4900.27,100,,,Fee Schedule,100% of CMS OPPS Rate,5078.72,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,4900.27,24179.33,
Lapt Stg/Restg Ovarian Tubal/Prim Mal 2nd Look PF,4223273,CDM,983,RC,58960,HCPCS,Outpatient,,,2089.45,1044.73,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
Clinic NST,3428544,CDM,920,RC,59025,HCPCS,Outpatient,,,1014.63,507.32,,760.97,75,,,percent of total billed charges,75% of total billed charges,760.97,75,,,percent of total billed charges,75% of total billed charges,167.47,100,,,Fee Schedule,100% of CMS OPPS Rate,15.57,102,,,Fee Schedule,102% of WV Medicaid Rate,276.31,165,,,Fee Schedule,165% of CMS OPPS Rate,173.56,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,481.04,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,659.7,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,826.34,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,15.26,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,167.47,100,,,Fee Schedule,100% of CMS OPPS Rate,173.56,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,142.05,14,,,percent of total billed charges,14% of total billed charges,15.26,826.34,
"HEPARIN ASSAY, POC",3430586,CDM,300,RC,59051,HCPCS,Outpatient,,,113.37,56.69,,85.03,75,,,percent of total billed charges,75% of total billed charges,85.03,75,,,percent of total billed charges,75% of total billed charges,36.28,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.87,14,,,percent of total billed charges,14% of total billed charges,15.87,85.03,
59412 - Antepartum Manipulation,4189312,CDM,960,RC,59412,HCPCS,Outpatient,,,221.75,110.88,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
62272- Spinal puncture/CSF drainage,3435332,CDM,510,RC,62272,HCPCS,Outpatient,,,438.7,219.35,,329.03,75,,,percent of total billed charges,75% of total billed charges,329.03,75,,,percent of total billed charges,75% of total billed charges,605.77,100,,,Fee Schedule,100% of CMS OPPS Rate,259.2,102,,,Fee Schedule,102% of WV Medicaid Rate,999.54,165,,,Fee Schedule,165% of CMS OPPS Rate,627.84,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1740.03,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2386.32,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,2989.1,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,254.12,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,605.77,100,,,Fee Schedule,100% of CMS OPPS Rate,627.84,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,61.42,14,,,percent of total billed charges,14% of total billed charges,61.42,2989.1,
62284- Inj/myelography/CT/lumbar,3435333,CDM,320,RC,62284,HCPCS,Outpatient,,,486.09,243.05,,364.57,75,,,percent of total billed charges,75% of total billed charges,364.57,75,,,percent of total billed charges,75% of total billed charges,155.55,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68.05,14,,,percent of total billed charges,14% of total billed charges,68.05,364.57,
62290- Inj/discography/ea lev/lumbar,3435334,CDM,510,RC,62290,HCPCS,Outpatient,,,902.82,451.41,,677.12,75,,,percent of total billed charges,75% of total billed charges,677.12,75,,,percent of total billed charges,75% of total billed charges,288.9,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,126.39,14,,,percent of total billed charges,14% of total billed charges,126.39,677.12,
62350- Implant intrathe/epi cath w/o lami,3435337,CDM,510,RC,62350,HCPCS,Outpatient,,,1045.35,522.68,,784.01,75,,,percent of total billed charges,75% of total billed charges,784.01,75,,,percent of total billed charges,75% of total billed charges,5808.95,100,,,Fee Schedule,100% of CMS OPPS Rate,2850.18,102,,,Fee Schedule,102% of WV Medicaid Rate,9584.77,165,,,Fee Schedule,165% of CMS OPPS Rate,6020.49,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,16685.43,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,22882.74,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,28662.96,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,2794.29,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,5808.95,100,,,Fee Schedule,100% of CMS OPPS Rate,6020.49,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,146.35,14,,,percent of total billed charges,14% of total billed charges,146.35,28662.96,
62351- Implant intrathe/epi cath/laminec,3435338,CDM,510,RC,62351,HCPCS,Outpatient,,,2414.56,1207.28,,1810.92,75,,,percent of total billed charges,75% of total billed charges,1810.92,75,,,percent of total billed charges,75% of total billed charges,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,10261.1,165,,,Fee Schedule,165% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,17862.79,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,24497.4,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,30685.48,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,338.04,14,,,percent of total billed charges,14% of total billed charges,338.04,30685.48,
62355- Rmv prev implt intrathecal/epi cat,3435339,CDM,510,RC,62355,HCPCS,Outpatient,,,707.7,353.85,,530.78,75,,,percent of total billed charges,75% of total billed charges,530.78,75,,,percent of total billed charges,75% of total billed charges,1689.96,100,,,Fee Schedule,100% of CMS OPPS Rate,650.73,102,,,Fee Schedule,102% of WV Medicaid Rate,2788.44,165,,,Fee Schedule,165% of CMS OPPS Rate,1751.5,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4854.2,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,6657.14,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,8338.75,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,637.97,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1689.96,100,,,Fee Schedule,100% of CMS OPPS Rate,1751.5,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,99.08,14,,,percent of total billed charges,14% of total billed charges,99.08,8338.75,
62362- Implant program pump/intrathe/epi,3435340,CDM,510,RC,62362,HCPCS,Outpatient,,,1011.98,505.99,,758.99,75,,,percent of total billed charges,75% of total billed charges,758.99,75,,,percent of total billed charges,75% of total billed charges,15924.96,100,,,Fee Schedule,100% of CMS OPPS Rate,11413.59,102,,,Fee Schedule,102% of WV Medicaid Rate,26276.19,165,,,Fee Schedule,165% of CMS OPPS Rate,16504.87,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,45742.29,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,62731.9,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,78578.07,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,11189.79,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,15924.96,100,,,Fee Schedule,100% of CMS OPPS Rate,16504.87,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,141.68,14,,,percent of total billed charges,14% of total billed charges,141.68,78578.07,
62365- Remove/SQ infusion reservoir/pump,3435341,CDM,510,RC,62365,HCPCS,Outpatient,,,773.57,386.79,,580.18,75,,,percent of total billed charges,75% of total billed charges,580.18,75,,,percent of total billed charges,75% of total billed charges,5808.96,100,,,Fee Schedule,100% of CMS OPPS Rate,1968.72,102,,,Fee Schedule,102% of WV Medicaid Rate,9584.78,165,,,Fee Schedule,165% of CMS OPPS Rate,6020.49,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,16685.43,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,22882.74,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,28662.96,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1930.12,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,5808.96,100,,,Fee Schedule,100% of CMS OPPS Rate,6020.49,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,108.3,14,,,percent of total billed charges,14% of total billed charges,108.3,28662.96,
62367- Analysis/implant pump/intrathe/epi,3435342,CDM,510,RC,62367,HCPCS,Outpatient,,,82.68,41.34,,62.01,75,,,percent of total billed charges,75% of total billed charges,62.01,75,,,percent of total billed charges,75% of total billed charges,260.08,100,,,Fee Schedule,100% of CMS OPPS Rate,10.65,102,,,Fee Schedule,102% of WV Medicaid Rate,429.14,165,,,Fee Schedule,165% of CMS OPPS Rate,269.56,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,747.08,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1024.57,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1283.38,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,10.44,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,260.08,100,,,Fee Schedule,100% of CMS OPPS Rate,269.56,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,11.58,14,,,percent of total billed charges,14% of total billed charges,10.44,1283.38,
62368- Reprogram/implant pump/intrath/epi,3435343,CDM,510,RC,62368,HCPCS,Outpatient,,,115.02,57.51,,86.27,75,,,percent of total billed charges,75% of total billed charges,86.27,75,,,percent of total billed charges,75% of total billed charges,260.08,100,,,Fee Schedule,100% of CMS OPPS Rate,15.01,102,,,Fee Schedule,102% of WV Medicaid Rate,429.14,165,,,Fee Schedule,165% of CMS OPPS Rate,269.56,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,747.08,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1024.57,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1283.38,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,14.72,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,260.08,100,,,Fee Schedule,100% of CMS OPPS Rate,269.56,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,16.1,14,,,percent of total billed charges,14% of total billed charges,14.72,1283.38,
62370- Refill/implant pump/intrathe/epi,3435344,CDM,510,RC,62370,HCPCS,Outpatient,,,234.39,117.2,,175.79,75,,,percent of total billed charges,75% of total billed charges,175.79,75,,,percent of total billed charges,75% of total billed charges,260.08,100,,,Fee Schedule,100% of CMS OPPS Rate,48.59,102,,,Fee Schedule,102% of WV Medicaid Rate,429.14,165,,,Fee Schedule,165% of CMS OPPS Rate,269.56,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,747.08,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1024.57,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1283.38,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,47.64,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,260.08,100,,,Fee Schedule,100% of CMS OPPS Rate,269.56,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,32.81,14,,,percent of total billed charges,14% of total billed charges,32.81,1283.38,
63012- Laminectomy/remove abnormal facets,3435345,CDM,510,RC,63012,HCPCS,Outpatient,,,3195.29,1597.65,,2396.47,75,,,percent of total billed charges,75% of total billed charges,2396.47,75,,,percent of total billed charges,75% of total billed charges,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,10261.1,165,,,Fee Schedule,165% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,17862.79,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,24497.4,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,30685.48,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,447.34,14,,,percent of total billed charges,14% of total billed charges,447.34,30685.48,
63015 - PF Laminectomy w/o FFD > 2 Vert Seg Cervical,4363325,CDM,960,RC,63015,HCPCS,Outpatient,,,3028.86,1514.43,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
63016- Laminectomy/explor/>2vert seg/cerv,3435346,CDM,510,RC,63016,HCPCS,Outpatient,,,4100.47,2050.24,,3075.35,75,,,percent of total billed charges,75% of total billed charges,3075.35,75,,,percent of total billed charges,75% of total billed charges,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,10261.1,165,,,Fee Schedule,165% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,17862.79,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,24497.4,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,30685.48,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,574.07,14,,,percent of total billed charges,14% of total billed charges,574.07,30685.48,
63020- Laminotomy/1 interspace/cervical,3435347,CDM,510,RC,63020,HCPCS,Outpatient,,,3088.03,1544.02,,2316.02,75,,,percent of total billed charges,75% of total billed charges,2316.02,75,,,percent of total billed charges,75% of total billed charges,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,2365.05,102,,,Fee Schedule,102% of WV Medicaid Rate,10261.1,165,,,Fee Schedule,165% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,17862.79,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,24497.4,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,30685.48,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,2318.68,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,432.32,14,,,percent of total billed charges,14% of total billed charges,432.32,30685.48,
63030- Laminotomy/sng interspace/lumbar,3435348,CDM,510,RC,63030,HCPCS,Outpatient,,,2589.16,1294.58,,1941.87,75,,,percent of total billed charges,75% of total billed charges,1941.87,75,,,percent of total billed charges,75% of total billed charges,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,2365.05,102,,,Fee Schedule,102% of WV Medicaid Rate,10261.1,165,,,Fee Schedule,165% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,17862.79,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,24497.4,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,30685.48,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,2318.68,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,362.48,14,,,percent of total billed charges,14% of total billed charges,362.48,30685.48,
63035- Laminotomy/add interspace/cerv/lum,3435349,CDM,510,RC,63035,HCPCS,Outpatient,,,516.23,258.12,,387.17,75,,,percent of total billed charges,75% of total billed charges,387.17,75,,,percent of total billed charges,75% of total billed charges,165.19,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72.27,14,,,percent of total billed charges,14% of total billed charges,72.27,387.17,
63040- Laminotomy/hemi/reexplor/sng/cerv,3435350,CDM,510,RC,63040,HCPCS,Outpatient,,,3694.98,1847.49,,2771.24,75,,,percent of total billed charges,75% of total billed charges,2771.24,75,,,percent of total billed charges,75% of total billed charges,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,10261.1,165,,,Fee Schedule,165% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,17862.79,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,24497.4,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,30685.48,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,517.3,14,,,percent of total billed charges,14% of total billed charges,517.3,30685.48,
63042- Laminotomy/re-explore/sng/lumbar,3435351,CDM,510,RC,63042,HCPCS,Outpatient,,,3446.9,1723.45,,2585.18,75,,,percent of total billed charges,75% of total billed charges,2585.18,75,,,percent of total billed charges,75% of total billed charges,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,10261.1,165,,,Fee Schedule,165% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,17862.79,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,24497.4,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,30685.48,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,482.57,14,,,percent of total billed charges,14% of total billed charges,482.57,30685.48,
63043- Laminotomy/hemi/reexplor/add cerv,3435352,CDM,510,RC,63043,HCPCS,Outpatient,,,726.43,363.22,,544.82,75,,,percent of total billed charges,75% of total billed charges,544.82,75,,,percent of total billed charges,75% of total billed charges,232.46,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,101.7,14,,,percent of total billed charges,14% of total billed charges,101.7,544.82,
63044- Laminotomy/addl lumbar interspace,3435353,CDM,510,RC,63044,HCPCS,Outpatient,,,726.43,363.22,,544.82,75,,,percent of total billed charges,75% of total billed charges,544.82,75,,,percent of total billed charges,75% of total billed charges,232.46,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,101.7,14,,,percent of total billed charges,14% of total billed charges,101.7,544.82,
63045 - PF Lam Facetectomy & Foramotomy 1 Crt Sgm Cervical,4363326,CDM,960,RC,63045,HCPCS,Outpatient,,,2615.82,1307.91,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
63045- Lamin/facetectomy/foraminotomy/cer,3435354,CDM,510,RC,63045,HCPCS,Outpatient,,,3445.56,1722.78,,2584.17,75,,,percent of total billed charges,75% of total billed charges,2584.17,75,,,percent of total billed charges,75% of total billed charges,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,10261.1,165,,,Fee Schedule,165% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,17862.79,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,24497.4,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,30685.48,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,482.38,14,,,percent of total billed charges,14% of total billed charges,482.38,30685.48,
63046- Lamin/facetectomy/foraminotomy/tho,3435355,CDM,510,RC,63046,HCPCS,Outpatient,,,3275.85,1637.93,,2456.89,75,,,percent of total billed charges,75% of total billed charges,2456.89,75,,,percent of total billed charges,75% of total billed charges,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,10261.1,165,,,Fee Schedule,165% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,17862.79,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,24497.4,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,30685.48,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,458.62,14,,,percent of total billed charges,14% of total billed charges,458.62,30685.48,
63047 - PF Lam Facetectomy & Foramotomy 1 Vrt Sgm Lumbar,4363327,CDM,960,RC,63047,HCPCS,Outpatient,,,2224.28,1112.14,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
63047- Laminectomy/lumbar,3435311,CDM,510,RC,63047,HCPCS,Outpatient,,,2939.76,1469.88,,2204.82,75,,,percent of total billed charges,75% of total billed charges,2204.82,75,,,percent of total billed charges,75% of total billed charges,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,10261.1,165,,,Fee Schedule,165% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,17862.79,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,24497.4,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,30685.48,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,411.57,14,,,percent of total billed charges,14% of total billed charges,411.57,30685.48,
63048 - PF Lam Facetectomy&Foramot 1 Vrt Sgm Ea Addl Sgm,4363328,CDM,960,RC,63048,HCPCS,Outpatient,,,428.22,214.11,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
63048- Laminectomy/addl seg/cerv/thor/lum,3435356,CDM,510,RC,63048,HCPCS,Outpatient,,,568.24,284.12,,426.18,75,,,percent of total billed charges,75% of total billed charges,426.18,75,,,percent of total billed charges,75% of total billed charges,181.84,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,79.55,14,,,percent of total billed charges,14% of total billed charges,79.55,426.18,
63052- PF Lam Facetec/Foramot Drg Arthrd Lumbar 1 Vrt Sgm,4363329,CDM,960,RC,63052,HCPCS,Outpatient,,,524.72,262.36,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
63053 - PF Lam Facetec/Foramot Drg Arthrd Lmbr Ea Addl Sgm,4363330,CDM,960,RC,63053,HCPCS,Outpatient,,,466.36,233.18,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
63055- Decompress spinal cord/thoracic,3435357,CDM,510,RC,63055,HCPCS,Outpatient,,,4371.25,2185.63,,3278.44,75,,,percent of total billed charges,75% of total billed charges,3278.44,75,,,percent of total billed charges,75% of total billed charges,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,10261.1,165,,,Fee Schedule,165% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,17862.79,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,24497.4,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,30685.48,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,611.98,14,,,percent of total billed charges,14% of total billed charges,611.98,30685.48,
63056- Decompress spinal cord/lumbar,3435358,CDM,510,RC,63056,HCPCS,Outpatient,,,3999.87,1999.94,,2999.9,75,,,percent of total billed charges,75% of total billed charges,2999.9,75,,,percent of total billed charges,75% of total billed charges,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,10261.1,165,,,Fee Schedule,165% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,17862.79,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,24497.4,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,30685.48,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,559.98,14,,,percent of total billed charges,14% of total billed charges,559.98,30685.48,
63057- Decomp spinal cord/transped/ad seg,3435359,CDM,510,RC,63057,HCPCS,Outpatient,,,868.01,434.01,,651.01,75,,,percent of total billed charges,75% of total billed charges,651.01,75,,,percent of total billed charges,75% of total billed charges,277.76,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,121.52,14,,,percent of total billed charges,14% of total billed charges,121.52,651.01,
63075- Discectomy/ant/cerv/sng interspace,3435360,CDM,510,RC,63075,HCPCS,Outpatient,,,3633.73,1816.87,,2725.3,75,,,percent of total billed charges,75% of total billed charges,2725.3,75,,,percent of total billed charges,75% of total billed charges,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,10261.1,165,,,Fee Schedule,165% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,17862.79,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,24497.4,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,30685.48,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,508.72,14,,,percent of total billed charges,14% of total billed charges,508.72,30685.48,
63076- Discectomy/ant/cerv/addl interspac,3435361,CDM,510,RC,63076,HCPCS,Outpatient,,,656.03,328.02,,492.02,75,,,percent of total billed charges,75% of total billed charges,492.02,75,,,percent of total billed charges,75% of total billed charges,209.93,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,91.84,14,,,percent of total billed charges,14% of total billed charges,91.84,492.02,
63081- Vertebral corpectomy/cervical,3435362,CDM,510,RC,63081,HCPCS,Outpatient,,,4713.31,2356.66,,3534.98,75,,,percent of total billed charges,75% of total billed charges,3534.98,75,,,percent of total billed charges,75% of total billed charges,4713.31,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,4713.31,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4713.31,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4713.31,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4713.31,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4713.31,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,4713.31,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4713.31,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,659.86,14,,,percent of total billed charges,14% of total billed charges,659.86,4713.31,
63082- Verteb resect/anterior/cerv/ad seg,3435363,CDM,510,RC,63082,HCPCS,Outpatient,,,714.96,357.48,,536.22,75,,,percent of total billed charges,75% of total billed charges,536.22,75,,,percent of total billed charges,75% of total billed charges,714.96,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,714.96,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,714.96,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,714.96,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,714.96,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,714.96,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,714.96,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,714.96,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,100.09,14,,,percent of total billed charges,14% of total billed charges,100.09,714.96,
63085- Vertebral corpectomy/thoracic,3435364,CDM,510,RC,63085,HCPCS,Outpatient,,,5178.43,2589.22,,3883.82,75,,,percent of total billed charges,75% of total billed charges,3883.82,75,,,percent of total billed charges,75% of total billed charges,5178.43,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,5178.43,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5178.43,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5178.43,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5178.43,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5178.43,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,5178.43,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5178.43,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,724.98,14,,,percent of total billed charges,14% of total billed charges,724.98,5178.43,
63086- Vertebral corpectomy/thoracic/addl,3435365,CDM,510,RC,63086,HCPCS,Outpatient,,,514.56,257.28,,385.92,75,,,percent of total billed charges,75% of total billed charges,385.92,75,,,percent of total billed charges,75% of total billed charges,514.56,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,514.56,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,514.56,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,514.56,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,514.56,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,514.56,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,514.56,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,514.56,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,72.04,14,,,percent of total billed charges,14% of total billed charges,72.04,514.56,
63087- Verteb corpect/low thoracic/lumbar,3435366,CDM,510,RC,63087,HCPCS,Outpatient,,,6463.48,3231.74,,4847.61,75,,,percent of total billed charges,75% of total billed charges,4847.61,75,,,percent of total billed charges,75% of total billed charges,6463.48,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,6463.48,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6463.48,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6463.48,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6463.48,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6463.48,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,6463.48,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6463.48,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,904.89,14,,,percent of total billed charges,14% of total billed charges,904.89,6463.48,
63090- Verteb corpect/low thor/lumbar/sac,3435367,CDM,510,RC,63090,HCPCS,Outpatient,,,5246.19,2623.1,,3934.64,75,,,percent of total billed charges,75% of total billed charges,3934.64,75,,,percent of total billed charges,75% of total billed charges,5246.19,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,5246.19,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5246.19,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5246.19,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5246.19,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5246.19,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,5246.19,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5246.19,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,734.47,14,,,percent of total billed charges,14% of total billed charges,734.47,5246.19,
63091- Vertebral corpect/trans peri/addl,3435368,CDM,510,RC,63091,HCPCS,Outpatient,,,477.3,238.65,,357.98,75,,,percent of total billed charges,75% of total billed charges,357.98,75,,,percent of total billed charges,75% of total billed charges,477.3,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,477.3,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,477.3,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,477.3,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,477.3,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,477.3,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,477.3,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,477.3,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,66.82,14,,,percent of total billed charges,14% of total billed charges,66.82,477.3,
"63199- Laminectomy w/cordotomy, thoracic",3435369,CDM,510,RC,63199,HCPCS,Outpatient,,,6285.11,3142.56,,4713.83,75,,,percent of total billed charges,75% of total billed charges,4713.83,75,,,percent of total billed charges,75% of total billed charges,2011.24,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,879.92,14,,,percent of total billed charges,14% of total billed charges,879.92,4713.83,
63267- Laminectomy/AV malformation/lumbar,3435370,CDM,510,RC,63267,HCPCS,Outpatient,,,3675.75,1837.88,,2756.81,75,,,percent of total billed charges,75% of total billed charges,2756.81,75,,,percent of total billed charges,75% of total billed charges,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,10261.1,165,,,Fee Schedule,165% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,17862.79,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,24497.4,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,30685.48,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,6218.84,100,,,Fee Schedule,100% of CMS OPPS Rate,6445.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,514.61,14,,,percent of total billed charges,14% of total billed charges,514.61,30685.48,
63301- Vertebral corpect/extradural/thor,3435371,CDM,510,RC,63301,HCPCS,Outpatient,,,5969.74,2984.87,,4477.31,75,,,percent of total billed charges,75% of total billed charges,4477.31,75,,,percent of total billed charges,75% of total billed charges,5969.74,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,5969.74,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5969.74,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5969.74,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5969.74,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5969.74,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,5969.74,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5969.74,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,835.76,14,,,percent of total billed charges,14% of total billed charges,835.76,5969.74,
63308- Verteb corpect/ intraspin les/addl,3435372,CDM,510,RC,63308,HCPCS,Outpatient,,,861.54,430.77,,646.16,75,,,percent of total billed charges,75% of total billed charges,646.16,75,,,percent of total billed charges,75% of total billed charges,861.54,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,861.54,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,861.54,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,861.54,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,861.54,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,861.54,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,861.54,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,861.54,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,120.62,14,,,percent of total billed charges,14% of total billed charges,120.62,861.54,
63650- Implant neurostim electrode/epidur,3435373,CDM,510,RC,63650,HCPCS,Outpatient,,,5707.03,2853.52,,4280.27,75,,,percent of total billed charges,75% of total billed charges,4280.27,75,,,percent of total billed charges,75% of total billed charges,6208.71,100,,,Fee Schedule,100% of CMS OPPS Rate,3605.01,102,,,Fee Schedule,102% of WV Medicaid Rate,10244.37,165,,,Fee Schedule,165% of CMS OPPS Rate,6434.8,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,17833.68,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,24457.48,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,30635.47,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,3534.32,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,6208.71,100,,,Fee Schedule,100% of CMS OPPS Rate,6434.8,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,798.98,14,,,percent of total billed charges,14% of total billed charges,798.98,30635.47,
63655- Laminect/implt neurostim elec/epid,3435374,CDM,510,RC,63655,HCPCS,Outpatient,,,2221.65,1110.83,,1666.24,75,,,percent of total billed charges,75% of total billed charges,1666.24,75,,,percent of total billed charges,75% of total billed charges,20228,100,,,Fee Schedule,100% of CMS OPPS Rate,13522.94,102,,,Fee Schedule,102% of WV Medicaid Rate,33376.22,165,,,Fee Schedule,165% of CMS OPPS Rate,20964.61,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,58102.21,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,79682.53,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,99810.46,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,13257.78,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,20228,100,,,Fee Schedule,100% of CMS OPPS Rate,20964.61,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,311.03,14,,,percent of total billed charges,14% of total billed charges,311.03,99810.46,
63661- Remove spinal neurostim electrode,3435312,CDM,510,RC,63661,HCPCS,Outpatient,,,1722.71,861.36,,1292.03,75,,,percent of total billed charges,75% of total billed charges,1292.03,75,,,percent of total billed charges,75% of total billed charges,1689.96,100,,,Fee Schedule,100% of CMS OPPS Rate,650.73,102,,,Fee Schedule,102% of WV Medicaid Rate,2788.44,165,,,Fee Schedule,165% of CMS OPPS Rate,1751.5,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4854.2,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,6657.14,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,8338.75,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,637.97,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1689.96,100,,,Fee Schedule,100% of CMS OPPS Rate,1751.5,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,241.18,14,,,percent of total billed charges,14% of total billed charges,241.18,8338.75,
63662- Rmv spinal neurostim/plate/paddle,3435375,CDM,510,RC,63662,HCPCS,Outpatient,,,2250.14,1125.07,,1687.61,75,,,percent of total billed charges,75% of total billed charges,1687.61,75,,,percent of total billed charges,75% of total billed charges,3053.35,100,,,Fee Schedule,100% of CMS OPPS Rate,1478.79,102,,,Fee Schedule,102% of WV Medicaid Rate,5038.03,165,,,Fee Schedule,165% of CMS OPPS Rate,3164.54,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8770.35,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,12027.84,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,15066.08,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1449.79,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,3053.35,100,,,Fee Schedule,100% of CMS OPPS Rate,3164.54,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,315.02,14,,,percent of total billed charges,14% of total billed charges,315.02,15066.08,
63663- Revise spinal neurostim electrode,3435376,CDM,510,RC,63663,HCPCS,Outpatient,,,2271.92,1135.96,,1703.94,75,,,percent of total billed charges,75% of total billed charges,1703.94,75,,,percent of total billed charges,75% of total billed charges,6208.71,100,,,Fee Schedule,100% of CMS OPPS Rate,3624.87,102,,,Fee Schedule,102% of WV Medicaid Rate,10244.37,165,,,Fee Schedule,165% of CMS OPPS Rate,6434.8,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,17833.68,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,24457.48,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,30635.47,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,3553.79,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,6208.71,100,,,Fee Schedule,100% of CMS OPPS Rate,6434.8,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,318.07,14,,,percent of total billed charges,14% of total billed charges,318.07,30635.47,
63664- Revise/spinal neurostim plate/pad,3435377,CDM,510,RC,63664,HCPCS,Outpatient,,,2343.74,1171.87,,1757.81,75,,,percent of total billed charges,75% of total billed charges,1757.81,75,,,percent of total billed charges,75% of total billed charges,11237.42,100,,,Fee Schedule,100% of CMS OPPS Rate,7320.35,102,,,Fee Schedule,102% of WV Medicaid Rate,18541.74,165,,,Fee Schedule,165% of CMS OPPS Rate,11646.62,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,32277.95,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,44266.64,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,55448.45,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,7176.81,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,11237.42,100,,,Fee Schedule,100% of CMS OPPS Rate,11646.62,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,328.12,14,,,percent of total billed charges,14% of total billed charges,328.12,55448.45,
63685- Ins/rplcmt spi npgr pocket,3435378,CDM,510,RC,63685,HCPCS,Outpatient,,,947.6,473.8,,710.7,75,,,percent of total billed charges,75% of total billed charges,710.7,75,,,percent of total billed charges,75% of total billed charges,27601.85,100,,,Fee Schedule,100% of CMS OPPS Rate,19265.3,102,,,Fee Schedule,102% of WV Medicaid Rate,45543.06,165,,,Fee Schedule,165% of CMS OPPS Rate,28606.97,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,79282.55,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,108729.69,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,136194.96,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,18887.55,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,27601.85,100,,,Fee Schedule,100% of CMS OPPS Rate,28606.97,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,132.66,14,,,percent of total billed charges,14% of total billed charges,132.66,136194.96,
63688- Rev/rmv imp spi npgr dtch cn,3435379,CDM,510,RC,63688,HCPCS,Outpatient,,,976.5,488.25,,732.38,75,,,percent of total billed charges,75% of total billed charges,732.38,75,,,percent of total billed charges,75% of total billed charges,3053.35,100,,,Fee Schedule,100% of CMS OPPS Rate,2043.11,102,,,Fee Schedule,102% of WV Medicaid Rate,5038.03,165,,,Fee Schedule,165% of CMS OPPS Rate,3164.54,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8770.35,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,12027.84,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,15066.08,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,2003.05,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,3053.35,100,,,Fee Schedule,100% of CMS OPPS Rate,3164.54,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,136.71,14,,,percent of total billed charges,14% of total billed charges,136.71,15066.08,
63709- Rpr/dural/CSF leak/laminectomy,3435380,CDM,510,RC,63709,HCPCS,Outpatient,,,2977.93,1488.97,,2233.45,75,,,percent of total billed charges,75% of total billed charges,2233.45,75,,,percent of total billed charges,75% of total billed charges,2977.93,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,2977.93,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2977.93,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2977.93,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2977.93,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2977.93,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,2977.93,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2977.93,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,416.91,14,,,percent of total billed charges,14% of total billed charges,416.91,2977.93,
63710- Dural graft/spinal,3435381,CDM,510,RC,63710,HCPCS,Outpatient,,,2885.11,1442.56,,2163.83,75,,,percent of total billed charges,75% of total billed charges,2163.83,75,,,percent of total billed charges,75% of total billed charges,2885.11,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,2885.11,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2885.11,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2885.11,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2885.11,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2885.11,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,2885.11,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2885.11,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,403.92,14,,,percent of total billed charges,14% of total billed charges,403.92,2885.11,
64400- Inj/anest/trigeminal nerve,3435382,CDM,510,RC,64400,HCPCS,Outpatient,,,283.75,141.88,,212.81,75,,,percent of total billed charges,75% of total billed charges,212.81,75,,,percent of total billed charges,75% of total billed charges,255.61,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,421.75,165,,,Fee Schedule,165% of CMS OPPS Rate,264.92,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,734.23,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1006.94,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1261.29,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,255.61,100,,,Fee Schedule,100% of CMS OPPS Rate,264.92,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,39.73,14,,,percent of total billed charges,14% of total billed charges,39.73,1261.29,
64402- Inj/anest/facial nerve,3435383,CDM,510,RC,64402,HCPCS,Outpatient,,,384.64,192.32,,288.48,75,,,percent of total billed charges,75% of total billed charges,288.48,75,,,percent of total billed charges,75% of total billed charges,123.08,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.85,14,,,percent of total billed charges,14% of total billed charges,53.85,288.48,
64418- Inj/anest/suprascapular nerve,3435385,CDM,510,RC,64418,HCPCS,Outpatient,,,225.01,112.51,,168.76,75,,,percent of total billed charges,75% of total billed charges,168.76,75,,,percent of total billed charges,75% of total billed charges,605.77,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,999.54,165,,,Fee Schedule,165% of CMS OPPS Rate,627.84,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1740.03,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2386.32,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,2989.1,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,605.77,100,,,Fee Schedule,100% of CMS OPPS Rate,627.84,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,31.5,14,,,percent of total billed charges,14% of total billed charges,31.5,2989.1,
64420 N block inj intercost sng,3428325,CDM,983,RC,64420,HCPCS,Outpatient,,,246.55,123.28,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
64421- Inj/anesth/intercostal nerves/mult,3435386,CDM,510,RC,64421,HCPCS,Outpatient,,,85.47,42.74,,64.1,75,,,percent of total billed charges,75% of total billed charges,64.1,75,,,percent of total billed charges,75% of total billed charges,801.18,100,,,Fee Schedule,100% of CMS OPPS Rate,336.02,102,,,Fee Schedule,102% of WV Medicaid Rate,1321.95,165,,,Fee Schedule,165% of CMS OPPS Rate,830.35,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,2301.31,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,3156.06,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,3953.29,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,329.43,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,801.18,100,,,Fee Schedule,100% of CMS OPPS Rate,830.35,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,11.97,14,,,percent of total billed charges,14% of total billed charges,11.97,3953.29,
64430- Pudendal nerve block,3435388,CDM,510,RC,64430,HCPCS,Outpatient,,,248.64,124.32,,186.48,75,,,percent of total billed charges,75% of total billed charges,186.48,75,,,percent of total billed charges,75% of total billed charges,801.18,100,,,Fee Schedule,100% of CMS OPPS Rate,336.02,102,,,Fee Schedule,102% of WV Medicaid Rate,1321.95,165,,,Fee Schedule,165% of CMS OPPS Rate,830.35,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,2301.31,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,3156.06,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,3953.29,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,329.43,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,801.18,100,,,Fee Schedule,100% of CMS OPPS Rate,830.35,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,34.81,14,,,percent of total billed charges,14% of total billed charges,34.81,3953.29,
64435- Inj/anest/paracervical nerve,3435389,CDM,510,RC,64435,HCPCS,Outpatient,,,204.32,102.16,,153.24,75,,,percent of total billed charges,75% of total billed charges,153.24,75,,,percent of total billed charges,75% of total billed charges,605.77,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,999.54,165,,,Fee Schedule,165% of CMS OPPS Rate,627.84,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1740.03,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2386.32,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,2989.1,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,605.77,100,,,Fee Schedule,100% of CMS OPPS Rate,627.84,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,28.6,14,,,percent of total billed charges,14% of total billed charges,28.6,2989.1,
64445 N block inj sciatic sng,3428326,CDM,983,RC,64445,HCPCS,Outpatient,,,313.09,156.55,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
64449- Inj/anesth/lumbar plex/cont infuse,3435390,CDM,510,RC,64449,HCPCS,Outpatient,,,162.17,81.09,,121.63,75,,,percent of total billed charges,75% of total billed charges,121.63,75,,,percent of total billed charges,75% of total billed charges,801.18,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1321.95,165,,,Fee Schedule,165% of CMS OPPS Rate,830.35,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,2301.31,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,3156.06,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,3953.29,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,801.18,100,,,Fee Schedule,100% of CMS OPPS Rate,830.35,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,22.7,14,,,percent of total billed charges,14% of total billed charges,22.7,3953.29,
64455- Inj/plantar common digital nerve,3435392,CDM,510,RC,64455,HCPCS,Outpatient,,,128.08,64.04,,96.06,75,,,percent of total billed charges,75% of total billed charges,96.06,75,,,percent of total billed charges,75% of total billed charges,255.61,100,,,Fee Schedule,100% of CMS OPPS Rate,17.75,102,,,Fee Schedule,102% of WV Medicaid Rate,421.75,165,,,Fee Schedule,165% of CMS OPPS Rate,264.92,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,734.23,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1006.94,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1261.29,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,17.4,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,255.61,100,,,Fee Schedule,100% of CMS OPPS Rate,264.92,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,17.93,14,,,percent of total billed charges,14% of total billed charges,17.4,1261.29,
64479- Epidural/cervical/thoracic w/image,3435393,CDM,510,RC,64479,HCPCS,Outpatient,,,668.5,334.25,,501.38,75,,,percent of total billed charges,75% of total billed charges,501.38,75,,,percent of total billed charges,75% of total billed charges,801.18,100,,,Fee Schedule,100% of CMS OPPS Rate,336.02,102,,,Fee Schedule,102% of WV Medicaid Rate,1321.95,165,,,Fee Schedule,165% of CMS OPPS Rate,830.35,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,2301.31,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,3156.06,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,3953.29,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,329.43,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,801.18,100,,,Fee Schedule,100% of CMS OPPS Rate,830.35,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,93.59,14,,,percent of total billed charges,14% of total billed charges,93.59,3953.29,
64480- Transforamin epi/cer/thor/ad level,3435394,CDM,510,RC,64480,HCPCS,Outpatient,,,339.71,169.86,,254.78,75,,,percent of total billed charges,75% of total billed charges,254.78,75,,,percent of total billed charges,75% of total billed charges,108.71,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.56,14,,,percent of total billed charges,14% of total billed charges,47.56,254.78,
64483- Inj/anes/steroid/lumbar/sacral/sng,3435313,CDM,360,RC,64483,HCPCS,Outpatient,,,618.25,309.13,,463.69,75,,,percent of total billed charges,75% of total billed charges,463.69,75,,,percent of total billed charges,75% of total billed charges,801.18,100,,,Fee Schedule,100% of CMS OPPS Rate,336.02,102,,,Fee Schedule,102% of WV Medicaid Rate,1321.95,165,,,Fee Schedule,165% of CMS OPPS Rate,830.35,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,2301.31,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,3156.06,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,3953.29,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,329.43,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,801.18,100,,,Fee Schedule,100% of CMS OPPS Rate,830.35,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,86.56,14,,,percent of total billed charges,14% of total billed charges,86.56,3953.29,
64484- Epidural/lumbar/sacral/ea add leve,3435395,CDM,360,RC,64484,HCPCS,Outpatient,,,282.29,141.15,,211.72,75,,,percent of total billed charges,75% of total billed charges,211.72,75,,,percent of total billed charges,75% of total billed charges,90.33,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.52,14,,,percent of total billed charges,14% of total billed charges,39.52,211.72,
64490- Inj/PV facet joint/cerv/thor/1 lev,3435396,CDM,360,RC,64490,HCPCS,Outpatient,,,480.12,240.06,,360.09,75,,,percent of total billed charges,75% of total billed charges,360.09,75,,,percent of total billed charges,75% of total billed charges,801.18,100,,,Fee Schedule,100% of CMS OPPS Rate,336.02,102,,,Fee Schedule,102% of WV Medicaid Rate,1321.95,165,,,Fee Schedule,165% of CMS OPPS Rate,830.35,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,2301.31,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,3156.06,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,3953.29,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,329.43,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,801.18,100,,,Fee Schedule,100% of CMS OPPS Rate,830.35,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,67.22,14,,,percent of total billed charges,14% of total billed charges,67.22,3953.29,
64491- Inj/PV facet joint/cerv/thor/2 lev,3435397,CDM,360,RC,64491,HCPCS,Outpatient,,,245.22,122.61,,183.92,75,,,percent of total billed charges,75% of total billed charges,183.92,75,,,percent of total billed charges,75% of total billed charges,78.47,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.33,14,,,percent of total billed charges,14% of total billed charges,34.33,183.92,
64492- Inj/PV facet joint/cerv/thor/3 lev,3435398,CDM,360,RC,64492,HCPCS,Outpatient,,,246.02,123.01,,184.52,75,,,percent of total billed charges,75% of total billed charges,184.52,75,,,percent of total billed charges,75% of total billed charges,78.73,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.44,14,,,percent of total billed charges,14% of total billed charges,34.44,184.52,
64493- Inj/paravert facet/lumb/sacr/1 lev,3435399,CDM,360,RC,64493,HCPCS,Outpatient,,,436.42,218.21,,327.32,75,,,percent of total billed charges,75% of total billed charges,327.32,75,,,percent of total billed charges,75% of total billed charges,801.18,100,,,Fee Schedule,100% of CMS OPPS Rate,336.02,102,,,Fee Schedule,102% of WV Medicaid Rate,1321.95,165,,,Fee Schedule,165% of CMS OPPS Rate,830.35,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,2301.31,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,3156.06,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,3953.29,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,329.43,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,801.18,100,,,Fee Schedule,100% of CMS OPPS Rate,830.35,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,61.1,14,,,percent of total billed charges,14% of total billed charges,61.1,3953.29,
64494- Inj/paravert facet/lumb/sacr/2 lev,3435400,CDM,360,RC,64494,HCPCS,Outpatient,,,229.39,114.7,,172.04,75,,,percent of total billed charges,75% of total billed charges,172.04,75,,,percent of total billed charges,75% of total billed charges,73.4,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.11,14,,,percent of total billed charges,14% of total billed charges,32.11,172.04,
64495- Inj/paravert facet/lumb/sacr/3 lev,3435401,CDM,360,RC,64495,HCPCS,Outpatient,,,228.6,114.3,,171.45,75,,,percent of total billed charges,75% of total billed charges,171.45,75,,,percent of total billed charges,75% of total billed charges,73.15,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32,14,,,percent of total billed charges,14% of total billed charges,32,171.45,
64505- Inj/anest/sphenopalatine ganglion,3435402,CDM,510,RC,64505,HCPCS,Outpatient,,,364,182,,273,75,,,percent of total billed charges,75% of total billed charges,273,75,,,percent of total billed charges,75% of total billed charges,255.61,100,,,Fee Schedule,100% of CMS OPPS Rate,69.62,102,,,Fee Schedule,102% of WV Medicaid Rate,421.75,165,,,Fee Schedule,165% of CMS OPPS Rate,264.92,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,734.23,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1006.94,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1261.29,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,68.25,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,255.61,100,,,Fee Schedule,100% of CMS OPPS Rate,264.92,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,50.96,14,,,percent of total billed charges,14% of total billed charges,50.96,1261.29,
64510- Inj/anest/stellate ganglion,3435403,CDM,510,RC,64510,HCPCS,Outpatient,,,366.83,183.42,,275.12,75,,,percent of total billed charges,75% of total billed charges,275.12,75,,,percent of total billed charges,75% of total billed charges,801.18,100,,,Fee Schedule,100% of CMS OPPS Rate,336.02,102,,,Fee Schedule,102% of WV Medicaid Rate,1321.95,165,,,Fee Schedule,165% of CMS OPPS Rate,830.35,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,2301.31,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,3156.06,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,3953.29,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,329.43,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,801.18,100,,,Fee Schedule,100% of CMS OPPS Rate,830.35,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,51.36,14,,,percent of total billed charges,14% of total billed charges,51.36,3953.29,
64561(50) Percutaneous neurostimulator,3623710,CDM,510,RC,64561,HCPCS,Outpatient,,,706.19,353.1,,529.64,75,,,percent of total billed charges,75% of total billed charges,529.64,75,,,percent of total billed charges,75% of total billed charges,6208.71,100,,,Fee Schedule,100% of CMS OPPS Rate,3685.66,102,,,Fee Schedule,102% of WV Medicaid Rate,10244.37,165,,,Fee Schedule,165% of CMS OPPS Rate,6434.8,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,17833.68,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,24457.48,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,30635.47,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,3613.39,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,6208.71,100,,,Fee Schedule,100% of CMS OPPS Rate,6434.8,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,98.87,14,,,percent of total billed charges,14% of total billed charges,98.87,30635.47,
Clinic PNE,3550634,CDM,510,RC,64561,HCPCS,Outpatient,,,32716.57,16358.29,,24537.43,75,,,percent of total billed charges,75% of total billed charges,24537.43,75,,,percent of total billed charges,75% of total billed charges,6208.71,100,,,Fee Schedule,100% of CMS OPPS Rate,3685.66,102,,,Fee Schedule,102% of WV Medicaid Rate,10244.37,165,,,Fee Schedule,165% of CMS OPPS Rate,6434.8,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,17833.68,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,24457.48,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,30635.47,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,3613.39,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,6208.71,100,,,Fee Schedule,100% of CMS OPPS Rate,6434.8,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4580.32,14,,,percent of total billed charges,14% of total billed charges,3613.39,30635.47,
64566- Post tib/neurostim/needle electrod,3435404,CDM,510,RC,64566,HCPCS,Outpatient,,,293.34,146.67,,220.01,75,,,percent of total billed charges,75% of total billed charges,220.01,75,,,percent of total billed charges,75% of total billed charges,255.61,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,421.75,165,,,Fee Schedule,165% of CMS OPPS Rate,264.92,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,734.23,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1006.94,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1261.29,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,255.61,100,,,Fee Schedule,100% of CMS OPPS Rate,264.92,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,41.07,14,,,percent of total billed charges,14% of total billed charges,41.07,1261.29,
"64568 - Incision for implantation of cranial nerve (eg, vagus nerve) neurostimulator electrode array",3572814,CDM,960,RC,64568,HCPCS,Outpatient,,,1615.07,807.54,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
64569 - Revise/Replcmt Neurostimulato Elctrd Cranial NRV,3899070,CDM,983,RC,64569,HCPCS,Outpatient,,,2055.51,1027.76,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
64600- Destruct/trigem nerv/inf alveolar,3435408,CDM,510,RC,64600,HCPCS,Outpatient,,,1166.52,583.26,,874.89,75,,,percent of total billed charges,75% of total billed charges,874.89,75,,,percent of total billed charges,75% of total billed charges,801.18,100,,,Fee Schedule,100% of CMS OPPS Rate,336.02,102,,,Fee Schedule,102% of WV Medicaid Rate,1321.95,165,,,Fee Schedule,165% of CMS OPPS Rate,830.35,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,2301.31,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,3156.06,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,3953.29,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,329.43,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,801.18,100,,,Fee Schedule,100% of CMS OPPS Rate,830.35,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,163.31,14,,,percent of total billed charges,14% of total billed charges,163.31,3953.29,
64612- Chemodenerv/facial nerv musc/uni,3435409,CDM,510,RC,64612,HCPCS,Outpatient,,,1734.39,867.2,,1300.79,75,,,percent of total billed charges,75% of total billed charges,1300.79,75,,,percent of total billed charges,75% of total billed charges,255.61,100,,,Fee Schedule,100% of CMS OPPS Rate,63.88,102,,,Fee Schedule,102% of WV Medicaid Rate,421.75,165,,,Fee Schedule,165% of CMS OPPS Rate,264.92,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,734.23,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1006.94,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1261.29,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,62.63,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,255.61,100,,,Fee Schedule,100% of CMS OPPS Rate,264.92,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,242.81,14,,,percent of total billed charges,14% of total billed charges,62.63,1300.79,
64612-OCC Chemodenerv/facial nerv musc/uni,3536974,CDM,983,RC,64612,HCPCS,Outpatient,,,1734.39,867.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
64615- Chemodenerv/fac/trigem/cerv spine,3435412,CDM,510,RC,64615,HCPCS,Outpatient,,,405.4,202.7,,304.05,75,,,percent of total billed charges,75% of total billed charges,304.05,75,,,percent of total billed charges,75% of total billed charges,255.61,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,421.75,165,,,Fee Schedule,165% of CMS OPPS Rate,264.92,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,734.23,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1006.94,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1261.29,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,255.61,100,,,Fee Schedule,100% of CMS OPPS Rate,264.92,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,56.76,14,,,percent of total billed charges,14% of total billed charges,56.76,1261.29,
64616- Chemodenerv/neck/unilateral,3435413,CDM,510,RC,64616,HCPCS,Outpatient,,,359.38,179.69,,269.54,75,,,percent of total billed charges,75% of total billed charges,269.54,75,,,percent of total billed charges,75% of total billed charges,255.61,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,421.75,165,,,Fee Schedule,165% of CMS OPPS Rate,264.92,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,734.23,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1006.94,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1261.29,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,255.61,100,,,Fee Schedule,100% of CMS OPPS Rate,264.92,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,50.31,14,,,percent of total billed charges,14% of total billed charges,50.31,1261.29,
64632- Inj neurolytic/plantar com dig ner,3435416,CDM,510,RC,64632,HCPCS,Outpatient,,,229.24,114.62,,171.93,75,,,percent of total billed charges,75% of total billed charges,171.93,75,,,percent of total billed charges,75% of total billed charges,255.61,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,421.75,165,,,Fee Schedule,165% of CMS OPPS Rate,264.92,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,734.23,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1006.94,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1261.29,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,255.61,100,,,Fee Schedule,100% of CMS OPPS Rate,264.92,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,32.09,14,,,percent of total billed charges,14% of total billed charges,32.09,1261.29,
64633- Neurolytic agent/cerv/thor sng jt,3435417,CDM,510,RC,64633,HCPCS,Outpatient,,,1100.75,550.38,,825.56,75,,,percent of total billed charges,75% of total billed charges,825.56,75,,,percent of total billed charges,75% of total billed charges,1689.96,100,,,Fee Schedule,100% of CMS OPPS Rate,650.73,102,,,Fee Schedule,102% of WV Medicaid Rate,2788.43,165,,,Fee Schedule,165% of CMS OPPS Rate,1751.5,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4854.2,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,6657.14,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,8338.75,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,637.97,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1689.96,100,,,Fee Schedule,100% of CMS OPPS Rate,1751.5,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,154.11,14,,,percent of total billed charges,14% of total billed charges,154.11,8338.75,
64634- Destruct/cerv/thor/addl facet jnt,3435418,CDM,510,RC,64634,HCPCS,Outpatient,,,640.85,320.43,,480.64,75,,,percent of total billed charges,75% of total billed charges,480.64,75,,,percent of total billed charges,75% of total billed charges,205.07,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,89.72,14,,,percent of total billed charges,14% of total billed charges,89.72,480.64,
64635- Destruct/lum/sacral/sng facet jnt,3435419,CDM,360,RC,64635,HCPCS,Outpatient,,,1109.9,554.95,,832.43,75,,,percent of total billed charges,75% of total billed charges,832.43,75,,,percent of total billed charges,75% of total billed charges,1689.96,100,,,Fee Schedule,100% of CMS OPPS Rate,650.73,102,,,Fee Schedule,102% of WV Medicaid Rate,2788.43,165,,,Fee Schedule,165% of CMS OPPS Rate,1751.5,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4854.2,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,6657.14,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,8338.75,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,637.97,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1689.96,100,,,Fee Schedule,100% of CMS OPPS Rate,1751.5,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,155.39,14,,,percent of total billed charges,14% of total billed charges,155.39,8338.75,
64636- Neurolyt agent/lumb/sac/ea add jt,3435420,CDM,360,RC,64636,HCPCS,Outpatient,,,603.69,301.85,,452.77,75,,,percent of total billed charges,75% of total billed charges,452.77,75,,,percent of total billed charges,75% of total billed charges,193.18,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,84.52,14,,,percent of total billed charges,14% of total billed charges,84.52,452.77,
64640- Destruct/other periph nerve/branch,3435421,CDM,360,RC,64640,HCPCS,Outpatient,,,618.83,309.42,,464.12,75,,,percent of total billed charges,75% of total billed charges,464.12,75,,,percent of total billed charges,75% of total billed charges,801.18,100,,,Fee Schedule,100% of CMS OPPS Rate,143.32,102,,,Fee Schedule,102% of WV Medicaid Rate,1321.95,165,,,Fee Schedule,165% of CMS OPPS Rate,830.35,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,2301.31,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,3156.06,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,3953.29,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,140.51,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,801.18,100,,,Fee Schedule,100% of CMS OPPS Rate,830.35,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,86.64,14,,,percent of total billed charges,14% of total billed charges,86.64,3953.29,
64642- Chemodenerv/1 extrem/1-4 musc,3435422,CDM,510,RC,64642,HCPCS,Outpatient,,,390.68,195.34,,293.01,75,,,percent of total billed charges,75% of total billed charges,293.01,75,,,percent of total billed charges,75% of total billed charges,605.77,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,999.54,165,,,Fee Schedule,165% of CMS OPPS Rate,627.84,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1740.03,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2386.32,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,2989.1,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,605.77,100,,,Fee Schedule,100% of CMS OPPS Rate,627.84,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,54.7,14,,,percent of total billed charges,14% of total billed charges,54.7,2989.1,
64643- Chemodenerv/addl extrem/1-4 musc,3435423,CDM,510,RC,64643,HCPCS,Outpatient,,,242.96,121.48,,182.22,75,,,percent of total billed charges,75% of total billed charges,182.22,75,,,percent of total billed charges,75% of total billed charges,77.75,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.01,14,,,percent of total billed charges,14% of total billed charges,34.01,182.22,
64644- Chemodenerv/1 extrem/5/> musc,3435424,CDM,510,RC,64644,HCPCS,Outpatient,,,455.6,227.8,,341.7,75,,,percent of total billed charges,75% of total billed charges,341.7,75,,,percent of total billed charges,75% of total billed charges,605.77,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,999.54,165,,,Fee Schedule,165% of CMS OPPS Rate,627.84,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1740.03,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2386.32,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,2989.1,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,605.77,100,,,Fee Schedule,100% of CMS OPPS Rate,627.84,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,63.78,14,,,percent of total billed charges,14% of total billed charges,63.78,2989.1,
64645- Chemodenerv/addl extrem/5/> musc,3435425,CDM,510,RC,64645,HCPCS,Outpatient,,,313.22,156.61,,234.92,75,,,percent of total billed charges,75% of total billed charges,234.92,75,,,percent of total billed charges,75% of total billed charges,100.23,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.85,14,,,percent of total billed charges,14% of total billed charges,43.85,234.92,
64646- Chemodenerv/trunk muscles/1-5,3435426,CDM,510,RC,64646,HCPCS,Outpatient,,,408.9,204.45,,306.68,75,,,percent of total billed charges,75% of total billed charges,306.68,75,,,percent of total billed charges,75% of total billed charges,605.77,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,999.54,165,,,Fee Schedule,165% of CMS OPPS Rate,627.84,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1740.03,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2386.32,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,2989.1,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,605.77,100,,,Fee Schedule,100% of CMS OPPS Rate,627.84,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,57.25,14,,,percent of total billed charges,14% of total billed charges,57.25,2989.1,
64647- Chemodenerv/trunk muscles/6/>,3435427,CDM,510,RC,64647,HCPCS,Outpatient,,,471.8,235.9,,353.85,75,,,percent of total billed charges,75% of total billed charges,353.85,75,,,percent of total billed charges,75% of total billed charges,605.77,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,999.54,165,,,Fee Schedule,165% of CMS OPPS Rate,627.84,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1740.03,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2386.32,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,2989.1,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,605.77,100,,,Fee Schedule,100% of CMS OPPS Rate,627.84,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,66.05,14,,,percent of total billed charges,14% of total billed charges,66.05,2989.1,
64650- Chemodenerv/eccrine gland/both ax,3435428,CDM,510,RC,64650,HCPCS,Outpatient,,,221.04,110.52,,165.78,75,,,percent of total billed charges,75% of total billed charges,165.78,75,,,percent of total billed charges,75% of total billed charges,255.61,100,,,Fee Schedule,100% of CMS OPPS Rate,49.96,102,,,Fee Schedule,102% of WV Medicaid Rate,421.75,165,,,Fee Schedule,165% of CMS OPPS Rate,264.92,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,734.23,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1006.94,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1261.29,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,48.98,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,255.61,100,,,Fee Schedule,100% of CMS OPPS Rate,264.92,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,30.95,14,,,percent of total billed charges,14% of total billed charges,30.95,1261.29,
64680- Inj neurolytic/celiac plexus,3435429,CDM,510,RC,64680,HCPCS,Outpatient,,,876.55,438.28,,657.41,75,,,percent of total billed charges,75% of total billed charges,657.41,75,,,percent of total billed charges,75% of total billed charges,801.18,100,,,Fee Schedule,100% of CMS OPPS Rate,336.02,102,,,Fee Schedule,102% of WV Medicaid Rate,1321.95,165,,,Fee Schedule,165% of CMS OPPS Rate,830.35,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,2301.31,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,3156.06,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,3953.29,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,329.43,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,801.18,100,,,Fee Schedule,100% of CMS OPPS Rate,830.35,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,122.72,14,,,percent of total billed charges,14% of total billed charges,122.72,3953.29,
64704- Neuroplasty/hand/foot nerve,3435430,CDM,510,RC,64704,HCPCS,Outpatient,,,835.27,417.64,,626.45,75,,,percent of total billed charges,75% of total billed charges,626.45,75,,,percent of total billed charges,75% of total billed charges,1689.96,100,,,Fee Schedule,100% of CMS OPPS Rate,650.73,102,,,Fee Schedule,102% of WV Medicaid Rate,2788.43,165,,,Fee Schedule,165% of CMS OPPS Rate,1751.5,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4854.2,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,6657.14,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,8338.75,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,637.97,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1689.96,100,,,Fee Schedule,100% of CMS OPPS Rate,1751.5,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,116.94,14,,,percent of total billed charges,14% of total billed charges,116.94,8338.75,
64718- Neuroplasty/ulnar nerve/elbow,3435431,CDM,510,RC,64718,HCPCS,Outpatient,,,1550.18,775.09,,1162.64,75,,,percent of total billed charges,75% of total billed charges,1162.64,75,,,percent of total billed charges,75% of total billed charges,1689.96,100,,,Fee Schedule,100% of CMS OPPS Rate,650.73,102,,,Fee Schedule,102% of WV Medicaid Rate,2788.43,165,,,Fee Schedule,165% of CMS OPPS Rate,1751.5,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4854.2,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,6657.14,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,8338.75,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,637.97,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1689.96,100,,,Fee Schedule,100% of CMS OPPS Rate,1751.5,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,217.03,14,,,percent of total billed charges,14% of total billed charges,217.03,8338.75,
64719- Neuroplasty/ulnar nerve at wrist,3435432,CDM,510,RC,64719,HCPCS,Outpatient,,,1051.68,525.84,,788.76,75,,,percent of total billed charges,75% of total billed charges,788.76,75,,,percent of total billed charges,75% of total billed charges,1689.96,100,,,Fee Schedule,100% of CMS OPPS Rate,650.73,102,,,Fee Schedule,102% of WV Medicaid Rate,2788.43,165,,,Fee Schedule,165% of CMS OPPS Rate,1751.5,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4854.2,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,6657.14,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,8338.75,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,637.97,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1689.96,100,,,Fee Schedule,100% of CMS OPPS Rate,1751.5,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,147.24,14,,,percent of total billed charges,14% of total billed charges,147.24,8338.75,
64721- Carpal tunnel surgery,3435433,CDM,510,RC,64721,HCPCS,Outpatient,,,1139.79,569.9,,854.84,75,,,percent of total billed charges,75% of total billed charges,854.84,75,,,percent of total billed charges,75% of total billed charges,1689.96,100,,,Fee Schedule,100% of CMS OPPS Rate,650.73,102,,,Fee Schedule,102% of WV Medicaid Rate,2788.43,165,,,Fee Schedule,165% of CMS OPPS Rate,1751.5,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4854.2,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,6657.14,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,8338.75,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,637.97,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1689.96,100,,,Fee Schedule,100% of CMS OPPS Rate,1751.5,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,159.57,14,,,percent of total billed charges,14% of total billed charges,159.57,8338.75,
64726- Decompression/plantar dig nerve,3435434,CDM,510,RC,64726,HCPCS,Outpatient,,,694.49,347.25,,520.87,75,,,percent of total billed charges,75% of total billed charges,520.87,75,,,percent of total billed charges,75% of total billed charges,1689.96,100,,,Fee Schedule,100% of CMS OPPS Rate,650.73,102,,,Fee Schedule,102% of WV Medicaid Rate,2788.43,165,,,Fee Schedule,165% of CMS OPPS Rate,1751.5,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4854.2,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,6657.14,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,8338.75,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,637.97,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1689.96,100,,,Fee Schedule,100% of CMS OPPS Rate,1751.5,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,97.23,14,,,percent of total billed charges,14% of total billed charges,97.23,8338.75,
64772- Transect/spinal nerve/extradural,3435435,CDM,510,RC,64772,HCPCS,Outpatient,,,1465.98,732.99,,1099.49,75,,,percent of total billed charges,75% of total billed charges,1099.49,75,,,percent of total billed charges,75% of total billed charges,1689.96,100,,,Fee Schedule,100% of CMS OPPS Rate,650.73,102,,,Fee Schedule,102% of WV Medicaid Rate,2788.43,165,,,Fee Schedule,165% of CMS OPPS Rate,1751.5,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4854.2,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,6657.14,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,8338.75,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,637.97,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1689.96,100,,,Fee Schedule,100% of CMS OPPS Rate,1751.5,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,205.24,14,,,percent of total billed charges,14% of total billed charges,205.24,8338.75,
64774- Exc neuroma/cutaneous nerve,3435436,CDM,510,RC,64774,HCPCS,Outpatient,,,1086.66,543.33,,815,75,,,percent of total billed charges,75% of total billed charges,815,75,,,percent of total billed charges,75% of total billed charges,1689.96,100,,,Fee Schedule,100% of CMS OPPS Rate,650.73,102,,,Fee Schedule,102% of WV Medicaid Rate,2788.43,165,,,Fee Schedule,165% of CMS OPPS Rate,1751.5,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4854.2,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,6657.14,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,8338.75,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,637.97,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1689.96,100,,,Fee Schedule,100% of CMS OPPS Rate,1751.5,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,152.13,14,,,percent of total billed charges,14% of total billed charges,152.13,8338.75,
64782- Exc neuroma/hand/foot/exc dig nerv,3435437,CDM,510,RC,64782,HCPCS,Outpatient,,,1184.86,592.43,,888.65,75,,,percent of total billed charges,75% of total billed charges,888.65,75,,,percent of total billed charges,75% of total billed charges,1689.96,100,,,Fee Schedule,100% of CMS OPPS Rate,650.73,102,,,Fee Schedule,102% of WV Medicaid Rate,2788.43,165,,,Fee Schedule,165% of CMS OPPS Rate,1751.5,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4854.2,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,6657.14,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,8338.75,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,637.97,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1689.96,100,,,Fee Schedule,100% of CMS OPPS Rate,1751.5,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,165.88,14,,,percent of total billed charges,14% of total billed charges,165.88,8338.75,
64784- Exc neuroma/major peripheral nerve,3435438,CDM,510,RC,64784,HCPCS,Outpatient,,,1905.65,952.83,,1429.24,75,,,percent of total billed charges,75% of total billed charges,1429.24,75,,,percent of total billed charges,75% of total billed charges,1689.96,100,,,Fee Schedule,100% of CMS OPPS Rate,650.73,102,,,Fee Schedule,102% of WV Medicaid Rate,2788.43,165,,,Fee Schedule,165% of CMS OPPS Rate,1751.5,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4854.2,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,6657.14,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,8338.75,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,637.97,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1689.96,100,,,Fee Schedule,100% of CMS OPPS Rate,1751.5,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,266.79,14,,,percent of total billed charges,14% of total billed charges,266.79,8338.75,
64787- Implant nerve end into bone/muscle,3435439,CDM,510,RC,64787,HCPCS,Outpatient,,,632.41,316.21,,474.31,75,,,percent of total billed charges,75% of total billed charges,474.31,75,,,percent of total billed charges,75% of total billed charges,202.37,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,88.54,14,,,percent of total billed charges,14% of total billed charges,88.54,474.31,
64831- Suture/1 digital nerve/hand/foot,3435440,CDM,510,RC,64831,HCPCS,Outpatient,,,1796.03,898.02,,1347.02,75,,,percent of total billed charges,75% of total billed charges,1347.02,75,,,percent of total billed charges,75% of total billed charges,1689.96,100,,,Fee Schedule,100% of CMS OPPS Rate,650.73,102,,,Fee Schedule,102% of WV Medicaid Rate,2788.43,165,,,Fee Schedule,165% of CMS OPPS Rate,1751.5,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4854.2,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,6657.14,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,8338.75,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,637.97,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1689.96,100,,,Fee Schedule,100% of CMS OPPS Rate,1751.5,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,251.44,14,,,percent of total billed charges,14% of total billed charges,251.44,8338.75,
64832- Suture/digital nerve/hand/foot/add,3435441,CDM,510,RC,64832,HCPCS,Outpatient,,,877.82,438.91,,658.37,75,,,percent of total billed charges,75% of total billed charges,658.37,75,,,percent of total billed charges,75% of total billed charges,280.9,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,122.89,14,,,percent of total billed charges,14% of total billed charges,122.89,658.37,
64835- Suture 1 nerve/median motor thenar,3435442,CDM,510,RC,64835,HCPCS,Outpatient,,,2141.61,1070.81,,1606.21,75,,,percent of total billed charges,75% of total billed charges,1606.21,75,,,percent of total billed charges,75% of total billed charges,5808.95,100,,,Fee Schedule,100% of CMS OPPS Rate,1968.72,102,,,Fee Schedule,102% of WV Medicaid Rate,9584.77,165,,,Fee Schedule,165% of CMS OPPS Rate,6020.49,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,16685.43,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,22882.74,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,28662.96,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1930.12,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,5808.95,100,,,Fee Schedule,100% of CMS OPPS Rate,6020.49,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,299.83,14,,,percent of total billed charges,14% of total billed charges,299.83,28662.96,
64857- Suture/maj perpheral nerve/arm/leg,3435443,CDM,510,RC,64857,HCPCS,Outpatient,,,2770.01,1385.01,,2077.51,75,,,percent of total billed charges,75% of total billed charges,2077.51,75,,,percent of total billed charges,75% of total billed charges,5808.95,100,,,Fee Schedule,100% of CMS OPPS Rate,1968.72,102,,,Fee Schedule,102% of WV Medicaid Rate,9584.77,165,,,Fee Schedule,165% of CMS OPPS Rate,6020.49,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,16685.43,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,22882.74,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,28662.96,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1930.12,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,5808.95,100,,,Fee Schedule,100% of CMS OPPS Rate,6020.49,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,387.8,14,,,percent of total billed charges,14% of total billed charges,387.8,28662.96,
64893- Nerve graft/arm/leg/> 4 cm,3435444,CDM,510,RC,64893,HCPCS,Outpatient,,,2948.49,1474.25,,2211.37,75,,,percent of total billed charges,75% of total billed charges,2211.37,75,,,percent of total billed charges,75% of total billed charges,5808.95,100,,,Fee Schedule,100% of CMS OPPS Rate,1968.72,102,,,Fee Schedule,102% of WV Medicaid Rate,9584.77,165,,,Fee Schedule,165% of CMS OPPS Rate,6020.49,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,16685.43,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,22882.74,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,28662.96,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1930.12,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,5808.95,100,,,Fee Schedule,100% of CMS OPPS Rate,6020.49,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,412.79,14,,,percent of total billed charges,14% of total billed charges,412.79,28662.96,
64910- Nerve rpr/synthetic/vein/ea nerve,3435445,CDM,510,RC,64910,HCPCS,Outpatient,,,1995.69,997.85,,1496.77,75,,,percent of total billed charges,75% of total billed charges,1496.77,75,,,percent of total billed charges,75% of total billed charges,5808.95,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,9584.77,165,,,Fee Schedule,165% of CMS OPPS Rate,6020.49,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,16685.43,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,22882.74,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,28662.96,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,5808.95,100,,,Fee Schedule,100% of CMS OPPS Rate,6020.49,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,279.4,14,,,percent of total billed charges,14% of total billed charges,279.4,28662.96,
65220- Removal/FB/corneal/slit lamp,3431305,CDM,510,RC,65220,HCPCS,Outpatient,,,3095.38,1547.69,,2321.54,75,,,percent of total billed charges,75% of total billed charges,2321.54,75,,,percent of total billed charges,75% of total billed charges,354.97,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,585.71,165,,,Fee Schedule,165% of CMS OPPS Rate,367.9,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1019.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1398.33,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1751.55,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,354.97,100,,,Fee Schedule,100% of CMS OPPS Rate,367.9,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,433.35,14,,,percent of total billed charges,14% of total billed charges,354.97,2321.54,
65222- Rmv FB/extern eye/cornea/slit lamp,3431306,CDM,510,RC,65222,HCPCS,Outpatient,,,743.9,371.95,,557.93,75,,,percent of total billed charges,75% of total billed charges,557.93,75,,,percent of total billed charges,75% of total billed charges,109.16,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,180.11,165,,,Fee Schedule,165% of CMS OPPS Rate,113.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,313.55,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,430.01,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,538.63,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,109.16,100,,,Fee Schedule,100% of CMS OPPS Rate,113.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,104.15,14,,,percent of total billed charges,14% of total billed charges,104.15,557.93,
67700- Drainage of eyelid abscess,3431315,CDM,510,RC,67700,HCPCS,Outpatient,,,1695.72,847.86,,1271.79,75,,,percent of total billed charges,75% of total billed charges,1271.79,75,,,percent of total billed charges,75% of total billed charges,248.85,100,,,Fee Schedule,100% of CMS OPPS Rate,106.77,102,,,Fee Schedule,102% of WV Medicaid Rate,410.63,165,,,Fee Schedule,165% of CMS OPPS Rate,257.92,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,714.84,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,980.35,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1227.99,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,104.68,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,248.85,100,,,Fee Schedule,100% of CMS OPPS Rate,257.92,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,237.4,14,,,percent of total billed charges,14% of total billed charges,104.68,1271.79,
67700-OCC Drainage of eyelid abscess,3536975,CDM,983,RC,67700,HCPCS,Outpatient,,,1695.72,847.86,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
67800- Excision of chalazion/single,3431316,CDM,510,RC,67800,HCPCS,Outpatient,,,1670.07,835.04,,1252.55,75,,,percent of total billed charges,75% of total billed charges,1252.55,75,,,percent of total billed charges,75% of total billed charges,248.85,100,,,Fee Schedule,100% of CMS OPPS Rate,61.15,102,,,Fee Schedule,102% of WV Medicaid Rate,410.63,165,,,Fee Schedule,165% of CMS OPPS Rate,257.92,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,714.84,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,980.35,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1227.99,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,59.95,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,248.85,100,,,Fee Schedule,100% of CMS OPPS Rate,257.92,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,233.81,14,,,percent of total billed charges,14% of total billed charges,59.95,1252.55,
67800-OCC Excision of chalazion/single,3536976,CDM,983,RC,67800,HCPCS,Outpatient,,,1670.07,835.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
"67801 Excision of chalazion; multiple, same lid",3621303,CDM,510,RC,67801,HCPCS,Outpatient,,,5369.15,2684.58,,4026.86,75,,,percent of total billed charges,75% of total billed charges,4026.86,75,,,percent of total billed charges,75% of total billed charges,820.41,100,,,Fee Schedule,100% of CMS OPPS Rate,73.71,102,,,Fee Schedule,102% of WV Medicaid Rate,1353.69,165,,,Fee Schedule,165% of CMS OPPS Rate,850.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,2356.56,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,3231.83,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,4048.2,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,72.26,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,820.41,100,,,Fee Schedule,100% of CMS OPPS Rate,850.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,751.68,14,,,percent of total billed charges,14% of total billed charges,72.26,4048.2,
67805- EXCIS CHALAZION MULT BOTH,3431317,CDM,510,RC,67805,HCPCS,Outpatient,,,1788.92,894.46,,1341.69,75,,,percent of total billed charges,75% of total billed charges,1341.69,75,,,percent of total billed charges,75% of total billed charges,248.85,100,,,Fee Schedule,100% of CMS OPPS Rate,95,102,,,Fee Schedule,102% of WV Medicaid Rate,410.63,165,,,Fee Schedule,165% of CMS OPPS Rate,257.92,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,714.84,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,980.35,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1227.99,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,93.14,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,248.85,100,,,Fee Schedule,100% of CMS OPPS Rate,257.92,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,250.45,14,,,percent of total billed charges,14% of total billed charges,93.14,1341.69,
67805 OCC EXCIS CHALAZION MULT BOTH,3686902,CDM,983,RC,67805,HCPCS,Outpatient,,,1788.92,894.46,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
"67808- Excision of chalazion; under general anesthesia and/or requiring hospitalization, single or m",3569414,CDM,983,RC,67808,HCPCS,Outpatient,,,712.32,356.16,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
67810- Incisional biopsy/eyelid,3586925,CDM,983,RC,67810,HCPCS,Outpatient,,,1606.24,803.12,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
67820- Revise eyelashes,3431319,CDM,510,RC,67820,HCPCS,Outpatient,,,688.27,344.14,,516.2,75,,,percent of total billed charges,75% of total billed charges,516.2,75,,,percent of total billed charges,75% of total billed charges,109.16,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,180.11,165,,,Fee Schedule,165% of CMS OPPS Rate,113.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,313.55,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,430.01,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,538.63,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,109.16,100,,,Fee Schedule,100% of CMS OPPS Rate,113.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,96.36,14,,,percent of total billed charges,14% of total billed charges,96.36,538.63,
67820-OCC Revise eyelashes,3536977,CDM,983,RC,67820,HCPCS,Outpatient,,,688.27,344.14,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
67840-EYE RMV EYELID LESION -NOT CHAL,3430499,CDM,510,RC,67840,HCPCS,Outpatient,,,5417.62,2708.81,,4063.22,75,,,percent of total billed charges,75% of total billed charges,4063.22,75,,,percent of total billed charges,75% of total billed charges,820.41,100,,,Fee Schedule,100% of CMS OPPS Rate,167.07,102,,,Fee Schedule,102% of WV Medicaid Rate,1353.69,165,,,Fee Schedule,165% of CMS OPPS Rate,850.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,2356.56,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,3231.83,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,4048.2,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,163.79,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,820.41,100,,,Fee Schedule,100% of CMS OPPS Rate,850.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,758.47,14,,,percent of total billed charges,14% of total billed charges,163.79,4063.22,
67840-OCC Exc eyelid lesion/excpt chalazion,3536978,CDM,983,RC,67840,HCPCS,Outpatient,,,5417.62,2708.81,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
67850- Destruction/lid lesion/up to 1 cm,3431321,CDM,510,RC,67850,HCPCS,Outpatient,,,5368.45,2684.23,,4026.34,75,,,percent of total billed charges,75% of total billed charges,4026.34,75,,,percent of total billed charges,75% of total billed charges,820.41,100,,,Fee Schedule,100% of CMS OPPS Rate,124.22,102,,,Fee Schedule,102% of WV Medicaid Rate,1353.69,165,,,Fee Schedule,165% of CMS OPPS Rate,850.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,2356.56,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,3231.83,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,4048.2,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,121.78,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,820.41,100,,,Fee Schedule,100% of CMS OPPS Rate,850.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,751.58,14,,,percent of total billed charges,14% of total billed charges,121.78,4048.2,
67850 -OCC Destruction/lid/lesion/up to 1 cm,3548666,CDM,983,RC,67850,HCPCS,Outpatient,,,5368.45,2684.23,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
67875 -OCC Temp eyelid closure/suture,3548667,CDM,983,RC,67875,HCPCS,Outpatient,,,5299.39,2649.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
67875- Temp eyelid closure/suture,3431322,CDM,510,RC,67875,HCPCS,Outpatient,,,5299.39,2649.7,,3974.54,75,,,percent of total billed charges,75% of total billed charges,3974.54,75,,,percent of total billed charges,75% of total billed charges,820.41,100,,,Fee Schedule,100% of CMS OPPS Rate,330.54,102,,,Fee Schedule,102% of WV Medicaid Rate,1353.69,165,,,Fee Schedule,165% of CMS OPPS Rate,850.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,2356.56,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,3231.83,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,4048.2,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,324.06,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,820.41,100,,,Fee Schedule,100% of CMS OPPS Rate,850.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,741.91,14,,,percent of total billed charges,14% of total billed charges,324.06,4048.2,
67880 -OCC Revision of eyelid,3548668,CDM,983,RC,67880,HCPCS,Outpatient,,,12512.66,6256.33,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
67880- Revision of eyelid,3431323,CDM,510,RC,67880,HCPCS,Outpatient,,,12512.66,6256.33,,9384.5,75,,,percent of total billed charges,75% of total billed charges,9384.5,75,,,percent of total billed charges,75% of total billed charges,1987.7,100,,,Fee Schedule,100% of CMS OPPS Rate,688.56,102,,,Fee Schedule,102% of WV Medicaid Rate,3279.73,165,,,Fee Schedule,165% of CMS OPPS Rate,2060.09,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,5709.44,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,7830.05,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,9807.93,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,675.06,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1987.7,100,,,Fee Schedule,100% of CMS OPPS Rate,2060.09,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1751.77,14,,,percent of total billed charges,14% of total billed charges,675.06,9807.93,
67900 -OCC Repair brow prosis,3548669,CDM,983,RC,67900,HCPCS,Outpatient,,,984.38,492.19,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
67901- OCC EYE Repair of blepharoptosis; frontalis muscle technique with suture or other material,3569420,CDM,983,RC,67901,HCPCS,Outpatient,,,1141.66,570.83,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
67904 -OCC Blepharoptosis/levator resct/ext,3548671,CDM,983,RC,67904,HCPCS,Outpatient,,,1157.12,578.56,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
67909 -OCC Revise eyelid defect,3548672,CDM,983,RC,67909,HCPCS,Outpatient,,,12647.24,6323.62,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
67909- Revise eyelid defect,3431327,CDM,510,RC,67909,HCPCS,Outpatient,,,12647.24,6323.62,,9485.43,75,,,percent of total billed charges,75% of total billed charges,9485.43,75,,,percent of total billed charges,75% of total billed charges,1987.7,100,,,Fee Schedule,100% of CMS OPPS Rate,688.56,102,,,Fee Schedule,102% of WV Medicaid Rate,3279.73,165,,,Fee Schedule,165% of CMS OPPS Rate,2060.09,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,5709.44,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,7830.05,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,9807.93,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,675.06,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1987.7,100,,,Fee Schedule,100% of CMS OPPS Rate,2060.09,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1770.61,14,,,percent of total billed charges,14% of total billed charges,675.06,9807.93,
67912 -OCC Lagophthalmos/implt/up eyelid load,3548673,CDM,983,RC,67912,HCPCS,Outpatient,,,948.74,474.37,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
67917 -OCC Repair etropion/extensive,3548675,CDM,983,RC,67917,HCPCS,Outpatient,,,884.23,442.12,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
67923 -OCC Rpr entropion/excise tarsal wedge,3548676,CDM,983,RC,67923,HCPCS,Outpatient,,,832.21,416.11,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
67924 -OCC Repair entropion/extensive,3548677,CDM,983,RC,67924,HCPCS,Outpatient,,,883.91,441.96,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
67935- Eyelid/recent wound sut/full thick,3431332,CDM,510,RC,67935,HCPCS,Outpatient,,,12658.14,6329.07,,9493.61,75,,,percent of total billed charges,75% of total billed charges,9493.61,75,,,percent of total billed charges,75% of total billed charges,1987.7,100,,,Fee Schedule,100% of CMS OPPS Rate,688.56,102,,,Fee Schedule,102% of WV Medicaid Rate,3279.73,165,,,Fee Schedule,165% of CMS OPPS Rate,2060.09,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,5709.44,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,7830.05,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,9807.93,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,675.06,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1987.7,100,,,Fee Schedule,100% of CMS OPPS Rate,2060.09,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1772.14,14,,,percent of total billed charges,14% of total billed charges,675.06,9807.93,
67935 -OCC Eyelid/recent wound sut/full thick,3548678,CDM,983,RC,67935,HCPCS,Outpatient,,,12658.14,6329.07,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
67938 -OCC Removal of embedded FB/eyelid,3548679,CDM,983,RC,67938,HCPCS,Outpatient,,,1697.27,848.64,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
67938- Removal of embedded FB/eyelid,3431333,CDM,510,RC,67938,HCPCS,Outpatient,,,1697.27,848.64,,1272.95,75,,,percent of total billed charges,75% of total billed charges,1272.95,75,,,percent of total billed charges,75% of total billed charges,248.85,100,,,Fee Schedule,100% of CMS OPPS Rate,106.77,102,,,Fee Schedule,102% of WV Medicaid Rate,410.63,165,,,Fee Schedule,165% of CMS OPPS Rate,257.92,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,714.84,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,980.35,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1227.99,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,104.68,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,248.85,100,,,Fee Schedule,100% of CMS OPPS Rate,257.92,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,237.62,14,,,percent of total billed charges,14% of total billed charges,104.68,1272.95,
67950 -OCC Canthoplasty/reconstruct canthus,3548680,CDM,983,RC,67950,HCPCS,Outpatient,,,896.57,448.29,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
67961- Exc/rpr eyelid/to 1/4 lid margin,3431335,CDM,510,RC,67961,HCPCS,Outpatient,,,12680,6340,,9510,75,,,percent of total billed charges,75% of total billed charges,9510,75,,,percent of total billed charges,75% of total billed charges,1987.7,100,,,Fee Schedule,100% of CMS OPPS Rate,688.56,102,,,Fee Schedule,102% of WV Medicaid Rate,3279.73,165,,,Fee Schedule,165% of CMS OPPS Rate,2060.09,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,5709.44,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,7830.05,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,9807.93,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,675.06,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1987.7,100,,,Fee Schedule,100% of CMS OPPS Rate,2060.09,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1775.2,14,,,percent of total billed charges,14% of total billed charges,675.06,9807.93,
67961 -OCC Exc/rpr eyelid/to 1/4 lid margin,3548681,CDM,983,RC,67961,HCPCS,Outpatient,,,12680,6340,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
"67966- OCC EYE Excision and repair of eyelid, involving lid margin, tarsus, conjunctiva, canthus,",3569424,CDM,983,RC,67966,HCPCS,Outpatient,,,13071.64,6535.82,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
"68110- OCC EYE Excision of lesion, conj up to 1 cm",3569429,CDM,983,RC,68110,HCPCS,Outpatient,,,286.5,143.25,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
68440- OCC EYE Snip incision of lacrimal punctum,3569422,CDM,983,RC,68440,HCPCS,Outpatient,,,1662.67,831.34,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
"68705 - Correction of everted punctum, cautery",3572818,CDM,983,RC,68705,HCPCS,Outpatient,,,1791.85,895.93,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
"68760 -Closure of the lacrimal punctum; by thermocauterization, ligation, or laser surgery PF",4333262,CDM,983,RC,68760,HCPCS,Outpatient,,,1752.99,876.5,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
68761- Close lacrimal punctum/plug/each,3431340,CDM,510,RC,68761,HCPCS,Outpatient,,,1696.02,848.01,,1272.02,75,,,percent of total billed charges,75% of total billed charges,1272.02,75,,,percent of total billed charges,75% of total billed charges,248.85,100,,,Fee Schedule,100% of CMS OPPS Rate,77.53,102,,,Fee Schedule,102% of WV Medicaid Rate,410.63,165,,,Fee Schedule,165% of CMS OPPS Rate,257.92,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,714.84,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,980.35,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1227.99,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,76.01,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,248.85,100,,,Fee Schedule,100% of CMS OPPS Rate,257.92,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,237.44,14,,,percent of total billed charges,14% of total billed charges,76.01,1272.02,
68761-OCC Close lacrimal punctum/plug/each,3536979,CDM,983,RC,68761,HCPCS,Outpatient,,,1696.02,848.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
68801- Dilation of lacrimal punctum,3431341,CDM,510,RC,68801,HCPCS,Outpatient,,,2163.94,1081.97,,1622.96,75,,,percent of total billed charges,75% of total billed charges,1622.96,75,,,percent of total billed charges,75% of total billed charges,354.97,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,585.71,165,,,Fee Schedule,165% of CMS OPPS Rate,367.9,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1019.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1398.33,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1751.55,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,354.97,100,,,Fee Schedule,100% of CMS OPPS Rate,367.9,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,302.95,14,,,percent of total billed charges,14% of total billed charges,302.95,1751.55,
68801-OCC Dilation of lacrimal punctum,3536980,CDM,983,RC,68801,HCPCS,Outpatient,,,2163.94,1081.97,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
"68811 - Probing of nasolacrimal duct, with or without irrigation; requiring general anesthesia",3699550,CDM,510,RC,68811,HCPCS,Outpatient,,,12062.46,6031.23,,9046.85,75,,,percent of total billed charges,75% of total billed charges,9046.85,75,,,percent of total billed charges,75% of total billed charges,1987.7,100,,,Fee Schedule,100% of CMS OPPS Rate,688.56,102,,,Fee Schedule,102% of WV Medicaid Rate,3279.73,165,,,Fee Schedule,165% of CMS OPPS Rate,2060.09,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,5709.44,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,7830.05,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,9807.93,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,675.06,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1987.7,100,,,Fee Schedule,100% of CMS OPPS Rate,2060.09,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1688.74,14,,,percent of total billed charges,14% of total billed charges,675.06,9807.93,
68815 -OCC Probe/nasolacrimal/tube/stent,3548684,CDM,983,RC,68815,HCPCS,Outpatient,,,12229.54,6114.77,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
68815- Probe/nasolacrimal/tube/stent,3431342,CDM,510,RC,68815,HCPCS,Outpatient,,,12229.54,6114.77,,9172.16,75,,,percent of total billed charges,75% of total billed charges,9172.16,75,,,percent of total billed charges,75% of total billed charges,1987.7,100,,,Fee Schedule,100% of CMS OPPS Rate,688.56,102,,,Fee Schedule,102% of WV Medicaid Rate,3279.73,165,,,Fee Schedule,165% of CMS OPPS Rate,2060.09,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,5709.44,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,7830.05,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,9807.93,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,675.06,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1987.7,100,,,Fee Schedule,100% of CMS OPPS Rate,2060.09,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1712.14,14,,,percent of total billed charges,14% of total billed charges,675.06,9807.93,
68840 -OCC Probe lacrimal canaliculi,3548685,CDM,983,RC,68840,HCPCS,Outpatient,,,1696.23,848.12,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
68840- Probe lacrimal canaliculi,3431343,CDM,510,RC,68840,HCPCS,Outpatient,,,1696.23,848.12,,1272.17,75,,,percent of total billed charges,75% of total billed charges,1272.17,75,,,percent of total billed charges,75% of total billed charges,248.85,100,,,Fee Schedule,100% of CMS OPPS Rate,68.26,102,,,Fee Schedule,102% of WV Medicaid Rate,410.63,165,,,Fee Schedule,165% of CMS OPPS Rate,257.92,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,714.84,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,980.35,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1227.99,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,66.92,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,248.85,100,,,Fee Schedule,100% of CMS OPPS Rate,257.92,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,237.47,14,,,percent of total billed charges,14% of total billed charges,66.92,1272.17,
69100- Biopsy external ear,3430622,CDM,510,RC,69100,HCPCS,Outpatient,,,1326.75,663.38,,995.06,75,,,percent of total billed charges,75% of total billed charges,995.06,75,,,percent of total billed charges,75% of total billed charges,195.39,100,,,Fee Schedule,100% of CMS OPPS Rate,54.05,102,,,Fee Schedule,102% of WV Medicaid Rate,322.39,165,,,Fee Schedule,165% of CMS OPPS Rate,202.5,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,561.23,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,769.7,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,964.12,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,52.99,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,195.39,100,,,Fee Schedule,100% of CMS OPPS Rate,202.5,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,185.75,14,,,percent of total billed charges,14% of total billed charges,52.99,995.06,
EAR REM IMPACT CERUMEN,3428422,CDM,360,RC,69210,HCPCS,Outpatient,,,121.35,60.68,,91.01,75,,,percent of total billed charges,75% of total billed charges,91.01,75,,,percent of total billed charges,75% of total billed charges,54.04,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,89.16,165,,,Fee Schedule,165% of CMS OPPS Rate,56,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,155.22,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,212.87,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,266.65,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,54.04,100,,,Fee Schedule,100% of CMS OPPS Rate,56,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,16.99,14,,,percent of total billed charges,14% of total billed charges,16.99,266.65,
"69220 Debridement, mastoidectomy cavity, simple (eg, routine cleaning)",3584875,CDM,960,RC,69220,HCPCS,Outpatient,,,195.11,97.56,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
Orbits for Foreign Body,602189,CDM,320,RC,70030,HCPCS,Outpatient,,,79.56,39.78,,59.67,75,,,percent of total billed charges,75% of total billed charges,59.67,75,,,percent of total billed charges,75% of total billed charges,81.68,100,,,Fee Schedule,100% of CMS OPPS Rate,21.14,100,,,Fee Schedule,100% of WV Medicaid Rate,134.77,165,,,Fee Schedule,165% of CMS OPPS Rate,84.65,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,234.61,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,321.76,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,403.03,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,21.14,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,81.68,100,,,Fee Schedule,100% of CMS OPPS Rate,84.65,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,11.14,14,,,percent of total billed charges,14% of total billed charges,11.14,403.03,
Mandible Less than 4 views,602136,CDM,320,RC,70100,HCPCS,Outpatient,,,93.77,46.89,,70.33,75,,,percent of total billed charges,75% of total billed charges,70.33,75,,,percent of total billed charges,75% of total billed charges,81.68,100,,,Fee Schedule,100% of CMS OPPS Rate,25.07,100,,,Fee Schedule,100% of WV Medicaid Rate,134.77,165,,,Fee Schedule,165% of CMS OPPS Rate,84.65,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,234.61,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,321.76,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,403.03,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,25.07,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,81.68,100,,,Fee Schedule,100% of CMS OPPS Rate,84.65,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,13.13,14,,,percent of total billed charges,14% of total billed charges,13.13,403.03,
Mandible Routine min 4 views,602134,CDM,320,RC,70110,HCPCS,Outpatient,,,107.34,53.67,,80.51,75,,,percent of total billed charges,75% of total billed charges,80.51,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,28.51,100,,,Fee Schedule,100% of WV Medicaid Rate,165.8,165,,,Fee Schedule,165% of CMS OPPS Rate,104.14,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.83,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,28.51,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.14,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,15.03,14,,,percent of total billed charges,14% of total billed charges,15.03,495.81,
WW Mandible Less than 4 views,3373266,CDM,972,RC,70110,HCPCS,Outpatient,,,107.34,53.67,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
Mastoids min 3 views per side,602132,CDM,320,RC,70130,HCPCS,Outpatient,,,153.82,76.91,,115.37,75,,,percent of total billed charges,75% of total billed charges,115.37,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,41.29,100,,,Fee Schedule,100% of WV Medicaid Rate,165.8,165,,,Fee Schedule,165% of CMS OPPS Rate,104.14,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.83,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,41.29,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.14,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,21.53,14,,,percent of total billed charges,14% of total billed charges,21.53,495.81,
WW Mastoids min 3 views per side,3373268,CDM,972,RC,70130,HCPCS,Outpatient,,,153.82,76.91,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
IAM,602096,CDM,320,RC,70134,HCPCS,Outpatient,,,150.36,75.18,,112.77,75,,,percent of total billed charges,75% of total billed charges,112.77,75,,,percent of total billed charges,75% of total billed charges,473.02,100,,,Fee Schedule,100% of CMS OPPS Rate,40.07,100,,,Fee Schedule,100% of WV Medicaid Rate,780.49,165,,,Fee Schedule,165% of CMS OPPS Rate,490.25,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1358.7,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1863.35,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,2334.03,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,40.07,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,473.02,100,,,Fee Schedule,100% of CMS OPPS Rate,490.25,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,21.05,14,,,percent of total billed charges,14% of total billed charges,21.05,2334.03,
Facial Bones,602068,CDM,320,RC,70150,HCPCS,Outpatient,,,116.13,58.07,,87.1,75,,,percent of total billed charges,75% of total billed charges,87.1,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,30.97,100,,,Fee Schedule,100% of WV Medicaid Rate,165.8,165,,,Fee Schedule,165% of CMS OPPS Rate,104.14,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.83,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,30.97,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.14,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,16.26,14,,,percent of total billed charges,14% of total billed charges,16.26,495.81,
WW Facial Bones,3373186,CDM,972,RC,70150,HCPCS,Outpatient,,,116.13,58.07,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
Nasal Bones,602181,CDM,320,RC,70160,HCPCS,Outpatient,,,92.87,46.44,,69.65,75,,,percent of total billed charges,75% of total billed charges,69.65,75,,,percent of total billed charges,75% of total billed charges,81.68,100,,,Fee Schedule,100% of CMS OPPS Rate,24.83,100,,,Fee Schedule,100% of WV Medicaid Rate,134.77,165,,,Fee Schedule,165% of CMS OPPS Rate,84.65,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,234.61,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,321.76,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,403.03,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,24.83,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,81.68,100,,,Fee Schedule,100% of CMS OPPS Rate,84.65,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,13,14,,,percent of total billed charges,14% of total billed charges,13,403.03,
WW Nasal Bones,3373270,CDM,972,RC,70160,HCPCS,Outpatient,,,92.87,46.44,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
Optic Foramina,602191,CDM,320,RC,70190,HCPCS,Outpatient,,,93.4,46.7,,70.05,75,,,percent of total billed charges,75% of total billed charges,70.05,75,,,percent of total billed charges,75% of total billed charges,81.68,100,,,Fee Schedule,100% of CMS OPPS Rate,24.83,100,,,Fee Schedule,100% of WV Medicaid Rate,134.77,165,,,Fee Schedule,165% of CMS OPPS Rate,84.65,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,234.61,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,321.76,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,403.03,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,24.83,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,81.68,100,,,Fee Schedule,100% of CMS OPPS Rate,84.65,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,13.08,14,,,percent of total billed charges,14% of total billed charges,13.08,403.03,
Orbits min 4 views,604260,CDM,320,RC,70200,HCPCS,Outpatient,,,118.76,59.38,,89.07,75,,,percent of total billed charges,75% of total billed charges,89.07,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,31.71,100,,,Fee Schedule,100% of WV Medicaid Rate,165.8,165,,,Fee Schedule,165% of CMS OPPS Rate,104.14,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.83,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,31.71,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.14,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,16.63,14,,,percent of total billed charges,14% of total billed charges,16.63,495.81,
WW Orbits min 4 views,3373272,CDM,972,RC,70200,HCPCS,Outpatient,,,118.76,59.38,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
Sinuses Less than 3 views,602257,CDM,320,RC,70210,HCPCS,Outpatient,,,79.46,39.73,,59.6,75,,,percent of total billed charges,75% of total billed charges,59.6,75,,,percent of total billed charges,75% of total billed charges,81.68,100,,,Fee Schedule,100% of CMS OPPS Rate,21.14,100,,,Fee Schedule,100% of WV Medicaid Rate,134.77,165,,,Fee Schedule,165% of CMS OPPS Rate,84.65,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,234.61,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,321.76,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,403.03,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,21.14,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,81.68,100,,,Fee Schedule,100% of CMS OPPS Rate,84.65,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,11.12,14,,,percent of total billed charges,14% of total billed charges,11.12,403.03,
WW Sinuses Less than 3 views,3373312,CDM,972,RC,70210,HCPCS,Outpatient,,,79.46,39.73,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
Sinus Series,602259,CDM,320,RC,70220,HCPCS,Outpatient,,,92.73,46.37,,69.55,75,,,percent of total billed charges,75% of total billed charges,69.55,75,,,percent of total billed charges,75% of total billed charges,81.68,100,,,Fee Schedule,100% of CMS OPPS Rate,24.58,100,,,Fee Schedule,100% of WV Medicaid Rate,134.77,165,,,Fee Schedule,165% of CMS OPPS Rate,84.65,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,234.61,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,321.76,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,403.03,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,24.58,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,81.68,100,,,Fee Schedule,100% of CMS OPPS Rate,84.65,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,12.98,14,,,percent of total billed charges,14% of total billed charges,12.98,403.03,
WW Sinus Series,3373310,CDM,972,RC,70220,HCPCS,Outpatient,,,92.73,46.37,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
Sella Turcica,602281,CDM,320,RC,70240,HCPCS,Outpatient,,,81.3,40.65,,60.98,75,,,percent of total billed charges,75% of total billed charges,60.98,75,,,percent of total billed charges,75% of total billed charges,81.68,100,,,Fee Schedule,100% of CMS OPPS Rate,21.63,100,,,Fee Schedule,100% of WV Medicaid Rate,134.77,165,,,Fee Schedule,165% of CMS OPPS Rate,84.65,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,234.61,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,321.76,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,403.03,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,21.63,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,81.68,100,,,Fee Schedule,100% of CMS OPPS Rate,84.65,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,11.38,14,,,percent of total billed charges,14% of total billed charges,11.38,403.03,
Skull AP and Lat,602255,CDM,320,RC,70250,HCPCS,Outpatient,,,87.46,43.73,,65.6,75,,,percent of total billed charges,75% of total billed charges,65.6,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,23.35,100,,,Fee Schedule,100% of WV Medicaid Rate,165.8,165,,,Fee Schedule,165% of CMS OPPS Rate,104.14,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.83,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,23.35,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.14,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,12.24,14,,,percent of total billed charges,14% of total billed charges,12.24,495.81,
WW Skull AP and Lat,3373314,CDM,972,RC,70250,HCPCS,Outpatient,,,87.46,43.73,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
Skull Series,602251,CDM,320,RC,70260,HCPCS,Outpatient,,,110.1,55.05,,82.58,75,,,percent of total billed charges,75% of total billed charges,82.58,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,29.25,100,,,Fee Schedule,100% of WV Medicaid Rate,165.8,165,,,Fee Schedule,165% of CMS OPPS Rate,104.14,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.83,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,29.25,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.14,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,15.41,14,,,percent of total billed charges,14% of total billed charges,15.41,495.81,
WW Skull Series,3373316,CDM,972,RC,70260,HCPCS,Outpatient,,,110.1,55.05,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
WW TMJ Open & Closed,3373338,CDM,972,RC,70328,HCPCS,Outpatient,,,85.1,42.55,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
Temporomandibular Jts open and closed,630441,CDM,320,RC,70330,HCPCS,Outpatient,,,130.09,65.05,,97.57,75,,,percent of total billed charges,75% of total billed charges,97.57,75,,,percent of total billed charges,75% of total billed charges,81.68,100,,,Fee Schedule,100% of CMS OPPS Rate,34.65,100,,,Fee Schedule,100% of WV Medicaid Rate,134.77,165,,,Fee Schedule,165% of CMS OPPS Rate,84.65,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,234.61,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,321.76,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,403.03,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,34.65,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,81.68,100,,,Fee Schedule,100% of CMS OPPS Rate,84.65,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,18.21,14,,,percent of total billed charges,14% of total billed charges,18.21,403.03,
WW Temporomandibular Jts open and closed,3373326,CDM,972,RC,70330,HCPCS,Outpatient,,,130.09,65.05,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
MRI TMJ,597371,CDM,614,RC,70336,HCPCS,Outpatient,,,687.3,343.65,,515.48,75,,,percent of total billed charges,75% of total billed charges,515.48,75,,,percent of total billed charges,75% of total billed charges,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,183.61,100,,,Fee Schedule,100% of WV Medicaid Rate,362.24,165,,,Fee Schedule,165% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,630.61,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,864.84,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1083.29,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,183.61,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,96.22,14,,,percent of total billed charges,14% of total billed charges,96.22,1083.29,
Soft Tissue Neck,602247,CDM,320,RC,70360,HCPCS,Outpatient,,,77.2,38.6,,57.9,75,,,percent of total billed charges,75% of total billed charges,57.9,75,,,percent of total billed charges,75% of total billed charges,81.68,100,,,Fee Schedule,100% of CMS OPPS Rate,20.39,100,,,Fee Schedule,100% of WV Medicaid Rate,134.77,165,,,Fee Schedule,165% of CMS OPPS Rate,84.65,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,234.61,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,321.76,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,403.03,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,20.39,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,81.68,100,,,Fee Schedule,100% of CMS OPPS Rate,84.65,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,10.81,14,,,percent of total billed charges,14% of total billed charges,10.81,403.03,
WW Soft Tissue Neck,3373318,CDM,972,RC,70360,HCPCS,Outpatient,,,77.2,38.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
DOL Chest PA,3325655,CDM,324,RC,71045,HCPCS,Outpatient,,,63.78,31.89,,47.84,75,,,percent of total billed charges,75% of total billed charges,47.84,75,,,percent of total billed charges,75% of total billed charges,81.67,100,,,Fee Schedule,100% of CMS OPPS Rate,16.96,100,,,Fee Schedule,100% of WV Medicaid Rate,134.76,165,,,Fee Schedule,165% of CMS OPPS Rate,84.65,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,234.61,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,321.75,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,403.03,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,16.96,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,81.67,100,,,Fee Schedule,100% of CMS OPPS Rate,84.65,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8.93,14,,,percent of total billed charges,14% of total billed charges,8.93,403.03,
DOL Chest PA:Read,3325656,CDM,972,RC,71045,HCPCS,Outpatient,,,63.78,31.89,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
Portable Chest,602311,CDM,324,RC,71045,HCPCS,Outpatient,,,63.78,31.89,,47.84,75,,,percent of total billed charges,75% of total billed charges,47.84,75,,,percent of total billed charges,75% of total billed charges,81.67,100,,,Fee Schedule,100% of CMS OPPS Rate,16.96,100,,,Fee Schedule,100% of WV Medicaid Rate,134.76,165,,,Fee Schedule,165% of CMS OPPS Rate,84.65,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,234.61,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,321.75,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,403.03,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,16.96,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,81.67,100,,,Fee Schedule,100% of CMS OPPS Rate,84.65,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8.93,14,,,percent of total billed charges,14% of total billed charges,8.93,403.03,
Read,3529345,CDM,972,RC,71045,HCPCS,Outpatient,,,63.78,31.89,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
WW Chest single view AP or PA,3373170,CDM,972,RC,71045,HCPCS,Outpatient,,,63.78,31.89,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
Chest PA and Lat: Read,602000,CDM,972,RC,71046,HCPCS,Outpatient,,,82.47,41.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
DOL Chest PA & Lat:Read,3325658,CDM,972,RC,71046,HCPCS,Outpatient,,,82.47,41.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
WW Chest PA and Lat:WW DR Exam,3373168,CDM,972,RC,71046,HCPCS,Outpatient,,,82.47,41.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
WW Chest with apical Lordotic view,3373172,CDM,972,RC,71047,HCPCS,Outpatient,,,103.67,51.84,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
WW Rib Lt 2 views with No Chest,3373276,CDM,972,RC,71100,HCPCS,Outpatient,,,90.37,45.19,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
WW Rib Rt 2 views with No Chest:WW DR Exam,3552736,CDM,972,RC,71100,HCPCS,Outpatient,,,90.37,45.19,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
Rib Rt with PA Chest Routine min 3 views,602299,CDM,320,RC,71101,HCPCS,Outpatient,,,103.67,51.84,,77.75,75,,,percent of total billed charges,75% of total billed charges,77.75,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,27.53,100,,,Fee Schedule,100% of WV Medicaid Rate,165.8,165,,,Fee Schedule,165% of CMS OPPS Rate,104.14,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.83,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,27.53,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.14,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,14.51,14,,,percent of total billed charges,14% of total billed charges,14.51,495.81,
WW DR Exam,3552738,CDM,972,RC,71101,HCPCS,Outpatient,,,103.67,51.84,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
WW Rib Lt with PA Chest Rout min 3 views,3373278,CDM,972,RC,71101,HCPCS,Outpatient,,,103.67,51.84,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
Ribs Bilat 3 views No Chest,602297,CDM,320,RC,71110,HCPCS,Outpatient,,,107.86,53.93,,80.9,75,,,percent of total billed charges,75% of total billed charges,80.9,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,28.76,100,,,Fee Schedule,100% of WV Medicaid Rate,165.8,165,,,Fee Schedule,165% of CMS OPPS Rate,104.14,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.83,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,28.76,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.14,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,15.1,14,,,percent of total billed charges,14% of total billed charges,15.1,495.81,
WW Ribs Bilat 3 views No Chest,3373280,CDM,972,RC,71110,HCPCS,Outpatient,,,107.86,53.93,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
Ribs Bilat min 4 with PA Chest,602295,CDM,320,RC,71111,HCPCS,Outpatient,,,128.77,64.39,,96.58,75,,,percent of total billed charges,75% of total billed charges,96.58,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,34.4,100,,,Fee Schedule,100% of WV Medicaid Rate,165.8,165,,,Fee Schedule,165% of CMS OPPS Rate,104.14,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.83,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,34.4,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.14,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,18.03,14,,,percent of total billed charges,14% of total billed charges,18.03,495.81,
WW Ribs Bilat min 4 with PA Chest,3373282,CDM,972,RC,71111,HCPCS,Outpatient,,,128.77,64.39,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
Sternum min 2 views,602241,CDM,320,RC,71120,HCPCS,Outpatient,,,82.98,41.49,,62.24,75,,,percent of total billed charges,75% of total billed charges,62.24,75,,,percent of total billed charges,75% of total billed charges,81.68,100,,,Fee Schedule,100% of CMS OPPS Rate,22.12,100,,,Fee Schedule,100% of WV Medicaid Rate,134.77,165,,,Fee Schedule,165% of CMS OPPS Rate,84.65,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,234.61,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,321.76,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,403.03,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,22.12,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,81.68,100,,,Fee Schedule,100% of CMS OPPS Rate,84.65,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,11.62,14,,,percent of total billed charges,14% of total billed charges,11.62,403.03,
WW Sternum min 2 views,3373324,CDM,972,RC,71120,HCPCS,Outpatient,,,82.98,41.49,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
Sternoclavicular Joints min 3 views,602243,CDM,320,RC,71130,HCPCS,Outpatient,,,101.4,50.7,,76.05,75,,,percent of total billed charges,75% of total billed charges,76.05,75,,,percent of total billed charges,75% of total billed charges,81.68,100,,,Fee Schedule,100% of CMS OPPS Rate,27.04,100,,,Fee Schedule,100% of WV Medicaid Rate,134.77,165,,,Fee Schedule,165% of CMS OPPS Rate,84.65,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,234.61,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,321.76,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,403.03,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,27.04,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,81.68,100,,,Fee Schedule,100% of CMS OPPS Rate,84.65,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,14.2,14,,,percent of total billed charges,14% of total billed charges,14.2,403.03,
WW Sternoclavicular Joints min 3 views,3373322,CDM,972,RC,71130,HCPCS,Outpatient,,,101.4,50.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
WW Spine single view,3373320,CDM,972,RC,72020,HCPCS,Outpatient,,,60.35,30.18,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
Cervical Spine AP Lat and Odontoid,602010,CDM,320,RC,72040,HCPCS,Outpatient,,,96.66,48.33,,72.5,75,,,percent of total billed charges,75% of total billed charges,72.5,75,,,percent of total billed charges,75% of total billed charges,81.68,100,,,Fee Schedule,100% of CMS OPPS Rate,25.81,100,,,Fee Schedule,100% of WV Medicaid Rate,134.77,165,,,Fee Schedule,165% of CMS OPPS Rate,84.65,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,234.61,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,321.76,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,403.03,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,25.81,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,81.68,100,,,Fee Schedule,100% of CMS OPPS Rate,84.65,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,13.53,14,,,percent of total billed charges,14% of total billed charges,13.53,403.03,
WW Cervical Spine AP Lat and Odontoid,3373162,CDM,972,RC,72040,HCPCS,Outpatient,,,96.66,48.33,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
Cervical Spine Series,602008,CDM,320,RC,72050,HCPCS,Outpatient,,,129.69,64.85,,97.27,75,,,percent of total billed charges,75% of total billed charges,97.27,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,34.65,100,,,Fee Schedule,100% of WV Medicaid Rate,165.8,165,,,Fee Schedule,165% of CMS OPPS Rate,104.14,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.83,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,34.65,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.14,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,18.16,14,,,percent of total billed charges,14% of total billed charges,18.16,495.81,
WW Cervical Spine Series,3373164,CDM,972,RC,72050,HCPCS,Outpatient,,,129.69,64.85,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
Cervical Spine Series with Flex and Ext,602006,CDM,320,RC,72052,HCPCS,Outpatient,,,150.62,75.31,,112.97,75,,,percent of total billed charges,75% of total billed charges,112.97,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,40.07,100,,,Fee Schedule,100% of WV Medicaid Rate,165.8,165,,,Fee Schedule,165% of CMS OPPS Rate,104.14,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.83,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,40.07,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.14,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,21.09,14,,,percent of total billed charges,14% of total billed charges,21.09,495.81,
WW Cervical Spine Series w Flex and Ext,3373166,CDM,972,RC,72052,HCPCS,Outpatient,,,150.62,75.31,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
Thoracic Spine AP Lat with no swimmers,602225,CDM,320,RC,72070,HCPCS,Outpatient,,,80.63,40.32,,60.47,75,,,percent of total billed charges,75% of total billed charges,60.47,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,21.38,100,,,Fee Schedule,100% of WV Medicaid Rate,165.8,165,,,Fee Schedule,165% of CMS OPPS Rate,104.14,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.83,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,21.38,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.14,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,11.29,14,,,percent of total billed charges,14% of total billed charges,11.29,495.81,
WW Thoracic Spine AP Lat w no swimmers,3373328,CDM,972,RC,72070,HCPCS,Outpatient,,,80.63,40.32,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
Thoracic Spine Routine AP Lat and Swim,602231,CDM,320,RC,72072,HCPCS,Outpatient,,,96.04,48.02,,72.03,75,,,percent of total billed charges,75% of total billed charges,72.03,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,25.56,100,,,Fee Schedule,100% of WV Medicaid Rate,165.8,165,,,Fee Schedule,165% of CMS OPPS Rate,104.14,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.83,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,25.56,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.14,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,13.45,14,,,percent of total billed charges,14% of total billed charges,13.45,495.81,
WW Thoracic Spine Routine 3 views,3373330,CDM,972,RC,72072,HCPCS,Outpatient,,,96.04,48.02,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
WW Thoracolumbar AP and Lat,3373332,CDM,972,RC,72080,HCPCS,Outpatient,,,85.5,42.75,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
Scoliosis Standing AP or PA Spine,602283,CDM,320,RC,72081,HCPCS,Outpatient,,,104.29,52.15,,78.22,75,,,percent of total billed charges,75% of total billed charges,78.22,75,,,percent of total billed charges,75% of total billed charges,81.68,100,,,Fee Schedule,100% of CMS OPPS Rate,27.78,100,,,Fee Schedule,100% of WV Medicaid Rate,134.77,165,,,Fee Schedule,165% of CMS OPPS Rate,84.65,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,234.61,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,321.76,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,403.03,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,27.78,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,81.68,100,,,Fee Schedule,100% of CMS OPPS Rate,84.65,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,14.6,14,,,percent of total billed charges,14% of total billed charges,14.6,403.03,
WW Scoliosis Standing AP and PA Spine,3373300,CDM,972,RC,72081,HCPCS,Outpatient,,,104.29,52.15,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
WW Scoliosis 2-3 views,3373294,CDM,972,RC,72082,HCPCS,Outpatient,,,170.82,85.41,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
WW Scoliosis 4-5 views,3373296,CDM,972,RC,72083,HCPCS,Outpatient,,,190.76,95.38,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
WW Scoliosis 6 view minimun,3373298,CDM,972,RC,72084,HCPCS,Outpatient,,,239.23,119.62,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
WW Lumbar Spine AP Lat and Spot,3373258,CDM,972,RC,72100,HCPCS,Outpatient,,,97.47,48.74,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
Lumbar Spine Series,602140,CDM,320,RC,72110,HCPCS,Outpatient,,,124.84,62.42,,93.63,75,,,percent of total billed charges,75% of total billed charges,93.63,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,33.18,100,,,Fee Schedule,100% of WV Medicaid Rate,165.8,165,,,Fee Schedule,165% of CMS OPPS Rate,104.14,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.83,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,33.18,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.14,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,17.48,14,,,percent of total billed charges,14% of total billed charges,17.48,495.81,
WW Lumbar Spine Series,3373264,CDM,972,RC,72110,HCPCS,Outpatient,,,124.84,62.42,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
WW Lumbar Spine Complete w Bending Views,3373262,CDM,972,RC,72114,HCPCS,Outpatient,,,150.62,75.31,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
WW Lumbar Spine Bending Views,3373260,CDM,972,RC,72120,HCPCS,Outpatient,,,99.83,49.92,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
Pelvis AP,602185,CDM,320,RC,72170,HCPCS,Outpatient,,,68.39,34.2,,51.29,75,,,percent of total billed charges,75% of total billed charges,51.29,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,18.19,100,,,Fee Schedule,100% of WV Medicaid Rate,165.8,165,,,Fee Schedule,165% of CMS OPPS Rate,104.14,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.83,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,18.19,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.14,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,9.57,14,,,percent of total billed charges,14% of total billed charges,9.57,495.81,
WW Pelvis AP,3373274,CDM,972,RC,72170,HCPCS,Outpatient,,,68.39,34.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
Pelvis with Judet Views,602183,CDM,320,RC,72190,HCPCS,Outpatient,,,103.39,51.7,,77.54,75,,,percent of total billed charges,75% of total billed charges,77.54,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,27.53,100,,,Fee Schedule,100% of WV Medicaid Rate,165.8,165,,,Fee Schedule,165% of CMS OPPS Rate,104.14,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.83,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,27.53,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.14,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,14.47,14,,,percent of total billed charges,14% of total billed charges,14.47,495.81,
WW Sacroiliac Jts 3 views,3373286,CDM,972,RC,72200,HCPCS,Outpatient,,,80.23,40.12,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
Sacroiliac Joints 3 or more views,602292,CDM,320,RC,72202,HCPCS,Outpatient,,,96.04,48.02,,72.03,75,,,percent of total billed charges,75% of total billed charges,72.03,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,25.56,100,,,Fee Schedule,100% of WV Medicaid Rate,165.8,165,,,Fee Schedule,165% of CMS OPPS Rate,104.14,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.83,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,25.56,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.14,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,13.45,14,,,percent of total billed charges,14% of total billed charges,13.45,495.81,
WW Sacroiliac Joints 3 or more views,3373284,CDM,972,RC,72202,HCPCS,Outpatient,,,96.04,48.02,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
Sacrum and Coccyx,601972,CDM,320,RC,72220,HCPCS,Outpatient,,,79.46,39.73,,59.6,75,,,percent of total billed charges,75% of total billed charges,59.6,75,,,percent of total billed charges,75% of total billed charges,81.68,100,,,Fee Schedule,100% of CMS OPPS Rate,21.14,100,,,Fee Schedule,100% of WV Medicaid Rate,134.77,165,,,Fee Schedule,165% of CMS OPPS Rate,84.65,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,234.61,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,321.76,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,403.03,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,21.14,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,81.68,100,,,Fee Schedule,100% of CMS OPPS Rate,84.65,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,11.12,14,,,percent of total billed charges,14% of total billed charges,11.12,403.03,
WW Sacrum and Coccyx,3373288,CDM,972,RC,72220,HCPCS,Outpatient,,,79.46,39.73,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
WW Clavicle Lt,3373174,CDM,972,RC,73000,HCPCS,Outpatient,,,78.54,39.27,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
WW Clavicle Rt,3373176,CDM,972,RC,73000,HCPCS,Outpatient,,,78.54,39.27,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
WW Scapula Lt,3373290,CDM,972,RC,73010,HCPCS,Outpatient,,,58.9,29.45,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
WW Scapula Rt,3373292,CDM,972,RC,73010,HCPCS,Outpatient,,,58.9,29.45,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
Shoulder Rt one view,602265,CDM,320,RC,73020,HCPCS,Outpatient,,,53.14,26.57,,39.86,75,,,percent of total billed charges,75% of total billed charges,39.86,75,,,percent of total billed charges,75% of total billed charges,81.68,100,,,Fee Schedule,100% of CMS OPPS Rate,14.01,100,,,Fee Schedule,100% of WV Medicaid Rate,134.77,165,,,Fee Schedule,165% of CMS OPPS Rate,84.65,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,234.61,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,321.76,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,403.03,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,14.01,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,81.68,100,,,Fee Schedule,100% of CMS OPPS Rate,84.65,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,7.44,14,,,percent of total billed charges,14% of total billed charges,7.44,403.03,
WW Shoulder Lt 1 view,3373302,CDM,972,RC,73020,HCPCS,Outpatient,,,53.14,26.57,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
WW Shoulder Rt 1 view,3373306,CDM,972,RC,73020,HCPCS,Outpatient,,,53.14,26.57,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
WW Shoulder Lt Rout 2 views,3373304,CDM,972,RC,73030,HCPCS,Outpatient,,,84.3,42.15,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
WW Shoulder Rt Rout 2 views,3373308,CDM,972,RC,73030,HCPCS,Outpatient,,,84.3,42.15,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
Acromioclavicular Joints Bilat,601905,CDM,320,RC,73050,HCPCS,Outpatient,,,70.11,35.06,,52.58,75,,,percent of total billed charges,75% of total billed charges,52.58,75,,,percent of total billed charges,75% of total billed charges,81.68,100,,,Fee Schedule,100% of CMS OPPS Rate,18.68,100,,,Fee Schedule,100% of WV Medicaid Rate,134.77,165,,,Fee Schedule,165% of CMS OPPS Rate,84.65,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,234.61,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,321.76,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,403.03,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,18.68,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,81.68,100,,,Fee Schedule,100% of CMS OPPS Rate,84.65,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,9.82,14,,,percent of total billed charges,14% of total billed charges,9.82,403.03,
WW Acromioclavicular Joints Bilat,3373146,CDM,972,RC,73050,HCPCS,Outpatient,,,70.11,35.06,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
WW Humerus Lt,3373240,CDM,972,RC,73060,HCPCS,Outpatient,,,77.74,38.87,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
WW Humerus Rt,3373238,CDM,972,RC,73060,HCPCS,Outpatient,,,77.74,38.87,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
WW Elbow Lt AP and Lat,3373178,CDM,972,RC,73070,HCPCS,Outpatient,,,71.4,35.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
WW Elbow Rt AP & Lat,3373182,CDM,972,RC,73070,HCPCS,Outpatient,,,71.4,35.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
WW Elbow Lt Rout AP Lat & Oblique,3373180,CDM,972,RC,73080,HCPCS,Outpatient,,,79.46,39.73,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
WW Elbow Rt Rout AP Lat & Oblique,3373184,CDM,972,RC,73080,HCPCS,Outpatient,,,79.46,39.73,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
WW Forearm Lt,3373208,CDM,972,RC,73090,HCPCS,Outpatient,,,71.4,35.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
WW Forearm Rt,3373210,CDM,972,RC,73090,HCPCS,Outpatient,,,71.4,35.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
Upper Extremity Rt Infant min 2 views,602199,CDM,320,RC,73092,HCPCS,Outpatient,,,77.74,38.87,,58.31,75,,,percent of total billed charges,75% of total billed charges,58.31,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,20.65,100,,,Fee Schedule,100% of WV Medicaid Rate,165.8,165,,,Fee Schedule,165% of CMS OPPS Rate,104.14,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.83,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,20.65,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.14,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,10.88,14,,,percent of total billed charges,14% of total billed charges,10.88,495.81,
WW Upper Extrem Lt Infant 2 views,3373344,CDM,972,RC,73092,HCPCS,Outpatient,,,77.74,38.87,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
WW Upper Extrem Rt Infant 2 views,3373346,CDM,972,RC,73092,HCPCS,Outpatient,,,77.74,38.87,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
WW Wrist Lt AP & Lat,3373348,CDM,972,RC,73100,HCPCS,Outpatient,,,82.47,41.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
WW Wrist Rt AP & Lat,3373352,CDM,972,RC,73100,HCPCS,Outpatient,,,82.47,41.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
WW Wrist Lt Rout AP Lat & Oblique,3373350,CDM,972,RC,73110,HCPCS,Outpatient,,,99.19,49.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
WW Wrist Rt Rout AP Lat & Oblique,3373354,CDM,972,RC,73110,HCPCS,Outpatient,,,99.19,49.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
WW Hand Lt AP & Lat,3373212,CDM,972,RC,73120,HCPCS,Outpatient,,,76.16,38.08,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
WW Hand Rt AP & Lat,3373216,CDM,972,RC,73120,HCPCS,Outpatient,,,76.16,38.08,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
WW Hand Lt AP Lat & Oblique,3373214,CDM,972,RC,73130,HCPCS,Outpatient,,,88.93,44.47,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
WW Hand Rt AP Lat & Oblique,3373218,CDM,972,RC,73130,HCPCS,Outpatient,,,88.93,44.47,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
Finger Rt,602058,CDM,320,RC,73140,HCPCS,Outpatient,,,90.76,45.38,,68.07,75,,,percent of total billed charges,75% of total billed charges,68.07,75,,,percent of total billed charges,75% of total billed charges,81.68,100,,,Fee Schedule,100% of CMS OPPS Rate,24.09,100,,,Fee Schedule,100% of WV Medicaid Rate,134.77,165,,,Fee Schedule,165% of CMS OPPS Rate,84.65,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,234.61,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,321.76,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,403.03,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,24.09,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,81.68,100,,,Fee Schedule,100% of CMS OPPS Rate,84.65,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,12.71,14,,,percent of total billed charges,14% of total billed charges,12.71,403.03,
WW Fingers Lt,3373198,CDM,972,RC,73140,HCPCS,Outpatient,,,90.76,45.38,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
WW Fingers Rt,3373196,CDM,972,RC,73140,HCPCS,Outpatient,,,90.76,45.38,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
"73206(26)- Computed tomographic angiography, upper extremity, with contrast material(s), including n",3621200,CDM,510,RC,73206,HCPCS,Outpatient,,,764.43,382.22,,573.32,75,,,percent of total billed charges,75% of total billed charges,573.32,75,,,percent of total billed charges,75% of total billed charges,169.55,100,,,Fee Schedule,100% of CMS OPPS Rate,171.61,100,,,Fee Schedule,100% of WV Medicaid Rate,279.75,165,,,Fee Schedule,165% of CMS OPPS Rate,175.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,486.99,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,667.88,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,836.59,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,171.61,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,169.55,100,,,Fee Schedule,100% of CMS OPPS Rate,175.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,107.02,14,,,percent of total billed charges,14% of total billed charges,107.02,836.59,
Hip Rt 1 view,602110,CDM,320,RC,73501,HCPCS,Outpatient,,,79.56,39.78,,59.67,75,,,percent of total billed charges,75% of total billed charges,59.67,75,,,percent of total billed charges,75% of total billed charges,81.68,100,,,Fee Schedule,100% of CMS OPPS Rate,21.14,100,,,Fee Schedule,100% of WV Medicaid Rate,134.77,165,,,Fee Schedule,165% of CMS OPPS Rate,84.65,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,234.61,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,321.76,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,403.03,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,21.14,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,81.68,100,,,Fee Schedule,100% of CMS OPPS Rate,84.65,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,11.14,14,,,percent of total billed charges,14% of total billed charges,11.14,403.03,
WW Hip Lt 1 view,3373220,CDM,972,RC,73501,HCPCS,Outpatient,,,79.56,39.78,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
WW Hip Rt 1 view,3373226,CDM,972,RC,73501,HCPCS,Outpatient,,,79.56,39.78,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
C Arm Rt Hip,602024,CDM,320,RC,73502,HCPCS,Outpatient,,,114.06,57.03,,85.55,75,,,percent of total billed charges,75% of total billed charges,85.55,75,,,percent of total billed charges,75% of total billed charges,81.68,100,,,Fee Schedule,100% of CMS OPPS Rate,30.48,100,,,Fee Schedule,100% of WV Medicaid Rate,134.77,165,,,Fee Schedule,165% of CMS OPPS Rate,84.65,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,234.61,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,321.76,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,403.03,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,30.48,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,81.68,100,,,Fee Schedule,100% of CMS OPPS Rate,84.65,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,15.97,14,,,percent of total billed charges,14% of total billed charges,15.97,403.03,
WW Hip Lt Rout include Pelvis,3373224,CDM,972,RC,73502,HCPCS,Outpatient,,,114.06,57.03,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
WW Hip Rt Rout include Pelvis,3373230,CDM,972,RC,73502,HCPCS,Outpatient,,,114.06,57.03,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
WW Hip Lt 4 views with Pelvis,3373222,CDM,972,RC,73503,HCPCS,Outpatient,,,143.13,71.57,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
WW Hip Rt 4 views with Pelvis,3373228,CDM,972,RC,73503,HCPCS,Outpatient,,,143.13,71.57,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
Hips Bilat,602106,CDM,320,RC,73521,HCPCS,Outpatient,,,100.63,50.32,,75.47,75,,,percent of total billed charges,75% of total billed charges,75.47,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,26.79,100,,,Fee Schedule,100% of WV Medicaid Rate,165.8,165,,,Fee Schedule,165% of CMS OPPS Rate,104.14,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.83,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,26.79,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.14,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,14.09,14,,,percent of total billed charges,14% of total billed charges,14.09,495.81,
WW Hips Bilat,3373232,CDM,972,RC,73521,HCPCS,Outpatient,,,100.63,50.32,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
WW Hips Bilat 3-4 views w Pelvis,3373234,CDM,972,RC,73522,HCPCS,Outpatient,,,130.73,65.37,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
WW Hips Bilat 5 views w Pelvis,3373236,CDM,972,RC,73523,HCPCS,Outpatient,,,149.18,74.59,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
WW Femur Lt 1 view,3373190,CDM,972,RC,73551,HCPCS,Outpatient,,,71.4,35.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
WW Femur Rt 1 view,3373194,CDM,972,RC,73551,HCPCS,Outpatient,,,71.4,35.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
WW Femur Lt,3373188,CDM,972,RC,73552,HCPCS,Outpatient,,,85.87,42.94,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
WW Femur Rt,3373192,CDM,972,RC,73552,HCPCS,Outpatient,,,85.87,42.94,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
WW Knee Lt AP & Lat,3373244,CDM,972,RC,73560,HCPCS,Outpatient,,,83.26,41.63,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
WW Knee Rt AP & Lat,3373250,CDM,972,RC,73560,HCPCS,Outpatient,,,83.26,41.63,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
WW Knee Lt 3 views,3373242,CDM,972,RC,73562,HCPCS,Outpatient,,,99.32,49.66,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
WW Knee Rt 3 views,3373248,CDM,972,RC,73562,HCPCS,Outpatient,,,99.32,49.66,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
WW Knee Lt Series,3373246,CDM,972,RC,73564,HCPCS,Outpatient,,,112.47,56.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
WW Knee Rt Series,3373252,CDM,972,RC,73564,HCPCS,Outpatient,,,112.47,56.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
Knees Bilat Standing AP,602157,CDM,320,RC,73565,HCPCS,Outpatient,,,98.26,49.13,,73.7,75,,,percent of total billed charges,75% of total billed charges,73.7,75,,,percent of total billed charges,75% of total billed charges,81.68,100,,,Fee Schedule,100% of CMS OPPS Rate,26.05,100,,,Fee Schedule,100% of WV Medicaid Rate,134.77,165,,,Fee Schedule,165% of CMS OPPS Rate,84.65,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,234.61,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,321.76,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,403.03,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,26.05,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,81.68,100,,,Fee Schedule,100% of CMS OPPS Rate,84.65,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,13.76,14,,,percent of total billed charges,14% of total billed charges,13.76,403.03,
WW Knees Bilat Standing AP,3373254,CDM,972,RC,73565,HCPCS,Outpatient,,,98.26,49.13,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
WW Tibia Fibula Lt,3373334,CDM,972,RC,73590,HCPCS,Outpatient,,,76.93,38.47,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
WW Tibia Fibula Rt,3373336,CDM,972,RC,73590,HCPCS,Outpatient,,,76.93,38.47,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
Lower Extremity Rt Infant min 2 views,602148,CDM,320,RC,73592,HCPCS,Outpatient,,,77.74,38.87,,58.31,75,,,percent of total billed charges,75% of total billed charges,58.31,75,,,percent of total billed charges,75% of total billed charges,81.68,100,,,Fee Schedule,100% of CMS OPPS Rate,20.65,100,,,Fee Schedule,100% of WV Medicaid Rate,134.77,165,,,Fee Schedule,165% of CMS OPPS Rate,84.65,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,234.61,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,321.76,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,403.03,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,20.65,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,81.68,100,,,Fee Schedule,100% of CMS OPPS Rate,84.65,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,10.88,14,,,percent of total billed charges,14% of total billed charges,10.88,403.03,
WW Lower Extremity Bilat Infant,3373256,CDM,972,RC,73592,HCPCS,Outpatient,,,77.74,38.87,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
WW Ankle Lt AP & Lat,3373148,CDM,972,RC,73600,HCPCS,Outpatient,,,78.49,39.25,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
WW Ankle Rt AP & Lat,3373152,CDM,972,RC,73600,HCPCS,Outpatient,,,78.49,39.25,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
WW Ankle Lt AP Lat & Oblique,3373150,CDM,972,RC,73610,HCPCS,Outpatient,,,89.73,44.87,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
WW Ankle Rt AP Lat & Oblique,3373154,CDM,972,RC,73610,HCPCS,Outpatient,,,89.73,44.87,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
WW Foot Lt AP & Lat,3373200,CDM,972,RC,73620,HCPCS,Outpatient,,,69.06,34.53,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
WW Foot Rt AP & Lat,3373204,CDM,972,RC,73620,HCPCS,Outpatient,,,69.06,34.53,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
Foot Rt AP Lat and Oblique,602042,CDM,320,RC,73630,HCPCS,Outpatient,,,84.17,42.09,,63.13,75,,,percent of total billed charges,75% of total billed charges,63.13,75,,,percent of total billed charges,75% of total billed charges,81.68,100,,,Fee Schedule,100% of CMS OPPS Rate,22.37,100,,,Fee Schedule,100% of WV Medicaid Rate,134.77,165,,,Fee Schedule,165% of CMS OPPS Rate,84.65,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,234.61,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,321.76,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,403.03,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,22.37,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,81.68,100,,,Fee Schedule,100% of CMS OPPS Rate,84.65,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,11.78,14,,,percent of total billed charges,14% of total billed charges,11.78,403.03,
WW Foot Lt AP Lat & Oblique,3373202,CDM,972,RC,73630,HCPCS,Outpatient,,,84.17,42.09,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
WW Foot Rt AP Lat & Oblique,3373206,CDM,972,RC,73630,HCPCS,Outpatient,,,84.17,42.09,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
Calcaneus Rt,602018,CDM,320,RC,73650,HCPCS,Outpatient,,,70.61,35.31,,52.96,75,,,percent of total billed charges,75% of total billed charges,52.96,75,,,percent of total billed charges,75% of total billed charges,81.68,100,,,Fee Schedule,100% of CMS OPPS Rate,18.68,100,,,Fee Schedule,100% of WV Medicaid Rate,134.77,165,,,Fee Schedule,165% of CMS OPPS Rate,84.65,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,234.61,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,321.76,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,403.03,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,18.68,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,81.68,100,,,Fee Schedule,100% of CMS OPPS Rate,84.65,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,9.89,14,,,percent of total billed charges,14% of total billed charges,9.89,403.03,
WW Calcaneus Lt,3373158,CDM,972,RC,73650,HCPCS,Outpatient,,,70.61,35.31,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
WW Calcaneus Rt,3373160,CDM,972,RC,73650,HCPCS,Outpatient,,,70.61,35.31,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
Toes Rt,602213,CDM,320,RC,73660,HCPCS,Outpatient,,,71.03,35.52,,53.27,75,,,percent of total billed charges,75% of total billed charges,53.27,75,,,percent of total billed charges,75% of total billed charges,81.68,100,,,Fee Schedule,100% of CMS OPPS Rate,18.93,100,,,Fee Schedule,100% of WV Medicaid Rate,134.77,165,,,Fee Schedule,165% of CMS OPPS Rate,84.65,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,234.61,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,321.76,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,403.03,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,18.93,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,81.68,100,,,Fee Schedule,100% of CMS OPPS Rate,84.65,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,9.94,14,,,percent of total billed charges,14% of total billed charges,9.94,403.03,
WW Toes Lt,3373340,CDM,972,RC,73660,HCPCS,Outpatient,,,71.03,35.52,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
WW Toes Rt,3373342,CDM,972,RC,73660,HCPCS,Outpatient,,,71.03,35.52,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
WW Abdomen AP,3373136,CDM,972,RC,74018,HCPCS,Outpatient,,,74.03,37.02,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
WW Abdomen Flat and Uprt No Chest,3373140,CDM,972,RC,74019,HCPCS,Outpatient,,,90.5,45.25,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
WW Abdomen Rout Flat & Uprt w PA Chest,3373142,CDM,972,RC,74021,HCPCS,Outpatient,,,106.03,53.02,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
Abdomen Routine Flat and Uprt w PA Chest,601903,CDM,320,RC,74022,HCPCS,Outpatient,,,122.46,61.23,,91.85,75,,,percent of total billed charges,75% of total billed charges,91.85,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,32.69,100,,,Fee Schedule,100% of WV Medicaid Rate,165.8,165,,,Fee Schedule,165% of CMS OPPS Rate,104.14,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.83,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,32.69,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.14,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,17.14,14,,,percent of total billed charges,14% of total billed charges,17.14,495.81,
WW Abdomen W/S/E/D views w Chest,3373144,CDM,972,RC,74022,HCPCS,Outpatient,,,122.46,61.23,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
Esophageal Dilatation:Read,3334677,CDM,972,RC,74360,HCPCS,Outpatient,,,142.96,71.48,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
"74740 - PF - Hysterosalpingography, radiological supervision and interpretation",3640903,CDM,510,RC,74740,HCPCS,Outpatient,,,238.05,119.03,,178.54,75,,,percent of total billed charges,75% of total billed charges,178.54,75,,,percent of total billed charges,75% of total billed charges,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,63.66,100,,,Fee Schedule,100% of WV Medicaid Rate,362.25,165,,,Fee Schedule,165% of CMS OPPS Rate,227.54,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,630.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,864.84,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1083.3,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,63.66,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,227.54,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,33.33,14,,,percent of total billed charges,14% of total billed charges,33.33,1083.3,
75557 - (PF) Cardiac magnetic resonance imaging for morphology and function without contrast mat,3635232,CDM,510,RC,75557,HCPCS,Outpatient,,,731.08,365.54,,548.31,75,,,percent of total billed charges,75% of total billed charges,548.31,75,,,percent of total billed charges,75% of total billed charges,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,195.17,100,,,Fee Schedule,100% of WV Medicaid Rate,362.24,165,,,Fee Schedule,165% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,630.61,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,864.84,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1083.29,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,195.17,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,102.35,14,,,percent of total billed charges,14% of total billed charges,102.35,1083.29,
75559 - (PF) Cardiac magnetic resonance imaging for morphology and function without contrast mat,3635233,CDM,510,RC,75559,HCPCS,Outpatient,,,982.73,491.37,,737.05,75,,,percent of total billed charges,75% of total billed charges,737.05,75,,,percent of total billed charges,75% of total billed charges,473.01,100,,,Fee Schedule,100% of CMS OPPS Rate,262.27,100,,,Fee Schedule,100% of WV Medicaid Rate,780.48,165,,,Fee Schedule,165% of CMS OPPS Rate,490.24,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1358.69,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1863.34,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,2334.03,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,262.27,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,473.01,100,,,Fee Schedule,100% of CMS OPPS Rate,490.24,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,137.58,14,,,percent of total billed charges,14% of total billed charges,137.58,2334.03,
75561(26)- Cardiac magnetic resonance imaging for morphology and function without contrast material(,3621301,CDM,510,RC,75561,HCPCS,Outpatient,,,952.9,476.45,,714.68,75,,,percent of total billed charges,75% of total billed charges,714.68,75,,,percent of total billed charges,75% of total billed charges,346.38,100,,,Fee Schedule,100% of CMS OPPS Rate,254.4,100,,,Fee Schedule,100% of WV Medicaid Rate,571.51,165,,,Fee Schedule,165% of CMS OPPS Rate,358.99,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,994.94,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1364.48,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1709.15,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,254.4,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,346.38,100,,,Fee Schedule,100% of CMS OPPS Rate,358.99,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,133.41,14,,,percent of total billed charges,14% of total billed charges,133.41,1709.15,
75565 (26) Cardiac MRI for velocity flow mapping,3620978,CDM,510,RC,75565,HCPCS,Outpatient,,,118.88,59.44,,89.16,75,,,percent of total billed charges,75% of total billed charges,89.16,75,,,percent of total billed charges,75% of total billed charges,38.04,32,,,percent of total billed charges,32% of total billed charges,31.71,100,,,Fee Schedule,100% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.71,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.64,14,,,percent of total billed charges,14% of total billed charges,16.64,89.16,
75565- Cardiac MRI for velocity flow mapping,3569427,CDM,510,RC,75565,HCPCS,Outpatient,,,118.88,59.44,,89.16,75,,,percent of total billed charges,75% of total billed charges,89.16,75,,,percent of total billed charges,75% of total billed charges,38.04,32,,,percent of total billed charges,32% of total billed charges,31.71,100,,,Fee Schedule,100% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.71,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.64,14,,,percent of total billed charges,14% of total billed charges,16.64,89.16,
"75572 - (PF) Computed tomography, heart, with contrast mater",3635236,CDM,510,RC,75572,HCPCS,Outpatient,,,582.52,291.26,,436.89,75,,,percent of total billed charges,75% of total billed charges,436.89,75,,,percent of total billed charges,75% of total billed charges,169.55,100,,,Fee Schedule,100% of CMS OPPS Rate,155.59,100,,,Fee Schedule,100% of WV Medicaid Rate,279.75,165,,,Fee Schedule,165% of CMS OPPS Rate,175.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,486.99,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,667.88,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,836.59,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,155.59,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,169.55,100,,,Fee Schedule,100% of CMS OPPS Rate,175.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,81.55,14,,,percent of total billed charges,14% of total billed charges,81.55,836.59,
"75574(26)- Computed tomographic angiography, heart, coronary arteries and bypass grafts (when presen",3621300,CDM,510,RC,75574,HCPCS,Outpatient,,,829.3,414.65,,621.98,75,,,percent of total billed charges,75% of total billed charges,621.98,75,,,percent of total billed charges,75% of total billed charges,169.55,100,,,Fee Schedule,100% of CMS OPPS Rate,191.04,100,,,Fee Schedule,100% of WV Medicaid Rate,279.75,165,,,Fee Schedule,165% of CMS OPPS Rate,175.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,486.99,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,667.88,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,836.59,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,191.04,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,169.55,100,,,Fee Schedule,100% of CMS OPPS Rate,175.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,116.1,14,,,percent of total billed charges,14% of total billed charges,116.1,836.59,
"75630 - PF - Aortography, abdominal plus bilateral iliofemoral lower extremity, catheter, by serialo",3640904,CDM,510,RC,75630,HCPCS,Outpatient,,,16287.33,8143.67,,12215.5,75,,,percent of total billed charges,75% of total billed charges,12215.5,75,,,percent of total billed charges,75% of total billed charges,2800.72,100,,,Fee Schedule,100% of CMS OPPS Rate,108.4,100,,,Fee Schedule,100% of WV Medicaid Rate,4621.2,165,,,Fee Schedule,165% of CMS OPPS Rate,2902.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8044.7,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11032.67,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13819.54,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,108.4,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2800.72,100,,,Fee Schedule,100% of CMS OPPS Rate,2902.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,2280.23,14,,,percent of total billed charges,14% of total billed charges,108.4,13819.54,
Peripheral Angio Aortagram w Runoff,3427191,CDM,320,RC,75630,HCPCS,Outpatient,,,16287.33,8143.67,,12215.5,75,,,percent of total billed charges,75% of total billed charges,12215.5,75,,,percent of total billed charges,75% of total billed charges,2800.72,100,,,Fee Schedule,100% of CMS OPPS Rate,108.4,100,,,Fee Schedule,100% of WV Medicaid Rate,4621.2,165,,,Fee Schedule,165% of CMS OPPS Rate,2902.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8044.7,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11032.67,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13819.54,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,108.4,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2800.72,100,,,Fee Schedule,100% of CMS OPPS Rate,2902.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,2280.23,14,,,percent of total billed charges,14% of total billed charges,108.4,13819.54,
"75710 - Angiography, extremity, unilateral, radiological supervision and interpretation",3640905,CDM,510,RC,75710,HCPCS,Outpatient,,,16265.83,8132.92,,12199.37,75,,,percent of total billed charges,75% of total billed charges,12199.37,75,,,percent of total billed charges,75% of total billed charges,2800.72,100,,,Fee Schedule,100% of CMS OPPS Rate,103.48,100,,,Fee Schedule,100% of WV Medicaid Rate,4621.2,165,,,Fee Schedule,165% of CMS OPPS Rate,2902.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8044.7,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11032.67,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13819.54,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,103.48,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2800.72,100,,,Fee Schedule,100% of CMS OPPS Rate,2902.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,2277.22,14,,,percent of total billed charges,14% of total billed charges,103.48,13819.54,
Peripheral Angio Lower Extremity LT,3427218,CDM,320,RC,75710,HCPCS,Outpatient,,,16265.83,8132.92,,12199.37,75,,,percent of total billed charges,75% of total billed charges,12199.37,75,,,percent of total billed charges,75% of total billed charges,2800.72,100,,,Fee Schedule,100% of CMS OPPS Rate,103.48,100,,,Fee Schedule,100% of WV Medicaid Rate,4621.2,165,,,Fee Schedule,165% of CMS OPPS Rate,2902.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8044.7,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11032.67,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13819.54,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,103.48,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2800.72,100,,,Fee Schedule,100% of CMS OPPS Rate,2902.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,2277.22,14,,,percent of total billed charges,14% of total billed charges,103.48,13819.54,
Peripheral Angio Lower Extremity RT,3427219,CDM,320,RC,75710,HCPCS,Outpatient,,,16265.83,8132.92,,12199.37,75,,,percent of total billed charges,75% of total billed charges,12199.37,75,,,percent of total billed charges,75% of total billed charges,2800.72,100,,,Fee Schedule,100% of CMS OPPS Rate,103.48,100,,,Fee Schedule,100% of WV Medicaid Rate,4621.2,165,,,Fee Schedule,165% of CMS OPPS Rate,2902.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8044.7,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11032.67,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13819.54,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,103.48,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2800.72,100,,,Fee Schedule,100% of CMS OPPS Rate,2902.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,2277.22,14,,,percent of total billed charges,14% of total billed charges,103.48,13819.54,
Peripheral Angio Tibal Peroneal,3427225,CDM,320,RC,75710,HCPCS,Outpatient,,,16265.83,8132.92,,12199.37,75,,,percent of total billed charges,75% of total billed charges,12199.37,75,,,percent of total billed charges,75% of total billed charges,2800.72,100,,,Fee Schedule,100% of CMS OPPS Rate,103.48,100,,,Fee Schedule,100% of WV Medicaid Rate,4621.2,165,,,Fee Schedule,165% of CMS OPPS Rate,2902.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8044.7,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11032.67,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13819.54,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,103.48,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2800.72,100,,,Fee Schedule,100% of CMS OPPS Rate,2902.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,2277.22,14,,,percent of total billed charges,14% of total billed charges,103.48,13819.54,
"75716 - PF - Angiography, extremity, bilateral, radiological supervision and interpretation",3640906,CDM,510,RC,75716,HCPCS,Outpatient,,,418.27,209.14,,313.7,75,,,percent of total billed charges,75% of total billed charges,313.7,75,,,percent of total billed charges,75% of total billed charges,2800.72,100,,,Fee Schedule,100% of CMS OPPS Rate,111.84,100,,,Fee Schedule,100% of WV Medicaid Rate,4621.2,165,,,Fee Schedule,165% of CMS OPPS Rate,2902.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8044.7,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11032.67,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13819.54,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,111.84,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2800.72,100,,,Fee Schedule,100% of CMS OPPS Rate,2902.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,58.56,14,,,percent of total billed charges,14% of total billed charges,58.56,13819.54,
75894 XR Transcatheter Embolization Any Meth RS&I,3436057,CDM,761,RC,75894,HCPCS,Outpatient,,,376.14,188.07,,282.11,75,,,percent of total billed charges,75% of total billed charges,282.11,75,,,percent of total billed charges,75% of total billed charges,120.36,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.66,14,,,percent of total billed charges,14% of total billed charges,52.66,282.11,
Foreign Body Nose to Rectum Child,602034,CDM,320,RC,76010,HCPCS,Outpatient,,,73.24,36.62,,54.93,75,,,percent of total billed charges,75% of total billed charges,54.93,75,,,percent of total billed charges,75% of total billed charges,81.68,100,,,Fee Schedule,100% of CMS OPPS Rate,19.42,100,,,Fee Schedule,100% of WV Medicaid Rate,134.77,165,,,Fee Schedule,165% of CMS OPPS Rate,84.65,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,234.61,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,321.76,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,403.03,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,19.42,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,81.68,100,,,Fee Schedule,100% of CMS OPPS Rate,84.65,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,10.25,14,,,percent of total billed charges,14% of total billed charges,10.25,403.03,
3D TEE Imaging,3569848,CDM,350,RC,76376,HCPCS,Outpatient,,,50.84,25.42,,38.13,75,,,percent of total billed charges,75% of total billed charges,38.13,75,,,percent of total billed charges,75% of total billed charges,16.27,32,,,percent of total billed charges,32% of total billed charges,14.99,100,,,Fee Schedule,100% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.99,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.12,14,,,percent of total billed charges,14% of total billed charges,7.12,38.13,
"76376(26)- 3D rendering with interpretation and reporting of computed tomography, magnetic resonance",3620958,CDM,510,RC,76376,HCPCS,Outpatient,,,56.94,28.47,,42.71,75,,,percent of total billed charges,75% of total billed charges,42.71,75,,,percent of total billed charges,75% of total billed charges,18.22,32,,,percent of total billed charges,32% of total billed charges,14.99,100,,,Fee Schedule,100% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.99,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.97,14,,,percent of total billed charges,14% of total billed charges,7.97,42.71,
76536- US head and neck,3430613,CDM,402,RC,76536,HCPCS,Outpatient,,,274.97,137.49,,206.23,75,,,percent of total billed charges,75% of total billed charges,206.23,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,73.48,100,,,Fee Schedule,100% of WV Medicaid Rate,165.8,165,,,Fee Schedule,165% of CMS OPPS Rate,104.14,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.83,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,73.48,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.14,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,38.5,14,,,percent of total billed charges,14% of total billed charges,38.5,495.81,
SCMP US Guided Fine Needle Asp. Thyroid,3370908,CDM,972,RC,76536,HCPCS,Outpatient,,,274.97,137.49,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
SCMP US Guided Fine Needle Asp. Thyroid,3575239,CDM,972,RC,76536,HCPCS,Outpatient,,,274.97,137.49,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
SCMP US Guided Fine Needle Asp. Thyroid,3575240,CDM,972,RC,76536,HCPCS,Outpatient,,,274.97,137.49,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
SCMP US Thyroid,3575246,CDM,972,RC,76536,HCPCS,Outpatient,,,274.97,137.49,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
SCMP US Thyroid,3370915,CDM,402,RC,76536,HCPCS,Outpatient,,,274.97,137.49,,206.23,75,,,percent of total billed charges,75% of total billed charges,206.23,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,73.48,100,,,Fee Schedule,100% of WV Medicaid Rate,165.8,165,,,Fee Schedule,165% of CMS OPPS Rate,104.14,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.83,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,73.48,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.14,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,38.5,14,,,percent of total billed charges,14% of total billed charges,38.5,495.81,
SCSN US Thyroid,3370964,CDM,402,RC,76536,HCPCS,Outpatient,,,274.97,137.49,,206.23,75,,,percent of total billed charges,75% of total billed charges,206.23,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,73.48,100,,,Fee Schedule,100% of WV Medicaid Rate,165.8,165,,,Fee Schedule,165% of CMS OPPS Rate,104.14,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.83,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,73.48,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.14,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,38.5,14,,,percent of total billed charges,14% of total billed charges,38.5,495.81,
US Chest Marking Rt,3351913,CDM,402,RC,76604,HCPCS,Outpatient,,,146.66,73.33,,110,75,,,percent of total billed charges,75% of total billed charges,110,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,39.08,100,,,Fee Schedule,100% of WV Medicaid Rate,165.8,165,,,Fee Schedule,165% of CMS OPPS Rate,104.14,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.83,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,39.08,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.14,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,20.53,14,,,percent of total billed charges,14% of total billed charges,20.53,495.81,
76641 - (26) US Breast Complete,3896985,CDM,960,RC,76641,HCPCS,Outpatient,,,255.87,127.94,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
76641 - (TC) US Breast Complete,3896992,CDM,960,RC,76641,HCPCS,Outpatient,,,255.87,127.94,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
76641 - US Breast Complete,3896999,CDM,960,RC,76641,HCPCS,Outpatient,,,255.87,127.94,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
76641- US  breast complete,3430614,CDM,402,RC,76641,HCPCS,Outpatient,,,255.87,127.94,,191.9,75,,,percent of total billed charges,75% of total billed charges,191.9,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,68.33,100,,,Fee Schedule,100% of WV Medicaid Rate,165.8,165,,,Fee Schedule,165% of CMS OPPS Rate,104.14,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.83,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,68.33,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.14,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,35.82,14,,,percent of total billed charges,14% of total billed charges,35.82,495.81,
Read,3575229,CDM,972,RC,76641,HCPCS,Outpatient,,,255.87,127.94,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
SCMP US Breast L,3370898,CDM,972,RC,76641,HCPCS,Outpatient,,,255.87,127.94,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
SCMP US Breast L,3575230,CDM,972,RC,76641,HCPCS,Outpatient,,,255.87,127.94,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
SCMP US Breast L,3575232,CDM,972,RC,76641,HCPCS,Outpatient,,,255.87,127.94,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
SCMP US Breast L:Read,4119871,CDM,983,RC,76641,HCPCS,Outpatient,,,228.46,114.23,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
SCMP US Breast R,3370900,CDM,972,RC,76641,HCPCS,Outpatient,,,255.87,127.94,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
SCMP US Breast R:Read,3575231,CDM,972,RC,76641,HCPCS,Outpatient,,,255.87,127.94,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
SCMP US Breast R:Read,4119897,CDM,983,RC,76641,HCPCS,Outpatient,,,228.46,114.23,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
US Breast Left:Read,3317746,CDM,972,RC,76641,HCPCS,Outpatient,,,255.87,127.94,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
US HKBT Breast Bilateral:Read,3317823,CDM,972,RC,76641,HCPCS,Outpatient,,,255.87,127.94,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
US HKBT Breast Left:Read,3317809,CDM,972,RC,76641,HCPCS,Outpatient,,,255.87,127.94,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
US HKBT Breast Right:Read,3317816,CDM,972,RC,76641,HCPCS,Outpatient,,,255.87,127.94,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
WHFMT US Breast Complete Bilateral,4165499,CDM,972,RC,76641,HCPCS,Outpatient,,,511.76,255.88,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
WHFMT US Exam,4165501,CDM,972,RC,76641,HCPCS,Outpatient,,,255.87,127.94,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
WHFMT US Exam,4165503,CDM,972,RC,76641,HCPCS,Outpatient,,,255.87,127.94,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
76642 - (26) US Breast Limited,3897005,CDM,960,RC,76642,HCPCS,Outpatient,,,211.01,105.51,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
76642 - (TC) US Breast Limited,3897012,CDM,960,RC,76642,HCPCS,Outpatient,,,211.01,105.51,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
76642 - US Breast Limited,3897019,CDM,960,RC,76642,HCPCS,Outpatient,,,211.01,105.51,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
76642- US  breast limited,3430615,CDM,402,RC,76642,HCPCS,Outpatient,,,211.01,105.51,,158.26,75,,,percent of total billed charges,75% of total billed charges,158.26,75,,,percent of total billed charges,75% of total billed charges,81.68,100,,,Fee Schedule,100% of CMS OPPS Rate,56.29,100,,,Fee Schedule,100% of WV Medicaid Rate,134.77,165,,,Fee Schedule,165% of CMS OPPS Rate,84.65,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,234.61,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,321.76,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,403.03,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,56.29,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,81.68,100,,,Fee Schedule,100% of CMS OPPS Rate,84.65,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,29.54,14,,,percent of total billed charges,14% of total billed charges,29.54,403.03,
Read,3569766,CDM,510,RC,76642,HCPCS,Outpatient,,,211.01,105.51,,158.26,75,,,percent of total billed charges,75% of total billed charges,158.26,75,,,percent of total billed charges,75% of total billed charges,81.68,100,,,Fee Schedule,100% of CMS OPPS Rate,56.29,100,,,Fee Schedule,100% of WV Medicaid Rate,134.77,165,,,Fee Schedule,165% of CMS OPPS Rate,84.65,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,234.61,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,321.76,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,403.03,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,56.29,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,81.68,100,,,Fee Schedule,100% of CMS OPPS Rate,84.65,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,29.54,14,,,percent of total billed charges,14% of total billed charges,29.54,403.03,
Read,3575277,CDM,972,RC,76642,HCPCS,Outpatient,,,211.01,105.51,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
SCSN US Breast Limite Bilat Interp,3575275,CDM,972,RC,76642,HCPCS,Outpatient,,,211.01,105.51,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
SCSN US Breast Limited Bilat,3569759,CDM,401,RC,76642,HCPCS,Outpatient,,,422.03,211.02,,316.52,75,,,percent of total billed charges,75% of total billed charges,316.52,75,,,percent of total billed charges,75% of total billed charges,81.68,100,,,Fee Schedule,100% of CMS OPPS Rate,56.29,100,,,Fee Schedule,100% of WV Medicaid Rate,134.77,165,,,Fee Schedule,165% of CMS OPPS Rate,84.65,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,234.61,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,321.76,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,403.03,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,56.29,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,81.68,100,,,Fee Schedule,100% of CMS OPPS Rate,84.65,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,59.08,14,,,percent of total billed charges,14% of total billed charges,56.29,403.03,
SCSN US Breast Limited LT,3569761,CDM,401,RC,76642,HCPCS,Outpatient,,,211.01,105.51,,158.26,75,,,percent of total billed charges,75% of total billed charges,158.26,75,,,percent of total billed charges,75% of total billed charges,81.68,100,,,Fee Schedule,100% of CMS OPPS Rate,56.29,100,,,Fee Schedule,100% of WV Medicaid Rate,134.77,165,,,Fee Schedule,165% of CMS OPPS Rate,84.65,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,234.61,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,321.76,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,403.03,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,56.29,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,81.68,100,,,Fee Schedule,100% of CMS OPPS Rate,84.65,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,29.54,14,,,percent of total billed charges,14% of total billed charges,29.54,403.03,
SCSN US Breast Limited RT,3569763,CDM,401,RC,76642,HCPCS,Outpatient,,,211.01,105.51,,158.26,75,,,percent of total billed charges,75% of total billed charges,158.26,75,,,percent of total billed charges,75% of total billed charges,81.68,100,,,Fee Schedule,100% of CMS OPPS Rate,56.29,100,,,Fee Schedule,100% of WV Medicaid Rate,134.77,165,,,Fee Schedule,165% of CMS OPPS Rate,84.65,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,234.61,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,321.76,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,403.03,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,56.29,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,81.68,100,,,Fee Schedule,100% of CMS OPPS Rate,84.65,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,29.54,14,,,percent of total billed charges,14% of total billed charges,29.54,403.03,
SCSN US Breast Limited RT Interp,3575279,CDM,972,RC,76642,HCPCS,Outpatient,,,211.01,105.51,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
SCSN US Breast w Axilla Bilat,3569765,CDM,401,RC,76642,HCPCS,Outpatient,,,422.03,211.02,,316.52,75,,,percent of total billed charges,75% of total billed charges,316.52,75,,,percent of total billed charges,75% of total billed charges,81.68,100,,,Fee Schedule,100% of CMS OPPS Rate,56.29,100,,,Fee Schedule,100% of WV Medicaid Rate,134.77,165,,,Fee Schedule,165% of CMS OPPS Rate,84.65,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,234.61,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,321.76,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,403.03,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,56.29,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,81.68,100,,,Fee Schedule,100% of CMS OPPS Rate,84.65,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,59.08,14,,,percent of total billed charges,14% of total billed charges,56.29,403.03,
SCSN US Breast w axilla Bilat Interp,3575281,CDM,972,RC,76642,HCPCS,Outpatient,,,211.01,105.51,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
SCSN US Breast w Axilla LT,3575283,CDM,972,RC,76642,HCPCS,Outpatient,,,211.01,105.51,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
SCSN US Breast w Axilla LT,3575285,CDM,972,RC,76642,HCPCS,Outpatient,,,211.01,105.51,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
SCSN US Breast w Axilla LT,3569767,CDM,401,RC,76642,HCPCS,Outpatient,,,211.01,105.51,,158.26,75,,,percent of total billed charges,75% of total billed charges,158.26,75,,,percent of total billed charges,75% of total billed charges,81.68,100,,,Fee Schedule,100% of CMS OPPS Rate,56.29,100,,,Fee Schedule,100% of WV Medicaid Rate,134.77,165,,,Fee Schedule,165% of CMS OPPS Rate,84.65,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,234.61,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,321.76,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,403.03,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,56.29,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,81.68,100,,,Fee Schedule,100% of CMS OPPS Rate,84.65,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,29.54,14,,,percent of total billed charges,14% of total billed charges,29.54,403.03,
SCSN US Breast w Axilla RT,3569769,CDM,401,RC,76642,HCPCS,Outpatient,,,211.01,105.51,,158.26,75,,,percent of total billed charges,75% of total billed charges,158.26,75,,,percent of total billed charges,75% of total billed charges,81.68,100,,,Fee Schedule,100% of CMS OPPS Rate,56.29,100,,,Fee Schedule,100% of WV Medicaid Rate,134.77,165,,,Fee Schedule,165% of CMS OPPS Rate,84.65,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,234.61,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,321.76,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,403.03,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,56.29,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,81.68,100,,,Fee Schedule,100% of CMS OPPS Rate,84.65,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,29.54,14,,,percent of total billed charges,14% of total billed charges,29.54,403.03,
US Breast Bilateral Limited:Read,3318563,CDM,972,RC,76642,HCPCS,Outpatient,,,211.01,105.51,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
US Breast Rt Limited,3318871,CDM,402,RC,76642,HCPCS,Outpatient,,,399.08,199.54,,299.31,75,,,percent of total billed charges,75% of total billed charges,299.31,75,,,percent of total billed charges,75% of total billed charges,81.68,100,,,Fee Schedule,100% of CMS OPPS Rate,56.29,100,,,Fee Schedule,100% of WV Medicaid Rate,134.77,165,,,Fee Schedule,165% of CMS OPPS Rate,84.65,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,234.61,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,321.76,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,403.03,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,56.29,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,81.68,100,,,Fee Schedule,100% of CMS OPPS Rate,84.65,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,55.87,14,,,percent of total billed charges,14% of total billed charges,55.87,403.03,
WHFMT US Exam,3610982,CDM,972,RC,76642,HCPCS,Outpatient,,,422.03,211.02,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
WHFMT US Exam,3610984,CDM,972,RC,76642,HCPCS,Outpatient,,,211.01,105.51,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
WHFMT US Exam,3610986,CDM,972,RC,76642,HCPCS,Outpatient,,,211.01,105.51,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
"76700 (26) Ultrasound, abdominal, real time with image documentation; complete",3621069,CDM,510,RC,76700,HCPCS,Outpatient,,,290.87,145.44,,218.15,75,,,percent of total billed charges,75% of total billed charges,218.15,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,77.67,100,,,Fee Schedule,100% of WV Medicaid Rate,165.79,165,,,Fee Schedule,165% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.82,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,77.67,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,40.72,14,,,percent of total billed charges,14% of total billed charges,40.72,495.81,
"76700 (TC) Ultrasound, abdominal, real time with image documentation; complete",3621070,CDM,510,RC,76700,HCPCS,Outpatient,,,290.87,145.44,,218.15,75,,,percent of total billed charges,75% of total billed charges,218.15,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,77.67,100,,,Fee Schedule,100% of WV Medicaid Rate,165.79,165,,,Fee Schedule,165% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.82,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,77.67,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,40.72,14,,,percent of total billed charges,14% of total billed charges,40.72,495.81,
76700- US abdommen complete,3430616,CDM,402,RC,76700,HCPCS,Outpatient,,,290.87,145.44,,218.15,75,,,percent of total billed charges,75% of total billed charges,218.15,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,77.67,100,,,Fee Schedule,100% of WV Medicaid Rate,165.79,165,,,Fee Schedule,165% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.82,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,77.67,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,40.72,14,,,percent of total billed charges,14% of total billed charges,40.72,495.81,
Read,3575253,CDM,983,RC,76700,HCPCS,Outpatient,,,290.87,145.44,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
SCSN US Abdomen Complete PR:SCSN US Exam,3575254,CDM,510,RC,76700,HCPCS,Outpatient,,,290.87,145.44,,218.15,75,,,percent of total billed charges,75% of total billed charges,218.15,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,77.67,100,,,Fee Schedule,100% of WV Medicaid Rate,165.79,165,,,Fee Schedule,165% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.82,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,77.67,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,40.72,14,,,percent of total billed charges,14% of total billed charges,40.72,495.81,
SCSN US Abdomen Complete:SCSN US Exam,3555174,CDM,402,RC,76700,HCPCS,Outpatient,,,290.87,145.44,,218.15,75,,,percent of total billed charges,75% of total billed charges,218.15,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,77.67,100,,,Fee Schedule,100% of WV Medicaid Rate,165.79,165,,,Fee Schedule,165% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.82,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,77.67,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,40.72,14,,,percent of total billed charges,14% of total billed charges,40.72,495.81,
US HKBT Abdomen  Complete,3317829,CDM,402,RC,76700,HCPCS,Outpatient,,,571.2,285.6,,428.4,75,,,percent of total billed charges,75% of total billed charges,428.4,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,77.67,100,,,Fee Schedule,100% of WV Medicaid Rate,165.79,165,,,Fee Schedule,165% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.82,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,77.67,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,79.97,14,,,percent of total billed charges,14% of total billed charges,77.67,495.81,
US HKBT Abdomen  Complete:Read,3317830,CDM,983,RC,76700,HCPCS,Outpatient,,,290.87,145.44,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
76705 - (TC) Echo Exam of Abdomen -Limited,3897025,CDM,960,RC,76705,HCPCS,Outpatient,,,217.72,108.86,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
"76705 (26) Ultrasound, abdominal, real time with image documentation; limited (eg, single organ, qua",3621066,CDM,510,RC,76705,HCPCS,Outpatient,,,217.72,108.86,,163.29,75,,,percent of total billed charges,75% of total billed charges,163.29,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,58.25,100,,,Fee Schedule,100% of WV Medicaid Rate,165.79,165,,,Fee Schedule,165% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.82,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,58.25,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,30.48,14,,,percent of total billed charges,14% of total billed charges,30.48,495.81,
"76705 Ultrasound, abdominal, real time with image documentation; limited (eg, single organ, qua",3715135,CDM,510,RC,76705,HCPCS,Outpatient,,,217.72,108.86,,163.29,75,,,percent of total billed charges,75% of total billed charges,163.29,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,58.25,100,,,Fee Schedule,100% of WV Medicaid Rate,165.79,165,,,Fee Schedule,165% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.82,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,58.25,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,30.48,14,,,percent of total billed charges,14% of total billed charges,30.48,495.81,
Read,,,972,RC,76705,HCPCS,Outpatient,,,69.19,34.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
Read,3575225,CDM,972,RC,76705,HCPCS,Outpatient,,,217.72,108.86,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
Read,3575309,CDM,972,RC,76705,HCPCS,Outpatient,,,217.72,108.86,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
SCMP US Abdomen,3370896,CDM,972,RC,76705,HCPCS,Outpatient,,,217.72,108.86,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
SCMP US Abdomen,3575226,CDM,972,RC,76705,HCPCS,Outpatient,,,217.72,108.86,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
SCSN US Exam,3575310,CDM,402,RC,76705,HCPCS,Outpatient,,,217.72,108.86,,163.29,75,,,percent of total billed charges,75% of total billed charges,163.29,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,58.25,100,,,Fee Schedule,100% of WV Medicaid Rate,165.79,165,,,Fee Schedule,165% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.82,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,58.25,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,30.48,14,,,percent of total billed charges,14% of total billed charges,30.48,495.81,
SCSN US RUQ/GB Ultrasound,3370960,CDM,402,RC,76705,HCPCS,Outpatient,,,217.72,108.86,,163.29,75,,,percent of total billed charges,75% of total billed charges,163.29,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,58.25,100,,,Fee Schedule,100% of WV Medicaid Rate,165.79,165,,,Fee Schedule,165% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.82,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,58.25,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,30.48,14,,,percent of total billed charges,14% of total billed charges,30.48,495.81,
URMC US Abdomen,3358605,CDM,402,RC,76705,HCPCS,Outpatient,,,534.4,267.2,,400.8,75,,,percent of total billed charges,75% of total billed charges,400.8,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,58.25,100,,,Fee Schedule,100% of WV Medicaid Rate,165.79,165,,,Fee Schedule,165% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.82,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,58.25,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,74.82,14,,,percent of total billed charges,14% of total billed charges,58.25,495.81,
US Abdomen Limited,596617,CDM,402,RC,76705,HCPCS,Outpatient,,,571.2,285.6,,428.4,75,,,percent of total billed charges,75% of total billed charges,428.4,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,58.25,100,,,Fee Schedule,100% of WV Medicaid Rate,165.79,165,,,Fee Schedule,165% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.82,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,58.25,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,79.97,14,,,percent of total billed charges,14% of total billed charges,58.25,495.81,
US Biliary Tree,3351907,CDM,402,RC,76705,HCPCS,Outpatient,,,571.2,285.6,,428.4,75,,,percent of total billed charges,75% of total billed charges,428.4,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,58.25,100,,,Fee Schedule,100% of WV Medicaid Rate,165.79,165,,,Fee Schedule,165% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.82,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,58.25,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,79.97,14,,,percent of total billed charges,14% of total billed charges,58.25,495.81,
US Biliary Tree:Read,3351906,CDM,972,RC,76705,HCPCS,Outpatient,,,217.72,108.86,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
US Gallbladder,3351919,CDM,402,RC,76705,HCPCS,Outpatient,,,571.2,285.6,,428.4,75,,,percent of total billed charges,75% of total billed charges,428.4,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,58.25,100,,,Fee Schedule,100% of WV Medicaid Rate,165.79,165,,,Fee Schedule,165% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.82,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,58.25,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,79.97,14,,,percent of total billed charges,14% of total billed charges,58.25,495.81,
US HKBT Abdomen Limited,3317838,CDM,402,RC,76705,HCPCS,Outpatient,,,571.2,285.6,,428.4,75,,,percent of total billed charges,75% of total billed charges,428.4,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,58.25,100,,,Fee Schedule,100% of WV Medicaid Rate,165.79,165,,,Fee Schedule,165% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.82,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,58.25,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,79.97,14,,,percent of total billed charges,14% of total billed charges,58.25,495.81,
US HKBT Abdomen Limited:Read,3317839,CDM,972,RC,76705,HCPCS,Outpatient,,,217.72,108.86,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
US Liver,3351923,CDM,402,RC,76705,HCPCS,Outpatient,,,571.2,285.6,,428.4,75,,,percent of total billed charges,75% of total billed charges,428.4,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,58.25,100,,,Fee Schedule,100% of WV Medicaid Rate,165.79,165,,,Fee Schedule,165% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.82,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,58.25,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,79.97,14,,,percent of total billed charges,14% of total billed charges,58.25,495.81,
76770- US abdomen back wall complete,3430617,CDM,402,RC,76770,HCPCS,Outpatient,,,269.45,134.73,,202.09,75,,,percent of total billed charges,75% of total billed charges,202.09,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,72.02,100,,,Fee Schedule,100% of WV Medicaid Rate,165.79,165,,,Fee Schedule,165% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.82,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,72.02,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,37.72,14,,,percent of total billed charges,14% of total billed charges,37.72,495.81,
Read,3569770,CDM,972,RC,76770,HCPCS,Outpatient,,,269.45,134.73,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
Read,3575227,CDM,972,RC,76770,HCPCS,Outpatient,,,269.45,134.73,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
Read,3575257,CDM,972,RC,76770,HCPCS,Outpatient,,,269.45,134.73,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
SCMP US Aorta/ Retro,3563000,CDM,972,RC,76770,HCPCS,Outpatient,,,269.45,134.73,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
SCMP US Exam,3575228,CDM,402,RC,76770,HCPCS,Outpatient,,,269.45,134.73,,202.09,75,,,percent of total billed charges,75% of total billed charges,202.09,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,72.02,100,,,Fee Schedule,100% of WV Medicaid Rate,165.79,165,,,Fee Schedule,165% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.82,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,72.02,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,37.72,14,,,percent of total billed charges,14% of total billed charges,37.72,495.81,
SCSN US Aorta/ Retro Complete,3575258,CDM,320,RC,76770,HCPCS,Outpatient,,,269.45,134.73,,202.09,75,,,percent of total billed charges,75% of total billed charges,202.09,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,72.02,100,,,Fee Schedule,100% of WV Medicaid Rate,165.79,165,,,Fee Schedule,165% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.82,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,72.02,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,37.72,14,,,percent of total billed charges,14% of total billed charges,37.72,495.81,
SCSN US Aorta/ Retro Complete,3370930,CDM,402,RC,76770,HCPCS,Outpatient,,,269.45,134.73,,202.09,75,,,percent of total billed charges,75% of total billed charges,202.09,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,72.02,100,,,Fee Schedule,100% of WV Medicaid Rate,165.79,165,,,Fee Schedule,165% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.82,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,72.02,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,37.72,14,,,percent of total billed charges,14% of total billed charges,37.72,495.81,
SCSN US Renal BILAT,3569771,CDM,402,RC,76770,HCPCS,Outpatient,,,269.45,134.73,,202.09,75,,,percent of total billed charges,75% of total billed charges,202.09,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,72.02,100,,,Fee Schedule,100% of WV Medicaid Rate,165.79,165,,,Fee Schedule,165% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.82,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,72.02,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,37.72,14,,,percent of total billed charges,14% of total billed charges,37.72,495.81,
SCSN US Renal Bilat Interp,3575303,CDM,972,RC,76770,HCPCS,Outpatient,,,269.45,134.73,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
SCSN US Renal Bilat Interp,3575304,CDM,402,RC,76770,HCPCS,Outpatient,,,269.45,134.73,,202.09,75,,,percent of total billed charges,75% of total billed charges,202.09,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,72.02,100,,,Fee Schedule,100% of WV Medicaid Rate,165.79,165,,,Fee Schedule,165% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.82,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,72.02,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,37.72,14,,,percent of total billed charges,14% of total billed charges,37.72,495.81,
76775- Us exam abdo back wall lim,3430507,CDM,402,RC,76775,HCPCS,Outpatient,,,707.38,353.69,,530.54,75,,,percent of total billed charges,75% of total billed charges,530.54,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,38.84,100,,,Fee Schedule,100% of WV Medicaid Rate,165.8,165,,,Fee Schedule,165% of CMS OPPS Rate,104.14,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.83,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,38.84,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.14,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,99.03,14,,,percent of total billed charges,14% of total billed charges,38.84,530.54,
CL Renal Artery Ultrasound LT,3427573,CDM,402,RC,76775,HCPCS,Outpatient,,,707.38,353.69,,530.54,75,,,percent of total billed charges,75% of total billed charges,530.54,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,38.84,100,,,Fee Schedule,100% of WV Medicaid Rate,165.8,165,,,Fee Schedule,165% of CMS OPPS Rate,104.14,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.83,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,38.84,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.14,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,99.03,14,,,percent of total billed charges,14% of total billed charges,38.84,530.54,
CL Renal Artery Ultrasound RT,3427574,CDM,402,RC,76775,HCPCS,Outpatient,,,707.38,353.69,,530.54,75,,,percent of total billed charges,75% of total billed charges,530.54,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,38.84,100,,,Fee Schedule,100% of WV Medicaid Rate,165.8,165,,,Fee Schedule,165% of CMS OPPS Rate,104.14,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.83,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,38.84,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.14,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,99.03,14,,,percent of total billed charges,14% of total billed charges,38.84,530.54,
SCSN US Aorta Stent,3370926,CDM,402,RC,76775,HCPCS,Outpatient,,,707.38,353.69,,530.54,75,,,percent of total billed charges,75% of total billed charges,530.54,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,38.84,100,,,Fee Schedule,100% of WV Medicaid Rate,165.8,165,,,Fee Schedule,165% of CMS OPPS Rate,104.14,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.83,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,38.84,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.14,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,99.03,14,,,percent of total billed charges,14% of total billed charges,38.84,530.54,
SCSN US Renal Artery,3370956,CDM,402,RC,76775,HCPCS,Outpatient,,,707.38,353.69,,530.54,75,,,percent of total billed charges,75% of total billed charges,530.54,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,38.84,100,,,Fee Schedule,100% of WV Medicaid Rate,165.8,165,,,Fee Schedule,165% of CMS OPPS Rate,104.14,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.83,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,38.84,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.14,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,99.03,14,,,percent of total billed charges,14% of total billed charges,38.84,530.54,
SCSN US Renal LT,3569773,CDM,402,RC,76775,HCPCS,Outpatient,,,130.63,65.32,,97.97,75,,,percent of total billed charges,75% of total billed charges,97.97,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,38.84,100,,,Fee Schedule,100% of WV Medicaid Rate,165.8,165,,,Fee Schedule,165% of CMS OPPS Rate,104.14,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.83,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,38.84,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.14,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,18.29,14,,,percent of total billed charges,14% of total billed charges,18.29,495.81,
SCSN US Renal RT,3569775,CDM,402,RC,76775,HCPCS,Outpatient,,,130.63,65.32,,97.97,75,,,percent of total billed charges,75% of total billed charges,97.97,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,38.84,100,,,Fee Schedule,100% of WV Medicaid Rate,165.8,165,,,Fee Schedule,165% of CMS OPPS Rate,104.14,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.83,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,38.84,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.14,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,18.29,14,,,percent of total billed charges,14% of total billed charges,18.29,495.81,
URMC US Kidney,3370978,CDM,402,RC,76775,HCPCS,Outpatient,,,707.38,353.69,,530.54,75,,,percent of total billed charges,75% of total billed charges,530.54,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,38.84,100,,,Fee Schedule,100% of WV Medicaid Rate,165.8,165,,,Fee Schedule,165% of CMS OPPS Rate,104.14,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.83,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,38.84,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.14,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,99.03,14,,,percent of total billed charges,14% of total billed charges,38.84,530.54,
US Transplanted Kidney Lt:Read,596511,CDM,972,RC,76776,HCPCS,Outpatient,,,366.35,183.18,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
US Transplanted Kidney Rt,596507,CDM,402,RC,76776,HCPCS,Outpatient,,,366.35,183.18,,274.76,75,,,percent of total billed charges,75% of total billed charges,274.76,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,97.83,100,,,Fee Schedule,100% of WV Medicaid Rate,165.79,165,,,Fee Schedule,165% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.82,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,97.83,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,51.29,14,,,percent of total billed charges,14% of total billed charges,51.29,495.81,
US Transplanted Kidney Rt:Read,596508,CDM,972,RC,76776,HCPCS,Outpatient,,,366.35,183.18,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
US Pilonidal Dimple,1587103,CDM,402,RC,76800,HCPCS,Outpatient,,,366.24,183.12,,274.68,75,,,percent of total billed charges,75% of total billed charges,274.68,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,97.83,100,,,Fee Schedule,100% of WV Medicaid Rate,165.8,165,,,Fee Schedule,165% of CMS OPPS Rate,104.14,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.83,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,97.83,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.14,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,51.27,14,,,percent of total billed charges,14% of total billed charges,51.27,495.81,
76801 Ob us < 14 wks single fetus,3428328,CDM,983,RC,76801,HCPCS,Outpatient,,,292.44,146.22,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
WHFMT US OB less than 14 wks,3561674,CDM,972,RC,76801,HCPCS,Outpatient,,,292.44,146.22,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
WHMP US OB less than 14 weeks,3372937,CDM,972,RC,76801,HCPCS,Outpatient,,,292.44,146.22,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
76802 Ob us < 14 wks addl fetus,3428329,CDM,983,RC,76802,HCPCS,Outpatient,,,155.81,77.91,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
WHFMT US OB < 14 wk Addtl fetus,3563035,CDM,972,RC,76802,HCPCS,Outpatient,,,155.81,77.91,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
WHMP US OB < 14 wk Addtl fetus,3548737,CDM,972,RC,76802,HCPCS,Outpatient,,,155.81,77.91,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
WHMP US OB less than 14 wks additional fetus,3372939,CDM,972,RC,76802,HCPCS,Outpatient,,,155.81,77.91,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
76805 Ob us >/= 14 wks sngl fetus,3428330,CDM,983,RC,76805,HCPCS,Outpatient,,,334.3,167.15,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
WHFMT US OB > 14 wks Fetal Anat Scan,3561670,CDM,972,RC,76805,HCPCS,Outpatient,,,334.3,167.15,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
WHMP US OB >14 wks Fetal Anatomy Scan,3372931,CDM,972,RC,76805,HCPCS,Outpatient,,,334.3,167.15,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
76810 Ob us >/= 14 wks addl fetus,3428331,CDM,983,RC,76810,HCPCS,Outpatient,,,222.03,111.02,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
WHFMT US OB > 14 wk addtl fetus,3563037,CDM,972,RC,76810,HCPCS,Outpatient,,,222.03,111.02,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
WHMP US OB > 14 wk addtl fetus,3548739,CDM,972,RC,76810,HCPCS,Outpatient,,,222.03,111.02,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
WHMP US OB >14 wk gest Fetal Anat add'l fetus,3372929,CDM,972,RC,76810,HCPCS,Outpatient,,,222.03,111.02,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
"76811 OB US, DETAILED SINGL FETUS",3430508,CDM,960,RC,76811,HCPCS,Outpatient,,,438.08,219.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
76813 -  US Fetal Nuchal Meas 1 Gest,4327193,CDM,983,RC,76813,HCPCS,Outpatient,,,523.7,261.85,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
WHFMT US OB Nuchal Translucency,3561678,CDM,972,RC,76813,HCPCS,Outpatient,,,295.74,147.87,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
WHMP US OB Nuchal Translucency,3372943,CDM,972,RC,76813,HCPCS,Outpatient,,,295.74,147.87,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
76815 Ob us limited fetus(s),3428332,CDM,983,RC,76815,HCPCS,Outpatient,,,202.73,101.37,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
WHFMT US OB Limited,3561676,CDM,972,RC,76815,HCPCS,Outpatient,,,202.73,101.37,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
WHFMT US OB Limited,3563043,CDM,972,RC,76815,HCPCS,Outpatient,,,202.73,101.37,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
WHMP US OB Limited,3372941,CDM,972,RC,76815,HCPCS,Outpatient,,,202.73,101.37,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
WHMP US OB Limited,3548745,CDM,972,RC,76815,HCPCS,Outpatient,,,202.73,101.37,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
WHMPLimited OB,3548724,CDM,972,RC,76815,HCPCS,Outpatient,,,202.73,101.37,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
76816 Ob us follow-up per fetus,3428333,CDM,983,RC,76816,HCPCS,Outpatient,,,272.47,136.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
US Pelvis OB follow up with Transvag,3351982,CDM,402,RC,76816,HCPCS,Outpatient,,,272.47,136.24,,204.35,75,,,percent of total billed charges,75% of total billed charges,204.35,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,72.76,100,,,Fee Schedule,100% of WV Medicaid Rate,165.8,165,,,Fee Schedule,165% of CMS OPPS Rate,104.14,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.83,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,72.76,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.14,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,38.15,14,,,percent of total billed charges,14% of total billed charges,38.15,495.81,
WHFMT US OB Follow Up,3561672,CDM,972,RC,76816,HCPCS,Outpatient,,,272.47,136.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
WHMP Follow Up OB,3548722,CDM,972,RC,76816,HCPCS,Outpatient,,,272.47,136.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
WHMP US Exam,3372949,CDM,972,RC,76816,HCPCS,Outpatient,,,272.47,136.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
"76817(TC)- Ultrasound, pregnant uterus, real time with image documentation, limited (eg, fetal heart",3621067,CDM,510,RC,76817,HCPCS,Outpatient,,,231.68,115.84,,173.76,75,,,percent of total billed charges,75% of total billed charges,173.76,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,61.94,100,,,Fee Schedule,100% of WV Medicaid Rate,165.8,165,,,Fee Schedule,165% of CMS OPPS Rate,104.14,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.83,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,61.94,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.14,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,32.44,14,,,percent of total billed charges,14% of total billed charges,32.44,495.81,
WHFMT US OB Transvaginal,3561682,CDM,972,RC,76817,HCPCS,Outpatient,,,231.68,115.84,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
WHFMT US OB Transvaginal,3563047,CDM,972,RC,76817,HCPCS,Outpatient,,,231.68,115.84,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
WHMP US OB Transvaginal,3548749,CDM,972,RC,76817,HCPCS,Outpatient,,,231.68,115.84,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
WHMP US OB Tranvaginal,3372947,CDM,402,RC,76817,HCPCS,Outpatient,,,231.68,115.84,,173.76,75,,,percent of total billed charges,75% of total billed charges,173.76,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,61.94,100,,,Fee Schedule,100% of WV Medicaid Rate,165.8,165,,,Fee Schedule,165% of CMS OPPS Rate,104.14,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.83,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,61.94,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.14,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,32.44,14,,,percent of total billed charges,14% of total billed charges,32.44,495.81,
76818- Fetal biophys profile/non-stress,3431737,CDM,402,RC,76818,HCPCS,Outpatient,,,285.64,142.82,,214.23,75,,,percent of total billed charges,75% of total billed charges,214.23,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,76.2,100,,,Fee Schedule,100% of WV Medicaid Rate,165.79,165,,,Fee Schedule,165% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.82,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,76.2,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,39.99,14,,,percent of total billed charges,14% of total billed charges,39.99,495.81,
WHFMT US Biophysical Profile,3561658,CDM,972,RC,76818,HCPCS,Outpatient,,,285.64,142.82,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
WHMP Biophysicial Profile,3548720,CDM,972,RC,76818,HCPCS,Outpatient,,,285.64,142.82,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
76819- Fetal biophy profile w/o non-stres,3431738,CDM,402,RC,76819,HCPCS,Outpatient,,,209.05,104.53,,156.79,75,,,percent of total billed charges,75% of total billed charges,156.79,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,55.8,100,,,Fee Schedule,100% of WV Medicaid Rate,165.79,165,,,Fee Schedule,165% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.82,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,55.8,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,29.27,14,,,percent of total billed charges,14% of total billed charges,29.27,495.81,
WHFMT US OB Biophysical Profile,3563039,CDM,972,RC,76819,HCPCS,Outpatient,,,209.05,104.53,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
WHMP US OB Biophysical Profile,3372933,CDM,972,RC,76819,HCPCS,Outpatient,,,209.05,104.53,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
WHMP US OB Biophysicial Profile,3548741,CDM,972,RC,76819,HCPCS,Outpatient,,,209.05,104.53,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
76820 Umbilical artery echo,3428335,CDM,983,RC,76820,HCPCS,Outpatient,,,114.06,57.03,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
WHFMT US Fetal Doppler,3561660,CDM,972,RC,76820,HCPCS,Outpatient,,,114.06,57.03,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
WHFMT US OB Fetal Doppler,3563041,CDM,972,RC,76820,HCPCS,Outpatient,,,114.06,57.03,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
WHMP Umbilical Cord Doppler,3548729,CDM,972,RC,76820,HCPCS,Outpatient,,,114.06,57.03,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
WHMP US OB Fetal Doppler,3372935,CDM,972,RC,76820,HCPCS,Outpatient,,,114.06,57.03,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
WHMP US OB Fetal Doppler,3548743,CDM,972,RC,76820,HCPCS,Outpatient,,,114.06,57.03,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
76821 Middle cerebral artery echo,3430509,CDM,960,RC,76821,HCPCS,Outpatient,,,219.35,109.68,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
76825 Echo exam of fetal heart,3430510,CDM,960,RC,76825,HCPCS,Outpatient,,,649.99,325,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
76826 Echo exam of fetal heart,3430511,CDM,960,RC,76826,HCPCS,Outpatient,,,389.38,194.69,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
76827 Echo exam of fetal heart,3430512,CDM,960,RC,76827,HCPCS,Outpatient,,,175.14,87.57,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
76828 Echo exam of fetal heart,3430513,CDM,960,RC,76828,HCPCS,Outpatient,,,125.12,62.56,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
"76830- US Transvaginal, non-ob",3430618,CDM,402,RC,76830,HCPCS,Outpatient,,,295.63,147.82,,221.72,75,,,percent of total billed charges,75% of total billed charges,221.72,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,78.9,100,,,Fee Schedule,100% of WV Medicaid Rate,165.79,165,,,Fee Schedule,165% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.82,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,78.9,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,41.39,14,,,percent of total billed charges,14% of total billed charges,41.39,495.81,
Read,3372926,CDM,972,RC,76830,HCPCS,Outpatient,,,295.63,147.82,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
WHFMT US Non OB Transvaginal,3561668,CDM,972,RC,76830,HCPCS,Outpatient,,,295.63,147.82,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
WHFMT US NON OB Transvaginal,3563033,CDM,972,RC,76830,HCPCS,Outpatient,,,295.63,147.82,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
WHMP TV OB,3548726,CDM,972,RC,76830,HCPCS,Outpatient,,,295.63,147.82,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
WHMP US Exam,3372927,CDM,972,RC,76830,HCPCS,Outpatient,,,295.63,147.82,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
WHMP US NON OB Transvagina,3548733,CDM,972,RC,76830,HCPCS,Outpatient,,,295.63,147.82,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
WHMP US NON OB Transvaginal,3548735,CDM,972,RC,76830,HCPCS,Outpatient,,,295.63,147.82,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
"76831 - PF - Saline infusion sonohysterography (SIS), including color flow Doppler, when performed",3640911,CDM,510,RC,76831,HCPCS,Outpatient,,,1529.09,764.55,,1146.82,75,,,percent of total billed charges,75% of total billed charges,1146.82,75,,,percent of total billed charges,75% of total billed charges,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,76.94,100,,,Fee Schedule,100% of WV Medicaid Rate,362.24,165,,,Fee Schedule,165% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,630.61,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,864.84,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1083.29,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,76.94,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,214.07,14,,,percent of total billed charges,14% of total billed charges,76.94,1146.82,
"76831 - Saline infusion sonohysterography (SIS), including color flow Doppler, when performed",3640909,CDM,510,RC,76831,HCPCS,Outpatient,,,1529.09,764.55,,1146.82,75,,,percent of total billed charges,75% of total billed charges,1146.82,75,,,percent of total billed charges,75% of total billed charges,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,76.94,100,,,Fee Schedule,100% of WV Medicaid Rate,362.24,165,,,Fee Schedule,165% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,630.61,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,864.84,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1083.29,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,76.94,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,214.07,14,,,percent of total billed charges,14% of total billed charges,76.94,1146.82,
WHFMT US OB Sonohysterography,3561680,CDM,972,RC,76831,HCPCS,Outpatient,,,1529.09,764.55,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
WHFMT US OB Sonohysterography,3563045,CDM,972,RC,76831,HCPCS,Outpatient,,,1529.09,764.55,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
WHMP US OB Sonohysterography,3372945,CDM,972,RC,76831,HCPCS,Outpatient,,,1529.09,764.55,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
WHMP US OB Sonohysterography,3548747,CDM,972,RC,76831,HCPCS,Outpatient,,,1529.09,764.55,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
76856- US pelvic complete,3430619,CDM,402,RC,76856,HCPCS,Outpatient,,,262.48,131.24,,196.86,75,,,percent of total billed charges,75% of total billed charges,196.86,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,70.05,100,,,Fee Schedule,100% of WV Medicaid Rate,165.79,165,,,Fee Schedule,165% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.82,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,70.05,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,36.75,14,,,percent of total billed charges,14% of total billed charges,36.75,495.81,
US HKBT Pelvis Complete:Read,3317848,CDM,972,RC,76856,HCPCS,Outpatient,,,262.48,131.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
WHFMT US Non OB Pelvic Transabdominal,3561664,CDM,972,RC,76856,HCPCS,Outpatient,,,262.48,131.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
WHMP US Non OB Pelvic Transabdominal,3372925,CDM,972,RC,76856,HCPCS,Outpatient,,,262.48,131.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
76857 Us exam pelvic limited,3428336,CDM,402,RC,76857,HCPCS,Outpatient,,,119.59,59.8,,89.69,75,,,percent of total billed charges,75% of total billed charges,89.69,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,31.95,100,,,Fee Schedule,100% of WV Medicaid Rate,165.79,165,,,Fee Schedule,165% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.82,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,31.95,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,16.74,14,,,percent of total billed charges,14% of total billed charges,16.74,495.81,
SCMP US Thyroid:Read,3575245,CDM,972,RC,76857,HCPCS,Outpatient,,,119.59,59.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
US Appendix,3351899,CDM,402,RC,76857,HCPCS,Outpatient,,,119.59,59.8,,89.69,75,,,percent of total billed charges,75% of total billed charges,89.69,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,31.95,100,,,Fee Schedule,100% of WV Medicaid Rate,165.79,165,,,Fee Schedule,165% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.82,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,31.95,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,16.74,14,,,percent of total billed charges,14% of total billed charges,16.74,495.81,
US HKBT Pelvis Limited:Read,3317850,CDM,972,RC,76857,HCPCS,Outpatient,,,119.59,59.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
US HKBT Thyroid:Read,3317772,CDM,972,RC,76857,HCPCS,Outpatient,,,119.59,59.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
WHFMT US NON OB Pelvic Limited,3563031,CDM,972,RC,76857,HCPCS,Outpatient,,,119.59,59.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
"WHFMT US Non OB Pelvic, Limited",3561666,CDM,972,RC,76857,HCPCS,Outpatient,,,119.59,59.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
WHMP US NON OB Pelvic Limited,3548731,CDM,972,RC,76857,HCPCS,Outpatient,,,119.59,59.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
"WHMP US NON OB Pelvic, Limited",3372921,CDM,972,RC,76857,HCPCS,Outpatient,,,119.59,59.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
URMC US Kidney,3584947,CDM,402,RC,76870,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,165.8,165,,,Fee Schedule,165% of CMS OPPS Rate,104.14,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.83,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.14,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,100.48,495.81,
Read,3575299,CDM,972,RC,76881,HCPCS,Outpatient,,,146.59,73.3,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
RHEUM US Complete Diagnostic MSK,3999132,CDM,402,RC,76881,HCPCS,Outpatient,,,146.59,73.3,,109.94,75,,,percent of total billed charges,75% of total billed charges,109.94,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,39.33,100,,,Fee Schedule,100% of WV Medicaid Rate,165.79,165,,,Fee Schedule,165% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.82,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,39.33,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,20.52,14,,,percent of total billed charges,14% of total billed charges,20.52,495.81,
RHEUM US Complete Diagnostic MSK,3999131,CDM,983,RC,76881,HCPCS,Outpatient,,,146.59,73.3,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
RHEUM US Complete Diagnostic MSK PR,3997152,CDM,402,RC,76881,HCPCS,Outpatient,,,146.59,73.3,,109.94,75,,,percent of total billed charges,75% of total billed charges,109.94,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,39.33,100,,,Fee Schedule,100% of WV Medicaid Rate,165.79,165,,,Fee Schedule,165% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.82,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,39.33,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,20.52,14,,,percent of total billed charges,14% of total billed charges,20.52,495.81,
RHEUM US Complete Diagnostic MSK PR,3997151,CDM,983,RC,76881,HCPCS,Outpatient,,,146.59,73.3,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
76882 US Extrem limited/nonvasc anatomic struct,3428337,CDM,983,RC,76882,HCPCS,Outpatient,,,139.19,69.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
Read,,,972,RC,76882,HCPCS,Outpatient,,,58.17,29.09,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
Read,3352342,CDM,972,RC,76882,HCPCS,Outpatient,,,139.19,69.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
RHEUM US Limited Diagnostic MSK,3997154,CDM,402,RC,76882,HCPCS,Outpatient,,,139.19,69.6,,104.39,75,,,percent of total billed charges,75% of total billed charges,104.39,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,37.36,100,,,Fee Schedule,100% of WV Medicaid Rate,165.8,165,,,Fee Schedule,165% of CMS OPPS Rate,104.14,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.83,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,37.36,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.14,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,19.49,14,,,percent of total billed charges,14% of total billed charges,19.49,495.81,
RHEUM US Limited Diagnostic MSK,3997153,CDM,983,RC,76882,HCPCS,Outpatient,,,139.19,69.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
RHEUM US Limited Diagnostic MSK PR,3999134,CDM,402,RC,76882,HCPCS,Outpatient,,,139.19,69.6,,104.39,75,,,percent of total billed charges,75% of total billed charges,104.39,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,37.36,100,,,Fee Schedule,100% of WV Medicaid Rate,165.8,165,,,Fee Schedule,165% of CMS OPPS Rate,104.14,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.83,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,37.36,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.14,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,19.49,14,,,percent of total billed charges,14% of total billed charges,19.49,495.81,
RHEUM US Limited Diagnostic MSK PR,3999133,CDM,983,RC,76882,HCPCS,Outpatient,,,139.19,69.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
US Lower Extremity Lt Non Vascular,3352341,CDM,402,RC,76882,HCPCS,Outpatient,,,139.19,69.6,,104.39,75,,,percent of total billed charges,75% of total billed charges,104.39,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,37.36,100,,,Fee Schedule,100% of WV Medicaid Rate,165.8,165,,,Fee Schedule,165% of CMS OPPS Rate,104.14,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.83,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,37.36,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.14,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,19.49,14,,,percent of total billed charges,14% of total billed charges,19.49,495.81,
US Compression of Pseudoaneurysm Lt:Read,596526,CDM,972,RC,76936,HCPCS,Outpatient,,,653.18,326.59,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
US Compression of Pseudoanuerysm Rt:Read,596529,CDM,972,RC,76936,HCPCS,Outpatient,,,653.18,326.59,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
76937-MA US GUIDE VASCULAR ACCESS,3430516,CDM,402,RC,76937,HCPCS,Outpatient,,,96.94,48.47,,72.71,75,,,percent of total billed charges,75% of total billed charges,72.71,75,,,percent of total billed charges,75% of total billed charges,31.02,32,,,percent of total billed charges,32% of total billed charges,25.81,100,,,Fee Schedule,100% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.81,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.57,14,,,percent of total billed charges,14% of total billed charges,13.57,72.71,
"76942- Ultrasonic guidance for needle placement (eg, biopsy, aspiration, injection, localizati",3676897,CDM,402,RC,76942,HCPCS,Outpatient,,,146.15,73.08,,109.61,75,,,percent of total billed charges,75% of total billed charges,109.61,75,,,percent of total billed charges,75% of total billed charges,46.77,32,,,percent of total billed charges,32% of total billed charges,39.08,100,,,Fee Schedule,100% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.08,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.46,14,,,percent of total billed charges,14% of total billed charges,20.46,109.61,
RHEUM US Procedural Ultrasound,3997156,CDM,972,RC,76942,HCPCS,Outpatient,,,129.6,64.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
RHEUM US Procedural Ultrasound PR,3997158,CDM,972,RC,76942,HCPCS,Outpatient,,,129.6,64.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
SCMP US Exam,3575236,CDM,972,RC,76942,HCPCS,Outpatient,,,129.6,64.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
SCMP US Exam,3575238,CDM,972,RC,76942,HCPCS,Outpatient,,,129.6,64.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
SCMP US Exam,3575242,CDM,972,RC,76942,HCPCS,Outpatient,,,129.6,64.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
SCSN US Exam,3575314,CDM,402,RC,76942,HCPCS,Outpatient,,,129.6,64.8,,97.2,75,,,percent of total billed charges,75% of total billed charges,97.2,75,,,percent of total billed charges,75% of total billed charges,41.47,32,,,percent of total billed charges,32% of total billed charges,39.08,100,,,Fee Schedule,100% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.08,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.14,14,,,percent of total billed charges,14% of total billed charges,18.14,97.2,
SCSN US Guided Mammotome Breast Bx PR,3575189,CDM,972,RC,76942,HCPCS,Outpatient,,,129.6,64.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
76965 (26) Ultrasonic guidance for interstitial radioelement application,3621073,CDM,510,RC,76965,HCPCS,Outpatient,,,234.66,117.33,,176,75,,,percent of total billed charges,75% of total billed charges,176,75,,,percent of total billed charges,75% of total billed charges,75.09,32,,,percent of total billed charges,32% of total billed charges,62.68,100,,,Fee Schedule,100% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62.68,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.85,14,,,percent of total billed charges,14% of total billed charges,32.85,176,
76965 (TC) Ultrasonic guidance for interstitial radioelement application,3621074,CDM,510,RC,76965,HCPCS,Outpatient,,,234.66,117.33,,176,75,,,percent of total billed charges,75% of total billed charges,176,75,,,percent of total billed charges,75% of total billed charges,75.09,32,,,percent of total billed charges,32% of total billed charges,62.68,100,,,Fee Schedule,100% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62.68,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.85,14,,,percent of total billed charges,14% of total billed charges,32.85,176,
"77001 (26) Fluoroscopic guidance for central venous access device placement, replacement (catheter o",3620979,CDM,510,RC,77001,HCPCS,Outpatient,,,249.74,124.87,,187.31,75,,,percent of total billed charges,75% of total billed charges,187.31,75,,,percent of total billed charges,75% of total billed charges,79.92,32,,,percent of total billed charges,32% of total billed charges,66.61,100,,,Fee Schedule,100% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.61,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.96,14,,,percent of total billed charges,14% of total billed charges,34.96,187.31,
Read,2960105,CDM,972,RC,77001,HCPCS,Outpatient,,,249.74,124.87,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
Read,3575271,CDM,972,RC,77001,HCPCS,Outpatient,,,249.74,124.87,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
MRI Breast Bilat UN and ENH,3347966,CDM,610,RC,77049,HCPCS,Outpatient,,,1713.94,856.97,,1285.46,75,,,percent of total billed charges,75% of total billed charges,1285.46,75,,,percent of total billed charges,75% of total billed charges,548.46,32,,,percent of total billed charges,32% of total billed charges,237.93,100,,,Fee Schedule,100% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,237.93,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,239.95,14,,,percent of total billed charges,14% of total billed charges,237.93,1285.46,
"77063 - Screening digital breast tomosynthesis, bilateral (List separately in addition to code for p",3800936,CDM,983,RC,77063,HCPCS,Outpatient,,,132.26,66.13,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
WHFMT MA Screening TOMO,3610995,CDM,972,RC,77063,HCPCS,Outpatient,,,132.26,66.13,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
77065 - (TC) DX MAMMO INCL CAD UNI,3997213,CDM,983,RC,77065,HCPCS,Outpatient,,,309.04,154.52,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
77065 (26) - DIAGNOSTIC MAMMOGRAPHY COMPUTER-AIDED DETCJ UNI,4037790,CDM,983,RC,77065,HCPCS,Outpatient,,,309.04,154.52,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
WHFMT MA Mammo LT Unilat Diagnostic:WHFMT MA Exam,3561688,CDM,972,RC,77065,HCPCS,Outpatient,,,309.04,154.52,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
WHFMT MA Mammo RT Unilat Diagnostic:WHFMT MA Exam,3561690,CDM,972,RC,77065,HCPCS,Outpatient,,,309.04,154.52,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
WHFMT MA TOMO Mammo Diagnostic LT:WHFMT MA Exam,3561700,CDM,972,RC,77065,HCPCS,Outpatient,,,309.04,154.52,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
WHFMT MA TOMO Mammo Diagnostic RT:WHFMT MA Exam,3561702,CDM,972,RC,77065,HCPCS,Outpatient,,,309.04,154.52,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
77066 - Dx Mammo Incl Cad Bil,4113118,CDM,983,RC,77066,HCPCS,Outpatient,,,348.23,174.12,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
WHFMT MA Mammo Bilat Diagnostic:WHFMT MA Exam,3561686,CDM,972,RC,77066,HCPCS,Outpatient,,,390.02,195.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
WHFMT MA TOMO Mammo Diagnostic Bilat:WHFMT MA Exam,3561698,CDM,972,RC,77066,HCPCS,Outpatient,,,390.02,195.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
"77067 (TC) Screening mammography, bilateral (2-view study of each breast), including computer-aided",3621068,CDM,510,RC,77067,HCPCS,Outpatient,,,313.93,156.97,,235.45,75,,,percent of total billed charges,75% of total billed charges,235.45,75,,,percent of total billed charges,75% of total billed charges,80.86,100,,,Fee Schedule,100% of CMS OPPS Rate,83.82,100,,,Fee Schedule,100% of WV Medicaid Rate,133.42,165,,,Fee Schedule,165% of CMS OPPS Rate,113.65,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,286.68,354.54,,,Fee Schedule,354.54% of CMS OPPS Fee Schedule Rate,346.65,428.7,,,Fee Schedule,428.7% of CMS OPPS Fee Schedule Rate,364.52,450.81,,,Fee Schedule,450.81% of CMS OPPS Fee Schedule Rate,83.82,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,80.86,100,,,Fee Schedule,100% of CMS OPPS Rate,113.65,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,43.95,14,,,percent of total billed charges,14% of total billed charges,43.95,364.52,
WHFMT MA Mammo Screening Bilat:WHFMT MA Exam,3561692,CDM,972,RC,77067,HCPCS,Outpatient,,,313.93,156.97,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
WHFMT MA Mammo Screening LT:WHFMT MA Exam,3561694,CDM,972,RC,77067,HCPCS,Outpatient,,,313.93,156.97,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
WHFMT MA Mammo Screening RT:WHFMT MA Exam,3561696,CDM,972,RC,77067,HCPCS,Outpatient,,,313.93,156.97,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
WHFMT MA TOMO Mammo Screening Bilat:WHFMT MA Exam,3561704,CDM,972,RC,77067,HCPCS,Outpatient,,,313.93,156.97,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
WHFMT MA TOMO Mammo Screening LT:WHFMT MA Exam,3561706,CDM,972,RC,77067,HCPCS,Outpatient,,,313.93,156.97,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
WHFMT MA TOMO Mammo Screening RT:WHFMT MA Exam,3561708,CDM,972,RC,77067,HCPCS,Outpatient,,,313.93,156.97,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
Bone Age Lt Wrist and Hand,601931,CDM,320,RC,77072,HCPCS,Outpatient,,,64.7,32.35,,48.53,75,,,percent of total billed charges,75% of total billed charges,48.53,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,17.21,100,,,Fee Schedule,100% of WV Medicaid Rate,165.8,165,,,Fee Schedule,165% of CMS OPPS Rate,104.14,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.83,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,17.21,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.14,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,9.06,14,,,percent of total billed charges,14% of total billed charges,9.06,495.81,
WW Bone Age Lt Wrist and Hand,3373156,CDM,972,RC,77072,HCPCS,Outpatient,,,64.7,32.35,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
Bone Length Study,601935,CDM,320,RC,77073,HCPCS,Outpatient,,,110.92,55.46,,83.19,75,,,percent of total billed charges,75% of total billed charges,83.19,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,29.74,100,,,Fee Schedule,100% of WV Medicaid Rate,165.8,165,,,Fee Schedule,165% of CMS OPPS Rate,104.14,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.83,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,29.74,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.14,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,15.53,14,,,percent of total billed charges,14% of total billed charges,15.53,495.81,
Bone Survey Metastases,601939,CDM,320,RC,77074,HCPCS,Outpatient,,,160.67,80.34,,120.5,75,,,percent of total billed charges,75% of total billed charges,120.5,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,43.02,100,,,Fee Schedule,100% of WV Medicaid Rate,165.8,165,,,Fee Schedule,165% of CMS OPPS Rate,104.14,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.83,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,43.02,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.14,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,22.49,14,,,percent of total billed charges,14% of total billed charges,22.49,495.81,
Bone Survey Infant,601937,CDM,320,RC,77076,HCPCS,Outpatient,,,263.4,131.7,,197.55,75,,,percent of total billed charges,75% of total billed charges,197.55,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,70.3,100,,,Fee Schedule,100% of WV Medicaid Rate,165.8,165,,,Fee Schedule,165% of CMS OPPS Rate,104.14,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.83,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,70.3,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.14,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,36.88,14,,,percent of total billed charges,14% of total billed charges,36.88,495.81,
"77080- Dual-energy X-ray absorptiometry (DXA), bone density study, 1 or more sites; axial skelet",3623708,CDM,510,RC,77080,HCPCS,Outpatient,,,90.1,45.05,,67.58,75,,,percent of total billed charges,75% of total billed charges,67.58,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,24.09,100,,,Fee Schedule,100% of WV Medicaid Rate,165.79,165,,,Fee Schedule,165% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.82,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,24.09,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,12.61,14,,,percent of total billed charges,14% of total billed charges,12.61,495.81,
"77080(26)- Dual-energy X-ray absorptiometry (DXA), bone density study, 1 or more sites; axial skelet",3620959,CDM,510,RC,77080,HCPCS,Outpatient,,,90.1,45.05,,67.58,75,,,percent of total billed charges,75% of total billed charges,67.58,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,24.09,100,,,Fee Schedule,100% of WV Medicaid Rate,165.79,165,,,Fee Schedule,165% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.82,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,24.09,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,12.61,14,,,percent of total billed charges,14% of total billed charges,12.61,495.81,
"77080(TC)- Dual-energy X-ray absorptiometry (DXA), bone density study, 1 or more sites; axial skelet",3623737,CDM,510,RC,77080,HCPCS,Outpatient,,,90.1,45.05,,67.58,75,,,percent of total billed charges,75% of total billed charges,67.58,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,24.09,100,,,Fee Schedule,100% of WV Medicaid Rate,165.79,165,,,Fee Schedule,165% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.82,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,24.09,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,12.61,14,,,percent of total billed charges,14% of total billed charges,12.61,495.81,
GYN Dexa Exam,3575424,CDM,972,RC,77080,HCPCS,Outpatient,,,90.1,45.05,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
HW GYN Dexa,3776905,CDM,510,RC,77080,HCPCS,Outpatient,,,90.1,45.05,,67.58,75,,,percent of total billed charges,75% of total billed charges,67.58,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,24.09,100,,,Fee Schedule,100% of WV Medicaid Rate,165.79,165,,,Fee Schedule,165% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.82,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,24.09,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,12.61,14,,,percent of total billed charges,14% of total billed charges,12.61,495.81,
Read,3575423,CDM,972,RC,77080,HCPCS,Outpatient,,,90.1,45.05,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
WHFMT Bone Density:WHFMT DR Exam,3561654,CDM,972,RC,77080,HCPCS,Outpatient,,,90.1,45.05,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
"77081 - Dual-energy X-ray absorptiometry (DXA), bone density study, 1 or more sites; appendicular sk",3640925,CDM,510,RC,77081,HCPCS,Outpatient,,,75.87,37.94,,56.9,75,,,percent of total billed charges,75% of total billed charges,56.9,75,,,percent of total billed charges,75% of total billed charges,81.67,100,,,Fee Schedule,100% of CMS OPPS Rate,20.16,100,,,Fee Schedule,100% of WV Medicaid Rate,134.76,165,,,Fee Schedule,165% of CMS OPPS Rate,84.65,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,234.61,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,321.75,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,403.03,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,20.16,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,81.67,100,,,Fee Schedule,100% of CMS OPPS Rate,84.65,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,10.62,14,,,percent of total billed charges,14% of total billed charges,10.62,403.03,
"77085- DEXA - Dual-energy X-ray absorptiometry (DXA), bone density study, 1 or more sites; axial ske",3715130,CDM,510,RC,77085,HCPCS,Outpatient,,,123.79,61.9,,92.84,75,,,percent of total billed charges,75% of total billed charges,92.84,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,32.94,100,,,Fee Schedule,100% of WV Medicaid Rate,165.8,165,,,Fee Schedule,165% of CMS OPPS Rate,104.14,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.83,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,32.94,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.14,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,17.33,14,,,percent of total billed charges,14% of total billed charges,17.33,495.81,
GYN VFA with DEXA:GYN Dexa Exam,3576813,CDM,972,RC,77085,HCPCS,Outpatient,,,123.79,61.9,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
GYN Dexa Exam,3575426,CDM,972,RC,77086,HCPCS,Outpatient,,,79.44,39.72,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
77263-RADIATION THERAPY PLANNING,3400483,CDM,983,RC,77263,HCPCS,Outpatient,,,400.09,200.05,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
Hospital Outpatient Clinic Visit,3400485,CDM,510,RC,77427,HCPCS,Outpatient,,,670.77,335.39,,503.08,75,,,percent of total billed charges,75% of total billed charges,503.08,75,,,percent of total billed charges,75% of total billed charges,214.65,32,,,percent of total billed charges,32% of total billed charges,131.26,100,,,Fee Schedule,100% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,131.26,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.91,14,,,percent of total billed charges,14% of total billed charges,93.91,503.08,
77770 - (26) Remote afterloading high dose rate radionuclide,3938961,CDM,333,RC,77770,HCPCS,Outpatient,,,832.59,416.3,,624.44,75,,,percent of total billed charges,75% of total billed charges,624.44,75,,,percent of total billed charges,75% of total billed charges,678.53,100,,,Fee Schedule,100% of CMS OPPS Rate,222.45,100,,,Fee Schedule,100% of WV Medicaid Rate,1119.56,165,,,Fee Schedule,165% of CMS OPPS Rate,703.23,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1948.99,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2672.9,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,3348.08,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,222.45,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,678.53,100,,,Fee Schedule,100% of CMS OPPS Rate,703.23,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,116.56,14,,,percent of total billed charges,14% of total billed charges,116.56,3348.08,
77770 - Remote afterloading high dose rate radionuclide brac,3938960,CDM,342,RC,77770,HCPCS,Outpatient,,,832.59,416.3,,624.44,75,,,percent of total billed charges,75% of total billed charges,624.44,75,,,percent of total billed charges,75% of total billed charges,678.53,100,,,Fee Schedule,100% of CMS OPPS Rate,222.45,100,,,Fee Schedule,100% of WV Medicaid Rate,1119.56,165,,,Fee Schedule,165% of CMS OPPS Rate,703.23,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1948.99,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2672.9,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,3348.08,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,222.45,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,678.53,100,,,Fee Schedule,100% of CMS OPPS Rate,703.23,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,116.56,14,,,percent of total billed charges,14% of total billed charges,116.56,3348.08,
77771 - (26) Remote afterloading high dose rate radionuclide,3938958,CDM,342,RC,77771,HCPCS,Outpatient,,,1437.26,718.63,,1077.95,75,,,percent of total billed charges,75% of total billed charges,1077.95,75,,,percent of total billed charges,75% of total billed charges,678.53,100,,,Fee Schedule,100% of CMS OPPS Rate,383.94,100,,,Fee Schedule,100% of WV Medicaid Rate,1119.56,165,,,Fee Schedule,165% of CMS OPPS Rate,703.23,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1948.99,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2672.9,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,3348.08,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,383.94,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,678.53,100,,,Fee Schedule,100% of CMS OPPS Rate,703.23,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,201.22,14,,,percent of total billed charges,14% of total billed charges,201.22,3348.08,
77771 - Remote afterloading high dose rate radionuclide brac,3938957,CDM,333,RC,77771,HCPCS,Outpatient,,,1437.26,718.63,,1077.95,75,,,percent of total billed charges,75% of total billed charges,1077.95,75,,,percent of total billed charges,75% of total billed charges,678.53,100,,,Fee Schedule,100% of CMS OPPS Rate,383.94,100,,,Fee Schedule,100% of WV Medicaid Rate,1119.56,165,,,Fee Schedule,165% of CMS OPPS Rate,703.23,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1948.99,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2672.9,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,3348.08,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,383.94,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,678.53,100,,,Fee Schedule,100% of CMS OPPS Rate,703.23,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,201.22,14,,,percent of total billed charges,14% of total billed charges,201.22,3348.08,
78428 (26) - Cardiac shunt detection,4037737,CDM,974,RC,78428,HCPCS,Outpatient,,,435.14,217.57,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
78451 - (TC) Myocardial Spect SNGL Study at Rest or Stress,3899087,CDM,960,RC,78451,HCPCS,Outpatient,,,781.58,390.79,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
78452-NM Myocardial EF Rest Stress Spect Add-on,4263188,CDM,340,RC,78452,HCPCS,Outpatient,,,6790.79,3395.4,,5093.09,75,,,percent of total billed charges,75% of total billed charges,5093.09,75,,,percent of total billed charges,75% of total billed charges,1247.84,100,,,Fee Schedule,100% of CMS OPPS Rate,290.04,100,,,Fee Schedule,100% of WV Medicaid Rate,2058.94,165,,,Fee Schedule,165% of CMS OPPS Rate,1293.28,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,3584.29,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,4915.56,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6157.24,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,290.04,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1247.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1293.28,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,950.71,14,,,percent of total billed charges,14% of total billed charges,290.04,6157.24,
78466 - (TC) MYOCARDIAL IMAGING INFARCT AVID PLANAR QUAL/QUA,3999225,CDM,960,RC,78466,HCPCS,Outpatient,,,448.18,224.09,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
80081 Obstetric panel,3430518,CDM,960,RC,80081,HCPCS,Outpatient,,,99.53,49.77,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
"80305 - Drug test(s), presumptive, any number of drug classe",3918905,CDM,300,RC,80305,HCPCS,Outpatient,,,171.93,85.97,,128.95,75,,,percent of total billed charges,75% of total billed charges,128.95,75,,,percent of total billed charges,75% of total billed charges,12.6,100,,,Fee Schedule,100% of CMS OPPS Rate,11.34,100,,,Fee Schedule,100% of WV Medicaid Rate,12.6,100,,,Fee Schedule,100% of CMS OPPS Rate,12.6,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,44.67,354.54,,,Fee Schedule,354.54% of CMS OPPS Fee Schedule Rate,54.01,428.7,,,Fee Schedule,428.7% of CMS OPPS Fee Schedule Rate,56.8,450.81,,,Fee Schedule,450.81% of CMS OPPS Fee Schedule Rate,11.34,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,12.6,100,,,Fee Schedule,100% of CMS OPPS Rate,12.6,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,24.07,14,,,percent of total billed charges,14% of total billed charges,11.34,128.95,
Drug Screening POC,3444188,CDM,300,RC,80305,HCPCS,Outpatient,,,171.93,85.97,,128.95,75,,,percent of total billed charges,75% of total billed charges,128.95,75,,,percent of total billed charges,75% of total billed charges,12.6,100,,,Fee Schedule,100% of CMS OPPS Rate,11.34,100,,,Fee Schedule,100% of WV Medicaid Rate,12.6,100,,,Fee Schedule,100% of CMS OPPS Rate,12.6,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,44.67,354.54,,,Fee Schedule,354.54% of CMS OPPS Fee Schedule Rate,54.01,428.7,,,Fee Schedule,428.7% of CMS OPPS Fee Schedule Rate,56.8,450.81,,,Fee Schedule,450.81% of CMS OPPS Fee Schedule Rate,11.34,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,12.6,100,,,Fee Schedule,100% of CMS OPPS Rate,12.6,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,24.07,14,,,percent of total billed charges,14% of total billed charges,11.34,128.95,
611S Steroid Testing,4285461,CDM,300,RC,80307,HCPCS,Outpatient,,,106,53,,79.5,75,,,percent of total billed charges,75% of total billed charges,79.5,75,,,percent of total billed charges,75% of total billed charges,62.14,100,,,Fee Schedule,100% of CMS OPPS Rate,55.93,100,,,Fee Schedule,100% of WV Medicaid Rate,62.14,100,,,Fee Schedule,100% of CMS OPPS Rate,62.14,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,220.31,354.54,,,Fee Schedule,354.54% of CMS OPPS Fee Schedule Rate,266.39,428.7,,,Fee Schedule,428.7% of CMS OPPS Fee Schedule Rate,280.13,450.81,,,Fee Schedule,450.81% of CMS OPPS Fee Schedule Rate,55.93,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,62.14,100,,,Fee Schedule,100% of CMS OPPS Rate,62.14,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,14.84,14,,,percent of total billed charges,14% of total billed charges,14.84,280.13,
81000 Urinalysis nonauto w/scope (also listed as AMB POC,3430519,CDM,300,RC,81000,HCPCS,Outpatient,,,5.34,2.67,,4.01,75,,,percent of total billed charges,75% of total billed charges,4.01,75,,,percent of total billed charges,75% of total billed charges,4.01,100,,,Fee Schedule,100% of CMS OPPS Rate,3.62,100,,,Fee Schedule,100% of WV Medicaid Rate,4.01,100,,,Fee Schedule,100% of CMS OPPS Rate,4.02,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,14.25,354.54,,,Fee Schedule,354.54% of CMS OPPS Fee Schedule Rate,17.23,428.7,,,Fee Schedule,428.7% of CMS OPPS Fee Schedule Rate,18.12,450.81,,,Fee Schedule,450.81% of CMS OPPS Fee Schedule Rate,3.62,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,4.01,100,,,Fee Schedule,100% of CMS OPPS Rate,4.02,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,,14,,,Other,Not Separately reimbursable,3.62,18.12,
Urinalysis Dipstick POC,3444209,CDM,300,RC,81002,HCPCS,Outpatient,,,9.26,4.63,,6.95,75,,,percent of total billed charges,75% of total billed charges,6.95,75,,,percent of total billed charges,75% of total billed charges,3.48,100,,,Fee Schedule,100% of CMS OPPS Rate,3.13,100,,,Fee Schedule,100% of WV Medicaid Rate,3.48,100,,,Fee Schedule,100% of CMS OPPS Rate,3.48,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,12.33,354.54,,,Fee Schedule,354.54% of CMS OPPS Fee Schedule Rate,14.91,428.7,,,Fee Schedule,428.7% of CMS OPPS Fee Schedule Rate,15.68,450.81,,,Fee Schedule,450.81% of CMS OPPS Fee Schedule Rate,3.13,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,3.48,100,,,Fee Schedule,100% of CMS OPPS Rate,3.48,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,1.3,14,,,percent of total billed charges,14% of total billed charges,1.3,15.68,
81003 - Urine Dipstick 2GP POC,3918906,CDM,300,RC,81003,HCPCS,Outpatient,,,6.63,3.32,,4.97,75,,,percent of total billed charges,75% of total billed charges,4.97,75,,,percent of total billed charges,75% of total billed charges,2.25,100,,,Fee Schedule,100% of CMS OPPS Rate,2.03,100,,,Fee Schedule,100% of WV Medicaid Rate,2.25,100,,,Fee Schedule,100% of CMS OPPS Rate,2.25,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,7.97,354.54,,,Fee Schedule,354.54% of CMS OPPS Fee Schedule Rate,9.64,428.7,,,Fee Schedule,428.7% of CMS OPPS Fee Schedule Rate,10.14,450.81,,,Fee Schedule,450.81% of CMS OPPS Fee Schedule Rate,2.03,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2.25,100,,,Fee Schedule,100% of CMS OPPS Rate,2.25,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,,14,,,Other,Not Separately reimbursable,2.03,10.14,
81003- Urinalysis Dipstick POC,3572706,CDM,300,RC,81003,HCPCS,Outpatient,,,13.36,6.68,,10.02,75,,,percent of total billed charges,75% of total billed charges,10.02,75,,,percent of total billed charges,75% of total billed charges,2.25,100,,,Fee Schedule,100% of CMS OPPS Rate,2.03,100,,,Fee Schedule,100% of WV Medicaid Rate,2.25,100,,,Fee Schedule,100% of CMS OPPS Rate,2.25,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,7.97,354.54,,,Fee Schedule,354.54% of CMS OPPS Fee Schedule Rate,9.64,428.7,,,Fee Schedule,428.7% of CMS OPPS Fee Schedule Rate,10.14,450.81,,,Fee Schedule,450.81% of CMS OPPS Fee Schedule Rate,2.03,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2.25,100,,,Fee Schedule,100% of CMS OPPS Rate,2.25,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,1.87,14,,,percent of total billed charges,14% of total billed charges,1.87,10.14,
OB Urine Dipstick 2 GP POC,3549808,CDM,300,RC,81003,HCPCS,Outpatient,,,13.36,6.68,,10.02,75,,,percent of total billed charges,75% of total billed charges,10.02,75,,,percent of total billed charges,75% of total billed charges,2.25,100,,,Fee Schedule,100% of CMS OPPS Rate,2.03,100,,,Fee Schedule,100% of WV Medicaid Rate,2.25,100,,,Fee Schedule,100% of CMS OPPS Rate,2.25,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,7.97,354.54,,,Fee Schedule,354.54% of CMS OPPS Fee Schedule Rate,9.64,428.7,,,Fee Schedule,428.7% of CMS OPPS Fee Schedule Rate,10.14,450.81,,,Fee Schedule,450.81% of CMS OPPS Fee Schedule Rate,2.03,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2.25,100,,,Fee Schedule,100% of CMS OPPS Rate,2.25,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,1.87,14,,,percent of total billed charges,14% of total billed charges,1.87,10.14,
Urinalysis Dipstick,1365116,CDM,300,RC,81003,HCPCS,Outpatient,,,13.36,6.68,,10.02,75,,,percent of total billed charges,75% of total billed charges,10.02,75,,,percent of total billed charges,75% of total billed charges,2.25,100,,,Fee Schedule,100% of CMS OPPS Rate,2.03,100,,,Fee Schedule,100% of WV Medicaid Rate,2.25,100,,,Fee Schedule,100% of CMS OPPS Rate,2.25,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,7.97,354.54,,,Fee Schedule,354.54% of CMS OPPS Fee Schedule Rate,9.64,428.7,,,Fee Schedule,428.7% of CMS OPPS Fee Schedule Rate,10.14,450.81,,,Fee Schedule,450.81% of CMS OPPS Fee Schedule Rate,2.03,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2.25,100,,,Fee Schedule,100% of CMS OPPS Rate,2.25,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,1.87,14,,,percent of total billed charges,14% of total billed charges,1.87,10.14,
Urine Dipstick 10 POC,3444215,CDM,300,RC,81003,HCPCS,Outpatient,,,13.36,6.68,,10.02,75,,,percent of total billed charges,75% of total billed charges,10.02,75,,,percent of total billed charges,75% of total billed charges,2.25,100,,,Fee Schedule,100% of CMS OPPS Rate,2.03,100,,,Fee Schedule,100% of WV Medicaid Rate,2.25,100,,,Fee Schedule,100% of CMS OPPS Rate,2.25,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,7.97,354.54,,,Fee Schedule,354.54% of CMS OPPS Fee Schedule Rate,9.64,428.7,,,Fee Schedule,428.7% of CMS OPPS Fee Schedule Rate,10.14,450.81,,,Fee Schedule,450.81% of CMS OPPS Fee Schedule Rate,2.03,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2.25,100,,,Fee Schedule,100% of CMS OPPS Rate,2.25,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,1.87,14,,,percent of total billed charges,14% of total billed charges,1.87,10.14,
Urine Dipstick 2GP POC,3444214,CDM,300,RC,81003,HCPCS,Outpatient,,,13.36,6.68,,10.02,75,,,percent of total billed charges,75% of total billed charges,10.02,75,,,percent of total billed charges,75% of total billed charges,2.25,100,,,Fee Schedule,100% of CMS OPPS Rate,2.03,100,,,Fee Schedule,100% of WV Medicaid Rate,2.25,100,,,Fee Schedule,100% of CMS OPPS Rate,2.25,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,7.97,354.54,,,Fee Schedule,354.54% of CMS OPPS Fee Schedule Rate,9.64,428.7,,,Fee Schedule,428.7% of CMS OPPS Fee Schedule Rate,10.14,450.81,,,Fee Schedule,450.81% of CMS OPPS Fee Schedule Rate,2.03,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2.25,100,,,Fee Schedule,100% of CMS OPPS Rate,2.25,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,1.87,14,,,percent of total billed charges,14% of total billed charges,1.87,10.14,
81025 - Urine Pregnancy Test,3918907,CDM,300,RC,81025,HCPCS,Outpatient,,,44.5,22.25,,33.38,75,,,percent of total billed charges,75% of total billed charges,33.38,75,,,percent of total billed charges,75% of total billed charges,8.61,100,,,Fee Schedule,100% of CMS OPPS Rate,7.75,100,,,Fee Schedule,100% of WV Medicaid Rate,8.61,100,,,Fee Schedule,100% of CMS OPPS Rate,8.61,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,30.52,354.54,,,Fee Schedule,354.54% of CMS OPPS Fee Schedule Rate,36.91,428.7,,,Fee Schedule,428.7% of CMS OPPS Fee Schedule Rate,38.81,450.81,,,Fee Schedule,450.81% of CMS OPPS Fee Schedule Rate,7.75,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,8.61,100,,,Fee Schedule,100% of CMS OPPS Rate,8.61,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,6.23,14,,,percent of total billed charges,14% of total billed charges,6.23,38.81,
CLINIC In-Office Urine Pregnancy Test,3347274,CDM,300,RC,81025,HCPCS,Outpatient,,,89.08,44.54,,66.81,75,,,percent of total billed charges,75% of total billed charges,66.81,75,,,percent of total billed charges,75% of total billed charges,8.61,100,,,Fee Schedule,100% of CMS OPPS Rate,7.75,100,,,Fee Schedule,100% of WV Medicaid Rate,8.61,100,,,Fee Schedule,100% of CMS OPPS Rate,8.61,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,30.52,354.54,,,Fee Schedule,354.54% of CMS OPPS Fee Schedule Rate,36.91,428.7,,,Fee Schedule,428.7% of CMS OPPS Fee Schedule Rate,38.81,450.81,,,Fee Schedule,450.81% of CMS OPPS Fee Schedule Rate,7.75,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,8.61,100,,,Fee Schedule,100% of CMS OPPS Rate,8.61,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,12.47,14,,,percent of total billed charges,14% of total billed charges,7.75,66.81,
"HCG, Urine POC",3444192,CDM,300,RC,81025,HCPCS,Outpatient,,,44.5,22.25,,33.38,75,,,percent of total billed charges,75% of total billed charges,33.38,75,,,percent of total billed charges,75% of total billed charges,8.61,100,,,Fee Schedule,100% of CMS OPPS Rate,7.75,100,,,Fee Schedule,100% of WV Medicaid Rate,8.61,100,,,Fee Schedule,100% of CMS OPPS Rate,8.61,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,30.52,354.54,,,Fee Schedule,354.54% of CMS OPPS Fee Schedule Rate,36.91,428.7,,,Fee Schedule,428.7% of CMS OPPS Fee Schedule Rate,38.81,450.81,,,Fee Schedule,450.81% of CMS OPPS Fee Schedule Rate,7.75,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,8.61,100,,,Fee Schedule,100% of CMS OPPS Rate,8.61,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,6.23,14,,,percent of total billed charges,14% of total billed charges,6.23,38.81,
81528  Oncology colorectal scr,3430522,CDM,960,RC,81528,HCPCS,Outpatient,,,676.62,338.31,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
Urine Microalbumin POC,3444210,CDM,300,RC,82043,HCPCS,Outpatient,,,17.08,8.54,,12.81,75,,,percent of total billed charges,75% of total billed charges,12.81,75,,,percent of total billed charges,75% of total billed charges,5.78,100,,,Fee Schedule,100% of CMS OPPS Rate,5.2,100,,,Fee Schedule,100% of WV Medicaid Rate,5.78,100,,,Fee Schedule,100% of CMS OPPS Rate,5.78,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,20.49,354.54,,,Fee Schedule,354.54% of CMS OPPS Fee Schedule Rate,24.77,428.7,,,Fee Schedule,428.7% of CMS OPPS Fee Schedule Rate,26.05,450.81,,,Fee Schedule,450.81% of CMS OPPS Fee Schedule Rate,5.2,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,5.78,100,,,Fee Schedule,100% of CMS OPPS Rate,5.78,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,2.39,14,,,percent of total billed charges,14% of total billed charges,2.39,26.05,
82044 Ur albumin semiquantitative,3430523,CDM,960,RC,82044,HCPCS,Outpatient,,,8.29,4.15,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
82075 Breath Alcohol,3435571,CDM,510,RC,82075,HCPCS,Outpatient,,,33.24,16.62,,24.93,75,,,percent of total billed charges,75% of total billed charges,24.93,75,,,percent of total billed charges,75% of total billed charges,30,100,,,Fee Schedule,100% of CMS OPPS Rate,27,100,,,Fee Schedule,100% of WV Medicaid Rate,30,100,,,Fee Schedule,100% of CMS OPPS Rate,30,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,106.36,354.54,,,Fee Schedule,354.54% of CMS OPPS Fee Schedule Rate,128.61,428.7,,,Fee Schedule,428.7% of CMS OPPS Fee Schedule Rate,135.24,450.81,,,Fee Schedule,450.81% of CMS OPPS Fee Schedule Rate,27,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,30,100,,,Fee Schedule,100% of CMS OPPS Rate,30,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,4.65,14,,,percent of total billed charges,14% of total billed charges,4.65,135.24,
82270 Occult blood feces,3428342,CDM,300,RC,82270,HCPCS,Outpatient,,,26,13,,19.5,75,,,percent of total billed charges,75% of total billed charges,19.5,75,,,percent of total billed charges,75% of total billed charges,4.38,100,,,Fee Schedule,100% of CMS OPPS Rate,3.94,100,,,Fee Schedule,100% of WV Medicaid Rate,4.38,100,,,Fee Schedule,100% of CMS OPPS Rate,4.38,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,15.52,354.54,,,Fee Schedule,354.54% of CMS OPPS Fee Schedule Rate,18.77,428.7,,,Fee Schedule,428.7% of CMS OPPS Fee Schedule Rate,19.74,450.81,,,Fee Schedule,450.81% of CMS OPPS Fee Schedule Rate,3.94,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,4.38,100,,,Fee Schedule,100% of CMS OPPS Rate,4.38,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,3.64,14,,,percent of total billed charges,14% of total billed charges,3.64,19.74,
Occult Blood,593508,CDM,300,RC,82272,HCPCS,Outpatient,,,107.14,53.57,,80.36,75,,,percent of total billed charges,75% of total billed charges,80.36,75,,,percent of total billed charges,75% of total billed charges,4.23,100,,,Fee Schedule,100% of CMS OPPS Rate,3.81,100,,,Fee Schedule,100% of WV Medicaid Rate,4.23,100,,,Fee Schedule,100% of CMS OPPS Rate,4.23,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,14.99,354.54,,,Fee Schedule,354.54% of CMS OPPS Fee Schedule Rate,18.13,428.7,,,Fee Schedule,428.7% of CMS OPPS Fee Schedule Rate,19.06,450.81,,,Fee Schedule,450.81% of CMS OPPS Fee Schedule Rate,3.81,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,4.23,100,,,Fee Schedule,100% of CMS OPPS Rate,4.23,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,15,14,,,percent of total billed charges,14% of total billed charges,3.81,80.36,
Stool for Occult Blood POC,3444208,CDM,300,RC,82272,HCPCS,Outpatient,,,15.95,7.98,,11.96,75,,,percent of total billed charges,75% of total billed charges,11.96,75,,,percent of total billed charges,75% of total billed charges,4.23,100,,,Fee Schedule,100% of CMS OPPS Rate,3.81,100,,,Fee Schedule,100% of WV Medicaid Rate,4.23,100,,,Fee Schedule,100% of CMS OPPS Rate,4.23,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,14.99,354.54,,,Fee Schedule,354.54% of CMS OPPS Fee Schedule Rate,18.13,428.7,,,Fee Schedule,428.7% of CMS OPPS Fee Schedule Rate,19.06,450.81,,,Fee Schedule,450.81% of CMS OPPS Fee Schedule Rate,3.81,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,4.23,100,,,Fee Schedule,100% of CMS OPPS Rate,4.23,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,2.23,14,,,percent of total billed charges,14% of total billed charges,2.23,19.06,
FIT POC,3444189,CDM,300,RC,82274,HCPCS,Outpatient,,,46.99,23.5,,35.24,75,,,percent of total billed charges,75% of total billed charges,35.24,75,,,percent of total billed charges,75% of total billed charges,15.92,100,,,Fee Schedule,100% of CMS OPPS Rate,14.33,100,,,Fee Schedule,100% of WV Medicaid Rate,15.92,100,,,Fee Schedule,100% of CMS OPPS Rate,15.92,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,56.44,354.54,,,Fee Schedule,354.54% of CMS OPPS Fee Schedule Rate,68.24,428.7,,,Fee Schedule,428.7% of CMS OPPS Fee Schedule Rate,71.76,450.81,,,Fee Schedule,450.81% of CMS OPPS Fee Schedule Rate,14.33,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,15.92,100,,,Fee Schedule,100% of CMS OPPS Rate,15.92,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,6.58,14,,,percent of total billed charges,14% of total billed charges,6.58,71.76,
Chloride POC,4326414,CDM,300,RC,82435,HCPCS,Outpatient,,,25.76,12.88,,19.32,75,,,percent of total billed charges,75% of total billed charges,19.32,75,,,percent of total billed charges,75% of total billed charges,4.59,100,,,Fee Schedule,100% of CMS OPPS Rate,4.14,100,,,Fee Schedule,100% of WV Medicaid Rate,4.59,100,,,Fee Schedule,100% of CMS OPPS Rate,4.6,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,16.3,354.54,,,Fee Schedule,354.54% of CMS OPPS Fee Schedule Rate,19.72,428.7,,,Fee Schedule,428.7% of CMS OPPS Fee Schedule Rate,20.73,450.81,,,Fee Schedule,450.81% of CMS OPPS Fee Schedule Rate,4.14,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,4.59,100,,,Fee Schedule,100% of CMS OPPS Rate,4.6,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,3.61,14,,,percent of total billed charges,14% of total billed charges,3.61,20.73,
Blood Gas (Art) CG4 POC,4323216,CDM,300,RC,82803,HCPCS,Outpatient,,,145.99,73,,109.49,75,,,percent of total billed charges,75% of total billed charges,109.49,75,,,percent of total billed charges,75% of total billed charges,26.07,100,,,Fee Schedule,100% of CMS OPPS Rate,23.46,100,,,Fee Schedule,100% of WV Medicaid Rate,26.07,100,,,Fee Schedule,100% of CMS OPPS Rate,26.07,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,92.42,354.54,,,Fee Schedule,354.54% of CMS OPPS Fee Schedule Rate,111.76,428.7,,,Fee Schedule,428.7% of CMS OPPS Fee Schedule Rate,117.52,450.81,,,Fee Schedule,450.81% of CMS OPPS Fee Schedule Rate,23.46,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,26.07,100,,,Fee Schedule,100% of CMS OPPS Rate,26.07,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,20.44,14,,,percent of total billed charges,14% of total billed charges,20.44,117.52,
pH (Ven POC BG),4326420,CDM,300,RC,82803,HCPCS,Outpatient,,,145.99,73,,109.49,75,,,percent of total billed charges,75% of total billed charges,109.49,75,,,percent of total billed charges,75% of total billed charges,26.07,100,,,Fee Schedule,100% of CMS OPPS Rate,23.46,100,,,Fee Schedule,100% of WV Medicaid Rate,26.07,100,,,Fee Schedule,100% of CMS OPPS Rate,26.07,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,92.42,354.54,,,Fee Schedule,354.54% of CMS OPPS Fee Schedule Rate,111.76,428.7,,,Fee Schedule,428.7% of CMS OPPS Fee Schedule Rate,117.52,450.81,,,Fee Schedule,450.81% of CMS OPPS Fee Schedule Rate,23.46,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,26.07,100,,,Fee Schedule,100% of CMS OPPS Rate,26.07,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,20.44,14,,,percent of total billed charges,14% of total billed charges,20.44,117.52,
O2 Saturation POC,3444202,CDM,300,RC,82810,HCPCS,Outpatient,,,25.98,12.99,,19.49,75,,,percent of total billed charges,75% of total billed charges,19.49,75,,,percent of total billed charges,75% of total billed charges,9.77,100,,,Fee Schedule,100% of CMS OPPS Rate,8.79,100,,,Fee Schedule,100% of WV Medicaid Rate,9.77,100,,,Fee Schedule,100% of CMS OPPS Rate,9.77,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,34.63,354.54,,,Fee Schedule,354.54% of CMS OPPS Fee Schedule Rate,41.88,428.7,,,Fee Schedule,428.7% of CMS OPPS Fee Schedule Rate,44.04,450.81,,,Fee Schedule,450.81% of CMS OPPS Fee Schedule Rate,8.79,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,9.77,100,,,Fee Schedule,100% of CMS OPPS Rate,9.77,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,3.64,14,,,percent of total billed charges,14% of total billed charges,3.64,44.04,
82947 - Glucose POC,3918908,CDM,960,RC,82947,HCPCS,Outpatient,,,13.4,6.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
Glucose POC,4326416,CDM,300,RC,82947,HCPCS,Outpatient,,,22.01,11.01,,16.51,75,,,percent of total billed charges,75% of total billed charges,16.51,75,,,percent of total billed charges,75% of total billed charges,3.93,100,,,Fee Schedule,100% of CMS OPPS Rate,3.54,100,,,Fee Schedule,100% of WV Medicaid Rate,3.93,100,,,Fee Schedule,100% of CMS OPPS Rate,3.93,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,13.93,354.54,,,Fee Schedule,354.54% of CMS OPPS Fee Schedule Rate,16.84,428.7,,,Fee Schedule,428.7% of CMS OPPS Fee Schedule Rate,17.71,450.81,,,Fee Schedule,450.81% of CMS OPPS Fee Schedule Rate,3.54,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,3.93,100,,,Fee Schedule,100% of CMS OPPS Rate,3.93,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,3.08,14,,,percent of total billed charges,14% of total billed charges,3.08,17.71,
Glucose POC,3444190,CDM,300,RC,82947,HCPCS,Outpatient,,,13.4,6.7,,10.05,75,,,percent of total billed charges,75% of total billed charges,10.05,75,,,percent of total billed charges,75% of total billed charges,3.93,100,,,Fee Schedule,100% of CMS OPPS Rate,3.54,100,,,Fee Schedule,100% of WV Medicaid Rate,3.93,100,,,Fee Schedule,100% of CMS OPPS Rate,3.93,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,13.93,354.54,,,Fee Schedule,354.54% of CMS OPPS Fee Schedule Rate,16.84,428.7,,,Fee Schedule,428.7% of CMS OPPS Fee Schedule Rate,17.71,450.81,,,Fee Schedule,450.81% of CMS OPPS Fee Schedule Rate,3.54,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,3.93,100,,,Fee Schedule,100% of CMS OPPS Rate,3.93,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,1.88,14,,,percent of total billed charges,14% of total billed charges,1.88,17.71,
82962 Gluc Bld Cluc Mntr Dev Cleared FDA Spec Home Use,3436058,CDM,761,RC,82962,HCPCS,Outpatient,,,8.72,4.36,,6.54,75,,,percent of total billed charges,75% of total billed charges,6.54,75,,,percent of total billed charges,75% of total billed charges,3.28,100,,,Fee Schedule,100% of CMS OPPS Rate,2.95,100,,,Fee Schedule,100% of WV Medicaid Rate,3.28,100,,,Fee Schedule,100% of CMS OPPS Rate,3.28,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,11.62,354.54,,,Fee Schedule,354.54% of CMS OPPS Fee Schedule Rate,14.06,428.7,,,Fee Schedule,428.7% of CMS OPPS Fee Schedule Rate,14.78,450.81,,,Fee Schedule,450.81% of CMS OPPS Fee Schedule Rate,2.95,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,3.28,100,,,Fee Schedule,100% of CMS OPPS Rate,3.28,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,1.22,14,,,percent of total billed charges,14% of total billed charges,1.22,14.78,
Lead Level POC,3444199,CDM,300,RC,83655,HCPCS,Outpatient,,,35.78,17.89,,26.84,75,,,percent of total billed charges,75% of total billed charges,26.84,75,,,percent of total billed charges,75% of total billed charges,12.11,100,,,Fee Schedule,100% of CMS OPPS Rate,10.9,100,,,Fee Schedule,100% of WV Medicaid Rate,12.11,100,,,Fee Schedule,100% of CMS OPPS Rate,12.11,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,42.93,354.54,,,Fee Schedule,354.54% of CMS OPPS Fee Schedule Rate,51.91,428.7,,,Fee Schedule,428.7% of CMS OPPS Fee Schedule Rate,54.59,450.81,,,Fee Schedule,450.81% of CMS OPPS Fee Schedule Rate,10.9,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,12.11,100,,,Fee Schedule,100% of CMS OPPS Rate,12.11,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,5.01,14,,,percent of total billed charges,14% of total billed charges,5.01,54.59,
Potassium POC,4326413,CDM,300,RC,84132,HCPCS,Outpatient,,,26.66,13.33,,20,75,,,percent of total billed charges,75% of total billed charges,20,75,,,percent of total billed charges,75% of total billed charges,4.76,100,,,Fee Schedule,100% of CMS OPPS Rate,4.28,100,,,Fee Schedule,100% of WV Medicaid Rate,4.76,100,,,Fee Schedule,100% of CMS OPPS Rate,4.76,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,16.87,354.54,,,Fee Schedule,354.54% of CMS OPPS Fee Schedule Rate,20.4,428.7,,,Fee Schedule,428.7% of CMS OPPS Fee Schedule Rate,21.45,450.81,,,Fee Schedule,450.81% of CMS OPPS Fee Schedule Rate,4.28,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,4.76,100,,,Fee Schedule,100% of CMS OPPS Rate,4.76,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,3.73,14,,,percent of total billed charges,14% of total billed charges,3.73,21.45,
Sodium POC,4326412,CDM,300,RC,84295,HCPCS,Outpatient,,,26.94,13.47,,20.21,75,,,percent of total billed charges,75% of total billed charges,20.21,75,,,percent of total billed charges,75% of total billed charges,4.8,100,,,Fee Schedule,100% of CMS OPPS Rate,4.33,100,,,Fee Schedule,100% of WV Medicaid Rate,4.8,100,,,Fee Schedule,100% of CMS OPPS Rate,4.81,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,17.05,354.54,,,Fee Schedule,354.54% of CMS OPPS Fee Schedule Rate,20.62,428.7,,,Fee Schedule,428.7% of CMS OPPS Fee Schedule Rate,21.68,450.81,,,Fee Schedule,450.81% of CMS OPPS Fee Schedule Rate,4.33,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,4.8,100,,,Fee Schedule,100% of CMS OPPS Rate,4.81,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,3.77,14,,,percent of total billed charges,14% of total billed charges,3.77,21.68,
Troponin I POC,1251035,CDM,510,RC,84484,HCPCS,Outpatient,,,74.02,37.01,,55.52,75,,,percent of total billed charges,75% of total billed charges,55.52,75,,,percent of total billed charges,75% of total billed charges,12.47,100,,,Fee Schedule,100% of CMS OPPS Rate,11.22,100,,,Fee Schedule,100% of WV Medicaid Rate,12.47,100,,,Fee Schedule,100% of CMS OPPS Rate,12.47,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,44.21,354.54,,,Fee Schedule,354.54% of CMS OPPS Fee Schedule Rate,53.45,428.7,,,Fee Schedule,428.7% of CMS OPPS Fee Schedule Rate,56.21,450.81,,,Fee Schedule,450.81% of CMS OPPS Fee Schedule Rate,11.22,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,12.47,100,,,Fee Schedule,100% of CMS OPPS Rate,12.47,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,10.36,14,,,percent of total billed charges,14% of total billed charges,10.36,56.21,
BUN POC,4326417,CDM,300,RC,84520,HCPCS,Outpatient,,,22.12,11.06,,16.59,75,,,percent of total billed charges,75% of total billed charges,16.59,75,,,percent of total billed charges,75% of total billed charges,3.95,100,,,Fee Schedule,100% of CMS OPPS Rate,3.56,100,,,Fee Schedule,100% of WV Medicaid Rate,3.95,100,,,Fee Schedule,100% of CMS OPPS Rate,3.95,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,14,354.54,,,Fee Schedule,354.54% of CMS OPPS Fee Schedule Rate,16.93,428.7,,,Fee Schedule,428.7% of CMS OPPS Fee Schedule Rate,17.8,450.81,,,Fee Schedule,450.81% of CMS OPPS Fee Schedule Rate,3.56,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,3.95,100,,,Fee Schedule,100% of CMS OPPS Rate,3.95,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,3.1,14,,,percent of total billed charges,14% of total billed charges,3.1,17.8,
Urine Pregnancy Test,1365117,CDM,510,RC,84703,HCPCS,Outpatient,,,44.64,22.32,,33.48,75,,,percent of total billed charges,75% of total billed charges,33.48,75,,,percent of total billed charges,75% of total billed charges,7.52,100,,,Fee Schedule,100% of CMS OPPS Rate,6.77,100,,,Fee Schedule,100% of WV Medicaid Rate,7.52,100,,,Fee Schedule,100% of CMS OPPS Rate,7.52,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,26.66,354.54,,,Fee Schedule,354.54% of CMS OPPS Fee Schedule Rate,32.23,428.7,,,Fee Schedule,428.7% of CMS OPPS Fee Schedule Rate,33.9,450.81,,,Fee Schedule,450.81% of CMS OPPS Fee Schedule Rate,6.77,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,7.52,100,,,Fee Schedule,100% of CMS OPPS Rate,7.52,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,6.25,14,,,percent of total billed charges,14% of total billed charges,6.25,33.9,
Hct POC,4326419,CDM,300,RC,85014,HCPCS,Outpatient,,,13.27,6.64,,9.95,75,,,percent of total billed charges,75% of total billed charges,9.95,75,,,percent of total billed charges,75% of total billed charges,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate,2.13,100,,,Fee Schedule,100% of WV Medicaid Rate,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate,2.37,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,8.4,354.54,,,Fee Schedule,354.54% of CMS OPPS Fee Schedule Rate,10.16,428.7,,,Fee Schedule,428.7% of CMS OPPS Fee Schedule Rate,10.68,450.81,,,Fee Schedule,450.81% of CMS OPPS Fee Schedule Rate,2.13,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate,2.37,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,1.86,14,,,percent of total billed charges,14% of total billed charges,1.86,10.68,
POC Hemoglobin Capillary,2990102,CDM,300,RC,85018,HCPCS,Outpatient,,,14.07,7.04,,10.55,75,,,percent of total billed charges,75% of total billed charges,10.55,75,,,percent of total billed charges,75% of total billed charges,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate,2.13,100,,,Fee Schedule,100% of WV Medicaid Rate,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate,2.37,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,8.4,354.54,,,Fee Schedule,354.54% of CMS OPPS Fee Schedule Rate,10.16,428.7,,,Fee Schedule,428.7% of CMS OPPS Fee Schedule Rate,10.68,450.81,,,Fee Schedule,450.81% of CMS OPPS Fee Schedule Rate,2.13,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate,2.37,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,1.97,14,,,percent of total billed charges,14% of total billed charges,1.97,10.68,
85025 - Complete Blood Count POC,3918909,CDM,300,RC,85025,HCPCS,Outpatient,,,124.98,62.49,,93.74,75,,,percent of total billed charges,75% of total billed charges,93.74,75,,,percent of total billed charges,75% of total billed charges,7.77,100,,,Fee Schedule,100% of CMS OPPS Rate,6.99,100,,,Fee Schedule,100% of WV Medicaid Rate,7.77,100,,,Fee Schedule,100% of CMS OPPS Rate,7.77,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,27.54,354.54,,,Fee Schedule,354.54% of CMS OPPS Fee Schedule Rate,33.3,428.7,,,Fee Schedule,428.7% of CMS OPPS Fee Schedule Rate,35.02,450.81,,,Fee Schedule,450.81% of CMS OPPS Fee Schedule Rate,6.99,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,7.77,100,,,Fee Schedule,100% of CMS OPPS Rate,7.77,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,17.5,14,,,percent of total billed charges,14% of total billed charges,6.99,93.74,
Complete Blood Count POC,3528247,CDM,300,RC,85025,HCPCS,Outpatient,,,124.98,62.49,,93.74,75,,,percent of total billed charges,75% of total billed charges,93.74,75,,,percent of total billed charges,75% of total billed charges,7.77,100,,,Fee Schedule,100% of CMS OPPS Rate,6.99,100,,,Fee Schedule,100% of WV Medicaid Rate,7.77,100,,,Fee Schedule,100% of CMS OPPS Rate,7.77,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,27.54,354.54,,,Fee Schedule,354.54% of CMS OPPS Fee Schedule Rate,33.3,428.7,,,Fee Schedule,428.7% of CMS OPPS Fee Schedule Rate,35.02,450.81,,,Fee Schedule,450.81% of CMS OPPS Fee Schedule Rate,6.99,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,7.77,100,,,Fee Schedule,100% of CMS OPPS Rate,7.77,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,17.5,14,,,percent of total billed charges,14% of total billed charges,6.99,93.74,
Pathology Billing Peripheral Smear with Path Interp,592827,CDM,971,RC,85060,HCPCS,Outpatient,,,55.51,27.76,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
Pathology Billing BM Aspirate Smear Interpretation,644404,CDM,971,RC,85097,HCPCS,Outpatient,,,153.05,76.53,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
85610- Prothrombin time,3430526,CDM,300,RC,85610,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.29,100,,,Fee Schedule,100% of CMS OPPS Rate,3.86,100,,,Fee Schedule,100% of WV Medicaid Rate,4.29,100,,,Fee Schedule,100% of CMS OPPS Rate,4.29,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,15.2,354.54,,,Fee Schedule,354.54% of CMS OPPS Fee Schedule Rate,18.39,428.7,,,Fee Schedule,428.7% of CMS OPPS Fee Schedule Rate,19.33,450.81,,,Fee Schedule,450.81% of CMS OPPS Fee Schedule Rate,3.86,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,4.29,100,,,Fee Schedule,100% of CMS OPPS Rate,4.29,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,,,,,Other,Not Separately reimbursable,3.86,19.33,
H Pylori POC,3444191,CDM,300,RC,86318,HCPCS,Outpatient,,,48.1,24.05,,36.08,75,,,percent of total billed charges,75% of total billed charges,36.08,75,,,percent of total billed charges,75% of total billed charges,18.09,100,,,Fee Schedule,100% of CMS OPPS Rate,16.28,100,,,Fee Schedule,100% of WV Medicaid Rate,18.09,100,,,Fee Schedule,100% of CMS OPPS Rate,18.09,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,64.13,354.54,,,Fee Schedule,354.54% of CMS OPPS Fee Schedule Rate,77.55,428.7,,,Fee Schedule,428.7% of CMS OPPS Fee Schedule Rate,81.55,450.81,,,Fee Schedule,450.81% of CMS OPPS Fee Schedule Rate,16.28,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,18.09,100,,,Fee Schedule,100% of CMS OPPS Rate,18.09,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,6.73,14,,,percent of total billed charges,14% of total billed charges,6.73,81.55,
BladderChek POC,3444187,CDM,300,RC,86386,HCPCS,Outpatient,,,35.9,17.95,,26.93,75,,,percent of total billed charges,75% of total billed charges,26.93,75,,,percent of total billed charges,75% of total billed charges,21.78,100,,,Fee Schedule,100% of CMS OPPS Rate,19.6,100,,,Fee Schedule,100% of WV Medicaid Rate,21.78,100,,,Fee Schedule,100% of CMS OPPS Rate,21.78,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,77.21,354.54,,,Fee Schedule,354.54% of CMS OPPS Fee Schedule Rate,93.37,428.7,,,Fee Schedule,428.7% of CMS OPPS Fee Schedule Rate,98.18,450.81,,,Fee Schedule,450.81% of CMS OPPS Fee Schedule Rate,19.6,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,21.78,100,,,Fee Schedule,100% of CMS OPPS Rate,21.78,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,5.03,14,,,percent of total billed charges,14% of total billed charges,5.03,98.18,
Monospot: Whole Blood POC,3444201,CDM,300,RC,86403,HCPCS,Outpatient,,,30.69,15.35,,23.02,75,,,percent of total billed charges,75% of total billed charges,23.02,75,,,percent of total billed charges,75% of total billed charges,11.54,100,,,Fee Schedule,100% of CMS OPPS Rate,10.39,100,,,Fee Schedule,100% of WV Medicaid Rate,11.54,100,,,Fee Schedule,100% of CMS OPPS Rate,11.54,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,40.91,354.54,,,Fee Schedule,354.54% of CMS OPPS Fee Schedule Rate,49.47,428.7,,,Fee Schedule,428.7% of CMS OPPS Fee Schedule Rate,52.02,450.81,,,Fee Schedule,450.81% of CMS OPPS Fee Schedule Rate,10.39,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,11.54,100,,,Fee Schedule,100% of CMS OPPS Rate,11.54,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,4.3,14,,,percent of total billed charges,14% of total billed charges,4.3,52.02,
86580 Tb intradermal test,3428347,CDM,983,RC,86580,HCPCS,Outpatient,,,24.79,12.4,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
AMB PPD Charge:5 unit PPD Inj,3444386,CDM,960,RC,86580,HCPCS,Outpatient,,,24.79,12.4,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
87210 Smear wet mount saline/ink,3428350,CDM,300,RC,87210,HCPCS,Outpatient,,,15.48,7.74,,11.61,75,,,percent of total billed charges,75% of total billed charges,11.61,75,,,percent of total billed charges,75% of total billed charges,5.82,100,,,Fee Schedule,100% of CMS OPPS Rate,5.24,100,,,Fee Schedule,100% of WV Medicaid Rate,5.82,100,,,Fee Schedule,100% of CMS OPPS Rate,5.82,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,20.63,354.54,,,Fee Schedule,354.54% of CMS OPPS Fee Schedule Rate,24.95,428.7,,,Fee Schedule,428.7% of CMS OPPS Fee Schedule Rate,26.23,450.81,,,Fee Schedule,450.81% of CMS OPPS Fee Schedule Rate,5.24,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,5.82,100,,,Fee Schedule,100% of CMS OPPS Rate,5.82,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,2.17,14,,,percent of total billed charges,14% of total billed charges,2.17,26.23,
KOH POC,3989023,CDM,300,RC,87210,HCPCS,Outpatient,,,15.48,7.74,,11.61,75,,,percent of total billed charges,75% of total billed charges,11.61,75,,,percent of total billed charges,75% of total billed charges,5.82,100,,,Fee Schedule,100% of CMS OPPS Rate,5.24,100,,,Fee Schedule,100% of WV Medicaid Rate,5.82,100,,,Fee Schedule,100% of CMS OPPS Rate,5.82,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,20.63,354.54,,,Fee Schedule,354.54% of CMS OPPS Fee Schedule Rate,24.95,428.7,,,Fee Schedule,428.7% of CMS OPPS Fee Schedule Rate,26.23,450.81,,,Fee Schedule,450.81% of CMS OPPS Fee Schedule Rate,5.24,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,5.82,100,,,Fee Schedule,100% of CMS OPPS Rate,5.82,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,2.17,14,,,percent of total billed charges,14% of total billed charges,2.17,26.23,
KOH/Wet Prep POC,3444198,CDM,300,RC,87210,HCPCS,Outpatient,,,15.48,7.74,,11.61,75,,,percent of total billed charges,75% of total billed charges,11.61,75,,,percent of total billed charges,75% of total billed charges,5.82,100,,,Fee Schedule,100% of CMS OPPS Rate,5.24,100,,,Fee Schedule,100% of WV Medicaid Rate,5.82,100,,,Fee Schedule,100% of CMS OPPS Rate,5.82,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,20.63,354.54,,,Fee Schedule,354.54% of CMS OPPS Fee Schedule Rate,24.95,428.7,,,Fee Schedule,428.7% of CMS OPPS Fee Schedule Rate,26.23,450.81,,,Fee Schedule,450.81% of CMS OPPS Fee Schedule Rate,5.24,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,5.82,100,,,Fee Schedule,100% of CMS OPPS Rate,5.82,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,2.17,14,,,percent of total billed charges,14% of total billed charges,2.17,26.23,
Wet Mount POC,3444213,CDM,300,RC,87210,HCPCS,Outpatient,,,15.48,7.74,,11.61,75,,,percent of total billed charges,75% of total billed charges,11.61,75,,,percent of total billed charges,75% of total billed charges,5.82,100,,,Fee Schedule,100% of CMS OPPS Rate,5.24,100,,,Fee Schedule,100% of WV Medicaid Rate,5.82,100,,,Fee Schedule,100% of CMS OPPS Rate,5.82,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,20.63,354.54,,,Fee Schedule,354.54% of CMS OPPS Fee Schedule Rate,24.95,428.7,,,Fee Schedule,428.7% of CMS OPPS Fee Schedule Rate,26.23,450.81,,,Fee Schedule,450.81% of CMS OPPS Fee Schedule Rate,5.24,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,5.82,100,,,Fee Schedule,100% of CMS OPPS Rate,5.82,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,2.17,14,,,percent of total billed charges,14% of total billed charges,2.17,26.23,
87220-KOH POC,3550577,CDM,300,RC,87220,HCPCS,Outpatient,,,117.01,58.51,,87.76,75,,,percent of total billed charges,75% of total billed charges,87.76,75,,,percent of total billed charges,75% of total billed charges,4.26,100,,,Fee Schedule,100% of CMS OPPS Rate,3.84,100,,,Fee Schedule,100% of WV Medicaid Rate,4.26,100,,,Fee Schedule,100% of CMS OPPS Rate,4.27,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,15.13,354.54,,,Fee Schedule,354.54% of CMS OPPS Fee Schedule Rate,18.3,428.7,,,Fee Schedule,428.7% of CMS OPPS Fee Schedule Rate,19.24,450.81,,,Fee Schedule,450.81% of CMS OPPS Fee Schedule Rate,3.84,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,4.26,100,,,Fee Schedule,100% of CMS OPPS Rate,4.27,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,16.38,14,,,percent of total billed charges,14% of total billed charges,3.84,87.76,
KOH POC,3986925,CDM,300,RC,87220,HCPCS,Outpatient,,,25.34,12.67,,19.01,75,,,percent of total billed charges,75% of total billed charges,19.01,75,,,percent of total billed charges,75% of total billed charges,4.26,100,,,Fee Schedule,100% of CMS OPPS Rate,3.84,100,,,Fee Schedule,100% of WV Medicaid Rate,4.26,100,,,Fee Schedule,100% of CMS OPPS Rate,4.27,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,15.13,354.54,,,Fee Schedule,354.54% of CMS OPPS Fee Schedule Rate,18.3,428.7,,,Fee Schedule,428.7% of CMS OPPS Fee Schedule Rate,19.24,450.81,,,Fee Schedule,450.81% of CMS OPPS Fee Schedule Rate,3.84,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,4.26,100,,,Fee Schedule,100% of CMS OPPS Rate,4.27,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,3.55,14,,,percent of total billed charges,14% of total billed charges,3.55,19.24,
KOH POC,3444196,CDM,300,RC,87220,HCPCS,Outpatient,,,117.01,58.51,,87.76,75,,,percent of total billed charges,75% of total billed charges,87.76,75,,,percent of total billed charges,75% of total billed charges,4.26,100,,,Fee Schedule,100% of CMS OPPS Rate,3.84,100,,,Fee Schedule,100% of WV Medicaid Rate,4.26,100,,,Fee Schedule,100% of CMS OPPS Rate,4.27,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,15.13,354.54,,,Fee Schedule,354.54% of CMS OPPS Fee Schedule Rate,18.3,428.7,,,Fee Schedule,428.7% of CMS OPPS Fee Schedule Rate,19.24,450.81,,,Fee Schedule,450.81% of CMS OPPS Fee Schedule Rate,3.84,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,4.26,100,,,Fee Schedule,100% of CMS OPPS Rate,4.27,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,16.38,14,,,percent of total billed charges,14% of total billed charges,3.84,87.76,
87320 Chylmd trach dna quant,3430528,CDM,960,RC,87320,HCPCS,Outpatient,,,19.95,9.98,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
87426 - Covid Antigen POC,3918910,CDM,960,RC,87426,HCPCS,Outpatient,,,214.08,107.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
Covid Antigen POC,3571323,CDM,960,RC,87426,HCPCS,Outpatient,,,214.08,107.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
Candidiasis Vaginitis,4283365,CDM,306,RC,87481,HCPCS,Outpatient,,,148.4,74.2,,111.3,75,,,percent of total billed charges,75% of total billed charges,111.3,75,,,percent of total billed charges,75% of total billed charges,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,31.58,100,,,Fee Schedule,100% of WV Medicaid Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,124.4,354.54,,,Fee Schedule,354.54% of CMS OPPS Fee Schedule Rate,150.43,428.7,,,Fee Schedule,428.7% of CMS OPPS Fee Schedule Rate,158.18,450.81,,,Fee Schedule,450.81% of CMS OPPS Fee Schedule Rate,31.58,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,20.78,14,,,percent of total billed charges,14% of total billed charges,20.78,158.18,
87804 - Influenze POC,3918911,CDM,300,RC,87804,HCPCS,Outpatient,,,44.01,22.01,,33.01,75,,,percent of total billed charges,75% of total billed charges,33.01,75,,,percent of total billed charges,75% of total billed charges,16.55,100,,,Fee Schedule,100% of CMS OPPS Rate,14.9,100,,,Fee Schedule,100% of WV Medicaid Rate,16.55,100,,,Fee Schedule,100% of CMS OPPS Rate,16.55,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,58.67,354.54,,,Fee Schedule,354.54% of CMS OPPS Fee Schedule Rate,70.94,428.7,,,Fee Schedule,428.7% of CMS OPPS Fee Schedule Rate,74.6,450.81,,,Fee Schedule,450.81% of CMS OPPS Fee Schedule Rate,14.9,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,16.55,100,,,Fee Schedule,100% of CMS OPPS Rate,16.55,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,6.16,14,,,percent of total billed charges,14% of total billed charges,6.16,74.6,
Influenza POC,3444195,CDM,300,RC,87804,HCPCS,Outpatient,,,44.01,22.01,,33.01,75,,,percent of total billed charges,75% of total billed charges,33.01,75,,,percent of total billed charges,75% of total billed charges,16.55,100,,,Fee Schedule,100% of CMS OPPS Rate,14.9,100,,,Fee Schedule,100% of WV Medicaid Rate,16.55,100,,,Fee Schedule,100% of CMS OPPS Rate,16.55,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,58.67,354.54,,,Fee Schedule,354.54% of CMS OPPS Fee Schedule Rate,70.94,428.7,,,Fee Schedule,428.7% of CMS OPPS Fee Schedule Rate,74.6,450.81,,,Fee Schedule,450.81% of CMS OPPS Fee Schedule Rate,14.9,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,16.55,100,,,Fee Schedule,100% of CMS OPPS Rate,16.55,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,6.16,14,,,percent of total billed charges,14% of total billed charges,6.16,74.6,
87807 - RSV POC,3918912,CDM,300,RC,87807,HCPCS,Outpatient,,,42.25,21.13,,31.69,75,,,percent of total billed charges,75% of total billed charges,31.69,75,,,percent of total billed charges,75% of total billed charges,13.1,100,,,Fee Schedule,100% of CMS OPPS Rate,11.79,100,,,Fee Schedule,100% of WV Medicaid Rate,13.1,100,,,Fee Schedule,100% of CMS OPPS Rate,13.1,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,46.44,354.54,,,Fee Schedule,354.54% of CMS OPPS Fee Schedule Rate,56.15,428.7,,,Fee Schedule,428.7% of CMS OPPS Fee Schedule Rate,59.05,450.81,,,Fee Schedule,450.81% of CMS OPPS Fee Schedule Rate,11.79,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,13.1,100,,,Fee Schedule,100% of CMS OPPS Rate,13.1,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,5.92,14,,,percent of total billed charges,14% of total billed charges,5.92,59.05,
RSV POC,3444205,CDM,300,RC,87807,HCPCS,Outpatient,,,42.25,21.13,,31.69,75,,,percent of total billed charges,75% of total billed charges,31.69,75,,,percent of total billed charges,75% of total billed charges,13.1,100,,,Fee Schedule,100% of CMS OPPS Rate,11.79,100,,,Fee Schedule,100% of WV Medicaid Rate,13.1,100,,,Fee Schedule,100% of CMS OPPS Rate,13.1,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,46.44,354.54,,,Fee Schedule,354.54% of CMS OPPS Fee Schedule Rate,56.15,428.7,,,Fee Schedule,428.7% of CMS OPPS Fee Schedule Rate,59.05,450.81,,,Fee Schedule,450.81% of CMS OPPS Fee Schedule Rate,11.79,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,13.1,100,,,Fee Schedule,100% of CMS OPPS Rate,13.1,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,5.92,14,,,percent of total billed charges,14% of total billed charges,5.92,59.05,
87810 Chylmd trach assay w/optic,3430529,CDM,960,RC,87810,HCPCS,Outpatient,,,46.92,23.46,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
87880 - Rapid Strep POC,3918913,CDM,300,RC,87880,HCPCS,Outpatient,,,30.69,15.35,,23.02,75,,,percent of total billed charges,75% of total billed charges,23.02,75,,,percent of total billed charges,75% of total billed charges,16.53,100,,,Fee Schedule,100% of CMS OPPS Rate,14.88,100,,,Fee Schedule,100% of WV Medicaid Rate,16.53,100,,,Fee Schedule,100% of CMS OPPS Rate,16.53,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,58.6,354.54,,,Fee Schedule,354.54% of CMS OPPS Fee Schedule Rate,70.86,428.7,,,Fee Schedule,428.7% of CMS OPPS Fee Schedule Rate,74.51,450.81,,,Fee Schedule,450.81% of CMS OPPS Fee Schedule Rate,14.88,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,16.53,100,,,Fee Schedule,100% of CMS OPPS Rate,16.53,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,4.3,14,,,percent of total billed charges,14% of total billed charges,4.3,74.51,
Rapid Strep POC,3444206,CDM,300,RC,87880,HCPCS,Outpatient,,,30.69,15.35,,23.02,75,,,percent of total billed charges,75% of total billed charges,23.02,75,,,percent of total billed charges,75% of total billed charges,16.53,100,,,Fee Schedule,100% of CMS OPPS Rate,14.88,100,,,Fee Schedule,100% of WV Medicaid Rate,16.53,100,,,Fee Schedule,100% of CMS OPPS Rate,16.53,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,58.6,354.54,,,Fee Schedule,354.54% of CMS OPPS Fee Schedule Rate,70.86,428.7,,,Fee Schedule,428.7% of CMS OPPS Fee Schedule Rate,74.51,450.81,,,Fee Schedule,450.81% of CMS OPPS Fee Schedule Rate,14.88,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,16.53,100,,,Fee Schedule,100% of CMS OPPS Rate,16.53,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,4.3,14,,,percent of total billed charges,14% of total billed charges,4.3,74.51,
Pathology Billing Non-Gyn Cytology,295380,CDM,310,RC,88104,HCPCS,Outpatient,,,149.82,74.91,,112.37,75,,,percent of total billed charges,75% of total billed charges,112.37,75,,,percent of total billed charges,75% of total billed charges,31.92,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,52.68,165,,,Fee Schedule,165% of CMS OPPS Rate,33.09,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,91.7,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,125.77,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,157.54,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,31.92,100,,,Fee Schedule,100% of CMS OPPS Rate,33.09,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,20.97,14,,,percent of total billed charges,14% of total billed charges,20.97,157.54,
Pathology Billing Non-Gyn Cytology Concentration Technique,592809,CDM,310,RC,88108,HCPCS,Outpatient,,,141.91,70.96,,106.43,75,,,percent of total billed charges,75% of total billed charges,106.43,75,,,percent of total billed charges,75% of total billed charges,31.92,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,52.68,165,,,Fee Schedule,165% of CMS OPPS Rate,33.09,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,91.7,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,125.77,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,157.54,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,31.92,100,,,Fee Schedule,100% of CMS OPPS Rate,33.09,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,19.87,14,,,percent of total billed charges,14% of total billed charges,19.87,157.54,
"Pathology Billing Cytopathology NG Thin Prep, with interpretation, except cervical or vaginal Profee",3549242,CDM,971,RC,88112,HCPCS,Outpatient,,,144.67,72.34,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
"88120 Urovysion, ISH",3513388,CDM,300,RC,88120,HCPCS,Outpatient,,,1248.57,624.29,,936.43,75,,,percent of total billed charges,75% of total billed charges,936.43,75,,,percent of total billed charges,75% of total billed charges,147.84,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,243.93,165,,,Fee Schedule,165% of CMS OPPS Rate,153.22,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,424.65,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,582.37,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,729.48,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,147.84,100,,,Fee Schedule,100% of CMS OPPS Rate,153.22,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,174.8,14,,,percent of total billed charges,14% of total billed charges,147.84,936.43,
Pathology Billing Gyn Cytology with Pathologist Interpretation Profee,3549245,CDM,971,RC,88141,HCPCS,Outpatient,,,50.32,25.16,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
88143 Cytopath c/v thin layer redo,3430530,CDM,960,RC,88143,HCPCS,Outpatient,,,30.63,15.32,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
88147 Cytopath c/v automated,3430531,CDM,960,RC,88147,HCPCS,Outpatient,,,67.24,33.62,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
88148 Cytopath c/v auto screen,3430532,CDM,960,RC,88148,HCPCS,Outpatient,,,21.27,10.64,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
88150 Cytopath c/v manual,3430533,CDM,960,RC,88150,HCPCS,Outpatient,,,20.1,10.05,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
88152 Cythopath c/v auto redo,3430534,CDM,960,RC,88152,HCPCS,Outpatient,,,36.76,18.38,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
88153 Cythopath c/v redo,3430536,CDM,960,RC,88153,HCPCS,Outpatient,,,31.95,15.98,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
88165 Cytopath tbs c/v redo,3430537,CDM,960,RC,88165,HCPCS,Outpatient,,,56.14,28.07,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
88166 Cytopath tbs c/v auto redo,3430538,CDM,960,RC,88166,HCPCS,Outpatient,,,20.1,10.05,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
88167 Cytopath tbs c/v select,3430539,CDM,960,RC,88167,HCPCS,Outpatient,,,20.1,10.05,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
Pathology Billing FNA Immediate Read,295386,CDM,311,RC,88172,HCPCS,Outpatient,,,350.46,175.23,,262.85,75,,,percent of total billed charges,75% of total billed charges,262.85,75,,,percent of total billed charges,75% of total billed charges,147.84,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,243.93,165,,,Fee Schedule,165% of CMS OPPS Rate,153.22,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,424.65,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,582.37,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,729.48,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,147.84,100,,,Fee Schedule,100% of CMS OPPS Rate,153.22,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,49.06,14,,,percent of total billed charges,14% of total billed charges,49.06,729.48,
Pathology Billing FNA Interp and Report,295388,CDM,311,RC,88173,HCPCS,Outpatient,,,350.46,175.23,,262.85,75,,,percent of total billed charges,75% of total billed charges,262.85,75,,,percent of total billed charges,75% of total billed charges,47.13,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,77.78,165,,,Fee Schedule,165% of CMS OPPS Rate,48.85,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,135.4,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,185.69,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,232.6,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,47.13,100,,,Fee Schedule,100% of CMS OPPS Rate,48.85,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,49.06,14,,,percent of total billed charges,14% of total billed charges,47.13,262.85,
Pathology Billing FNA Interp and Report Profee,3549244,CDM,971,RC,88173,HCPCS,Outpatient,,,350.46,175.23,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
Pathology Billing Flow Cytometry,644405,CDM,971,RC,88180,HCPCS,Outpatient,,,171.53,85.77,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
"Anti-IgE Receptor, Ea Add Marker",1373096,CDM,311,RC,88185,HCPCS,Outpatient,,,49.13,24.57,,36.85,75,,,percent of total billed charges,75% of total billed charges,36.85,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.88,14,,,percent of total billed charges,14% of total billed charges,6.88,36.85,
"IGE Receptor, Each Additional Marker",3010110,CDM,300,RC,88185,HCPCS,Outpatient,,,49.13,24.57,,36.85,75,,,percent of total billed charges,75% of total billed charges,36.85,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.88,14,,,percent of total billed charges,14% of total billed charges,6.88,36.85,
Leuk/Lymphoma Flow Cyt-each add Marker,1337216,CDM,311,RC,88185,HCPCS,Outpatient,,,49.13,24.57,,36.85,75,,,percent of total billed charges,75% of total billed charges,36.85,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.88,14,,,percent of total billed charges,14% of total billed charges,6.88,36.85,
Pathology Billing Flow Cyto Each Add Marker,653858,CDM,311,RC,88185,HCPCS,Outpatient,,,49.13,24.57,,36.85,75,,,percent of total billed charges,75% of total billed charges,36.85,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.88,14,,,percent of total billed charges,14% of total billed charges,6.88,36.85,
"ZAP-70, Flow Cytometry each add marker",1337218,CDM,311,RC,88185,HCPCS,Outpatient,,,49.13,24.57,,36.85,75,,,percent of total billed charges,75% of total billed charges,36.85,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.88,14,,,percent of total billed charges,14% of total billed charges,6.88,36.85,
Pathology Billing Flow Cyto Interp 2-8 Markers,653859,CDM,971,RC,88187,HCPCS,Outpatient,,,81.61,40.81,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
"ZAP-70, Flow Cytometry Interpretation",1337219,CDM,311,RC,88187,HCPCS,Outpatient,,,81.61,40.81,,61.21,75,,,percent of total billed charges,75% of total billed charges,61.21,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.43,14,,,percent of total billed charges,14% of total billed charges,11.43,61.21,
Pathology Billing Flow Cyto Interp 9-15 Markers,653860,CDM,971,RC,88188,HCPCS,Outpatient,,,141.41,70.71,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
Leuk/Lymphoma Flow Cyt Interpretation,1337217,CDM,971,RC,88189,HCPCS,Outpatient,,,192,96,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
Pathology Billing Flow Cyto Interp 16>Markers,653861,CDM,971,RC,88189,HCPCS,Outpatient,,,192,96,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
Pathology Billing Chrom Anal BM MBC,644609,CDM,971,RC,88291,HCPCS,Outpatient,,,84.65,42.33,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
"Pathology Billing, Gross Only",295346,CDM,310,RC,88300,HCPCS,Outpatient,,,34.76,17.38,,26.07,75,,,percent of total billed charges,75% of total billed charges,26.07,75,,,percent of total billed charges,75% of total billed charges,23.46,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,38.71,165,,,Fee Schedule,165% of CMS OPPS Rate,24.32,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,67.4,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,92.43,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,115.79,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,23.46,100,,,Fee Schedule,100% of CMS OPPS Rate,24.32,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4.87,14,,,percent of total billed charges,14% of total billed charges,4.87,115.79,
"Pathology Billing, Gross Only Profee",3549255,CDM,971,RC,88300,HCPCS,Outpatient,,,34.76,17.38,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
Pathology Billing Surgical Pathology Level II Complexity Profee,3549250,CDM,971,RC,88302,HCPCS,Outpatient,,,69.93,34.97,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
88304- Tissue exam by pathologist; Level III,3430540,CDM,310,RC,88304,HCPCS,Outpatient,,,91.01,45.51,,68.26,75,,,percent of total billed charges,75% of total billed charges,68.26,75,,,percent of total billed charges,75% of total billed charges,47.13,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,77.78,165,,,Fee Schedule,165% of CMS OPPS Rate,48.85,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,135.4,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,185.69,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,232.6,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,47.13,100,,,Fee Schedule,100% of CMS OPPS Rate,48.85,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,12.74,14,,,percent of total billed charges,14% of total billed charges,12.74,232.6,
Pathology Billing Surgical Pathology Level III Complexity Profee,3549251,CDM,971,RC,88304,HCPCS,Outpatient,,,91.01,45.51,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
Pathology Billing Surgical Pathology Level IV Complexity Profee,3549252,CDM,971,RC,88305,HCPCS,Outpatient,,,155.81,77.91,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
Pathology Billing Surgical Pathology Level VI Complexity,295356,CDM,310,RC,88309,HCPCS,Outpatient,,,935.8,467.9,,701.85,75,,,percent of total billed charges,75% of total billed charges,701.85,75,,,percent of total billed charges,75% of total billed charges,730.04,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1204.58,165,,,Fee Schedule,165% of CMS OPPS Rate,756.63,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,2096.96,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2875.81,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,3602.25,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,730.04,100,,,Fee Schedule,100% of CMS OPPS Rate,756.63,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,131.01,14,,,percent of total billed charges,14% of total billed charges,131.01,3602.25,
Pathology Billing Surgical Pathology Level VI Complexity Profee,3549254,CDM,971,RC,88309,HCPCS,Outpatient,,,935.8,467.9,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
Pathology Billing Decalcification Profee,3549243,CDM,971,RC,88311,HCPCS,Outpatient,,,45.57,22.79,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
Pathology Billing Special Stains Group I,295362,CDM,310,RC,88312,HCPCS,Outpatient,,,238.55,119.28,,178.91,75,,,percent of total billed charges,75% of total billed charges,178.91,75,,,percent of total billed charges,75% of total billed charges,47.13,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,77.78,165,,,Fee Schedule,165% of CMS OPPS Rate,48.85,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,135.4,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,185.69,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,232.6,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,47.13,100,,,Fee Schedule,100% of CMS OPPS Rate,48.85,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,33.4,14,,,percent of total billed charges,14% of total billed charges,33.4,232.6,
Special Stain AFB Stain,295230,CDM,310,RC,88312,HCPCS,Outpatient,,,238.55,119.28,,178.91,75,,,percent of total billed charges,75% of total billed charges,178.91,75,,,percent of total billed charges,75% of total billed charges,47.13,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,77.78,165,,,Fee Schedule,165% of CMS OPPS Rate,48.85,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,135.4,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,185.69,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,232.6,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,47.13,100,,,Fee Schedule,100% of CMS OPPS Rate,48.85,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,33.4,14,,,percent of total billed charges,14% of total billed charges,33.4,232.6,
SPECIAL STAIN BACTERIA,605495,CDM,310,RC,88312,HCPCS,Outpatient,,,238.55,119.28,,178.91,75,,,percent of total billed charges,75% of total billed charges,178.91,75,,,percent of total billed charges,75% of total billed charges,47.13,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,77.78,165,,,Fee Schedule,165% of CMS OPPS Rate,48.85,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,135.4,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,185.69,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,232.6,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,47.13,100,,,Fee Schedule,100% of CMS OPPS Rate,48.85,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,33.4,14,,,percent of total billed charges,14% of total billed charges,33.4,232.6,
Special Stain GMS Stain,295258,CDM,310,RC,88312,HCPCS,Outpatient,,,238.55,119.28,,178.91,75,,,percent of total billed charges,75% of total billed charges,178.91,75,,,percent of total billed charges,75% of total billed charges,47.13,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,77.78,165,,,Fee Schedule,165% of CMS OPPS Rate,48.85,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,135.4,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,185.69,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,232.6,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,47.13,100,,,Fee Schedule,100% of CMS OPPS Rate,48.85,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,33.4,14,,,percent of total billed charges,14% of total billed charges,33.4,232.6,
Special Stain GMS Stain Profee,3549260,CDM,971,RC,88312,HCPCS,Outpatient,,,238.55,119.28,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
Special Stain PAS FUNGUS,295294,CDM,310,RC,88312,HCPCS,Outpatient,,,238.55,119.28,,178.91,75,,,percent of total billed charges,75% of total billed charges,178.91,75,,,percent of total billed charges,75% of total billed charges,47.13,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,77.78,165,,,Fee Schedule,165% of CMS OPPS Rate,48.85,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,135.4,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,185.69,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,232.6,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,47.13,100,,,Fee Schedule,100% of CMS OPPS Rate,48.85,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,33.4,14,,,percent of total billed charges,14% of total billed charges,33.4,232.6,
Special Stain PAS FUNGUS Profee,3549262,CDM,971,RC,88312,HCPCS,Outpatient,,,238.55,119.28,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
Special Stain SPIROCH,605661,CDM,310,RC,88312,HCPCS,Outpatient,,,238.55,119.28,,178.91,75,,,percent of total billed charges,75% of total billed charges,178.91,75,,,percent of total billed charges,75% of total billed charges,47.13,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,77.78,165,,,Fee Schedule,165% of CMS OPPS Rate,48.85,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,135.4,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,185.69,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,232.6,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,47.13,100,,,Fee Schedule,100% of CMS OPPS Rate,48.85,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,33.4,14,,,percent of total billed charges,14% of total billed charges,33.4,232.6,
Pathology Billing Special Stains Group II,295364,CDM,310,RC,88313,HCPCS,Outpatient,,,172.19,86.1,,129.14,75,,,percent of total billed charges,75% of total billed charges,129.14,75,,,percent of total billed charges,75% of total billed charges,31.92,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,52.68,165,,,Fee Schedule,165% of CMS OPPS Rate,33.09,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,91.7,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,125.77,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,157.54,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,31.92,100,,,Fee Schedule,100% of CMS OPPS Rate,33.09,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,24.11,14,,,percent of total billed charges,14% of total billed charges,24.11,157.54,
SPECIAL STAIN ALCIAN BLUE pH 0.4,605479,CDM,310,RC,88313,HCPCS,Outpatient,,,172.19,86.1,,129.14,75,,,percent of total billed charges,75% of total billed charges,129.14,75,,,percent of total billed charges,75% of total billed charges,31.92,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,52.68,165,,,Fee Schedule,165% of CMS OPPS Rate,33.09,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,91.7,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,125.77,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,157.54,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,31.92,100,,,Fee Schedule,100% of CMS OPPS Rate,33.09,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,24.11,14,,,percent of total billed charges,14% of total billed charges,24.11,157.54,
Special Stain Congo Red Stain,295246,CDM,310,RC,88313,HCPCS,Outpatient,,,172.19,86.1,,129.14,75,,,percent of total billed charges,75% of total billed charges,129.14,75,,,percent of total billed charges,75% of total billed charges,31.92,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,52.68,165,,,Fee Schedule,165% of CMS OPPS Rate,33.09,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,91.7,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,125.77,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,157.54,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,31.92,100,,,Fee Schedule,100% of CMS OPPS Rate,33.09,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,24.11,14,,,percent of total billed charges,14% of total billed charges,24.11,157.54,
Special Stain Giemsa Stain,295262,CDM,310,RC,88313,HCPCS,Outpatient,,,172.19,86.1,,129.14,75,,,percent of total billed charges,75% of total billed charges,129.14,75,,,percent of total billed charges,75% of total billed charges,31.92,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,52.68,165,,,Fee Schedule,165% of CMS OPPS Rate,33.09,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,91.7,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,125.77,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,157.54,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,31.92,100,,,Fee Schedule,100% of CMS OPPS Rate,33.09,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,24.11,14,,,percent of total billed charges,14% of total billed charges,24.11,157.54,
Special Stain Iron Stain,295274,CDM,310,RC,88313,HCPCS,Outpatient,,,172.19,86.1,,129.14,75,,,percent of total billed charges,75% of total billed charges,129.14,75,,,percent of total billed charges,75% of total billed charges,31.92,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,52.68,165,,,Fee Schedule,165% of CMS OPPS Rate,33.09,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,91.7,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,125.77,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,157.54,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,31.92,100,,,Fee Schedule,100% of CMS OPPS Rate,33.09,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,24.11,14,,,percent of total billed charges,14% of total billed charges,24.11,157.54,
Special Stain Melanin,605640,CDM,310,RC,88313,HCPCS,Outpatient,,,172.19,86.1,,129.14,75,,,percent of total billed charges,75% of total billed charges,129.14,75,,,percent of total billed charges,75% of total billed charges,31.92,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,52.68,165,,,Fee Schedule,165% of CMS OPPS Rate,33.09,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,91.7,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,125.77,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,157.54,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,31.92,100,,,Fee Schedule,100% of CMS OPPS Rate,33.09,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,24.11,14,,,percent of total billed charges,14% of total billed charges,24.11,157.54,
Special Stain MUCIN,605654,CDM,310,RC,88313,HCPCS,Outpatient,,,172.19,86.1,,129.14,75,,,percent of total billed charges,75% of total billed charges,129.14,75,,,percent of total billed charges,75% of total billed charges,31.92,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,52.68,165,,,Fee Schedule,165% of CMS OPPS Rate,33.09,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,91.7,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,125.77,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,157.54,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,31.92,100,,,Fee Schedule,100% of CMS OPPS Rate,33.09,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,24.11,14,,,percent of total billed charges,14% of total billed charges,24.11,157.54,
Special Stain Oil Red O Stain,295290,CDM,310,RC,88313,HCPCS,Outpatient,,,172.19,86.1,,129.14,75,,,percent of total billed charges,75% of total billed charges,129.14,75,,,percent of total billed charges,75% of total billed charges,31.92,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,52.68,165,,,Fee Schedule,165% of CMS OPPS Rate,33.09,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,91.7,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,125.77,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,157.54,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,31.92,100,,,Fee Schedule,100% of CMS OPPS Rate,33.09,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,24.11,14,,,percent of total billed charges,14% of total billed charges,24.11,157.54,
Special Stain PAS with Diastase Stain,295302,CDM,310,RC,88313,HCPCS,Outpatient,,,172.19,86.1,,129.14,75,,,percent of total billed charges,75% of total billed charges,129.14,75,,,percent of total billed charges,75% of total billed charges,31.92,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,52.68,165,,,Fee Schedule,165% of CMS OPPS Rate,33.09,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,91.7,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,125.77,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,157.54,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,31.92,100,,,Fee Schedule,100% of CMS OPPS Rate,33.09,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,24.11,14,,,percent of total billed charges,14% of total billed charges,24.11,157.54,
Special Stain PAS without Diastase Stain,295306,CDM,310,RC,88313,HCPCS,Outpatient,,,172.19,86.1,,129.14,75,,,percent of total billed charges,75% of total billed charges,129.14,75,,,percent of total billed charges,75% of total billed charges,31.92,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,52.68,165,,,Fee Schedule,165% of CMS OPPS Rate,33.09,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,91.7,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,125.77,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,157.54,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,31.92,100,,,Fee Schedule,100% of CMS OPPS Rate,33.09,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,24.11,14,,,percent of total billed charges,14% of total billed charges,24.11,157.54,
Special Stain Reticulin Stain,295298,CDM,310,RC,88313,HCPCS,Outpatient,,,172.19,86.1,,129.14,75,,,percent of total billed charges,75% of total billed charges,129.14,75,,,percent of total billed charges,75% of total billed charges,31.92,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,52.68,165,,,Fee Schedule,165% of CMS OPPS Rate,33.09,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,91.7,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,125.77,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,157.54,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,31.92,100,,,Fee Schedule,100% of CMS OPPS Rate,33.09,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,24.11,14,,,percent of total billed charges,14% of total billed charges,24.11,157.54,
Special Stain SUDAN BLACK,605565,CDM,310,RC,88313,HCPCS,Outpatient,,,172.19,86.1,,129.14,75,,,percent of total billed charges,75% of total billed charges,129.14,75,,,percent of total billed charges,75% of total billed charges,31.92,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,52.68,165,,,Fee Schedule,165% of CMS OPPS Rate,33.09,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,91.7,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,125.77,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,157.54,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,31.92,100,,,Fee Schedule,100% of CMS OPPS Rate,33.09,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,24.11,14,,,percent of total billed charges,14% of total billed charges,24.11,157.54,
Special Stain TRICHROM,605663,CDM,310,RC,88313,HCPCS,Outpatient,,,172.19,86.1,,129.14,75,,,percent of total billed charges,75% of total billed charges,129.14,75,,,percent of total billed charges,75% of total billed charges,31.92,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,52.68,165,,,Fee Schedule,165% of CMS OPPS Rate,33.09,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,91.7,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,125.77,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,157.54,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,31.92,100,,,Fee Schedule,100% of CMS OPPS Rate,33.09,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,24.11,14,,,percent of total billed charges,14% of total billed charges,24.11,157.54,
Special Stain WRIGHT,605665,CDM,310,RC,88313,HCPCS,Outpatient,,,172.19,86.1,,129.14,75,,,percent of total billed charges,75% of total billed charges,129.14,75,,,percent of total billed charges,75% of total billed charges,31.92,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,52.68,165,,,Fee Schedule,165% of CMS OPPS Rate,33.09,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,91.7,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,125.77,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,157.54,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,31.92,100,,,Fee Schedule,100% of CMS OPPS Rate,33.09,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,24.11,14,,,percent of total billed charges,14% of total billed charges,24.11,157.54,
"Special Stain, CRYSTALV",605559,CDM,310,RC,88313,HCPCS,Outpatient,,,172.19,86.1,,129.14,75,,,percent of total billed charges,75% of total billed charges,129.14,75,,,percent of total billed charges,75% of total billed charges,31.92,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,52.68,165,,,Fee Schedule,165% of CMS OPPS Rate,33.09,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,91.7,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,125.77,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,157.54,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,31.92,100,,,Fee Schedule,100% of CMS OPPS Rate,33.09,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,24.11,14,,,percent of total billed charges,14% of total billed charges,24.11,157.54,
SS Alcian Blue pH 1.0 Stain,295234,CDM,310,RC,88313,HCPCS,Outpatient,,,172.19,86.1,,129.14,75,,,percent of total billed charges,75% of total billed charges,129.14,75,,,percent of total billed charges,75% of total billed charges,31.92,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,52.68,165,,,Fee Schedule,165% of CMS OPPS Rate,33.09,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,91.7,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,125.77,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,157.54,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,31.92,100,,,Fee Schedule,100% of CMS OPPS Rate,33.09,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,24.11,14,,,percent of total billed charges,14% of total billed charges,24.11,157.54,
SS Alcian Blue pH 2.5,295240,CDM,310,RC,88313,HCPCS,Outpatient,,,172.19,86.1,,129.14,75,,,percent of total billed charges,75% of total billed charges,129.14,75,,,percent of total billed charges,75% of total billed charges,31.92,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,52.68,165,,,Fee Schedule,165% of CMS OPPS Rate,33.09,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,91.7,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,125.77,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,157.54,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,31.92,100,,,Fee Schedule,100% of CMS OPPS Rate,33.09,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,24.11,14,,,percent of total billed charges,14% of total billed charges,24.11,157.54,
SS ELASTIC,763980,CDM,310,RC,88313,HCPCS,Outpatient,,,172.19,86.1,,129.14,75,,,percent of total billed charges,75% of total billed charges,129.14,75,,,percent of total billed charges,75% of total billed charges,31.92,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,52.68,165,,,Fee Schedule,165% of CMS OPPS Rate,33.09,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,91.7,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,125.77,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,157.54,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,31.92,100,,,Fee Schedule,100% of CMS OPPS Rate,33.09,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,24.11,14,,,percent of total billed charges,14% of total billed charges,24.11,157.54,
Pathology Billing Muscle Bx Histochem Stain for FS,644639,CDM,971,RC,88314,HCPCS,Outpatient,,,192.56,96.28,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
Pathology Billing Muscle Bx ID Enz Constituents,644638,CDM,971,RC,88319,HCPCS,Outpatient,,,286.5,143.25,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
Pathology Billing Consultation Fee Outside Slides and Report,295358,CDM,971,RC,88321,HCPCS,Outpatient,,,219.56,109.78,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
Pathology Billing Fee Outside Consultation requiring slide prep,2970102,CDM,971,RC,88323,HCPCS,Outpatient,,,255.15,127.58,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
Pathology Billing Non-Gyn Cytology Intraoperative Consultation,592811,CDM,310,RC,88329,HCPCS,Outpatient,,,124.42,62.21,,93.32,75,,,percent of total billed charges,75% of total billed charges,93.32,75,,,percent of total billed charges,75% of total billed charges,31.92,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,52.68,165,,,Fee Schedule,165% of CMS OPPS Rate,33.09,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,91.7,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,125.77,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,157.54,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,31.92,100,,,Fee Schedule,100% of CMS OPPS Rate,33.09,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,17.42,14,,,percent of total billed charges,14% of total billed charges,17.42,157.54,
Pathology Billing Non-Gyn Cytology Intraoperative Consultation w/o FS,592951,CDM,971,RC,88329,HCPCS,Outpatient,,,124.42,62.21,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
"Freeze, Cut and Stain (H&E)",294976,CDM,310,RC,88331,HCPCS,Outpatient,,,224.05,112.03,,168.04,75,,,percent of total billed charges,75% of total billed charges,168.04,75,,,percent of total billed charges,75% of total billed charges,147.84,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,243.93,165,,,Fee Schedule,165% of CMS OPPS Rate,153.22,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,424.65,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,582.37,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,729.48,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,147.84,100,,,Fee Schedule,100% of CMS OPPS Rate,153.22,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,31.37,14,,,percent of total billed charges,14% of total billed charges,31.37,729.48,
"Freeze, Cut and Stain (H&E) Profee",3549241,CDM,971,RC,88331,HCPCS,Outpatient,,,224.05,112.03,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
Pathology Billing Frozen Single Specimen,592817,CDM,310,RC,88331,HCPCS,Outpatient,,,224.05,112.03,,168.04,75,,,percent of total billed charges,75% of total billed charges,168.04,75,,,percent of total billed charges,75% of total billed charges,147.84,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,243.93,165,,,Fee Schedule,165% of CMS OPPS Rate,153.22,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,424.65,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,582.37,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,729.48,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,147.84,100,,,Fee Schedule,100% of CMS OPPS Rate,153.22,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,31.37,14,,,percent of total billed charges,14% of total billed charges,31.37,729.48,
Cut and Stain Add'l Frozen H&E Slide,294978,CDM,310,RC,88332,HCPCS,Outpatient,,,68.55,34.28,,51.41,75,,,percent of total billed charges,75% of total billed charges,51.41,75,,,percent of total billed charges,75% of total billed charges,21.94,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.6,14,,,percent of total billed charges,14% of total billed charges,9.6,51.41,
Pathology Billing Frozen add'l block,592815,CDM,310,RC,88332,HCPCS,Outpatient,,,68.55,34.28,,51.41,75,,,percent of total billed charges,75% of total billed charges,51.41,75,,,percent of total billed charges,75% of total billed charges,21.94,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.6,14,,,percent of total billed charges,14% of total billed charges,9.6,51.41,
Pathology Billing Cyto Exam Initial Site,1285503,CDM,310,RC,88333,HCPCS,Outpatient,,,205.48,102.74,,154.11,75,,,percent of total billed charges,75% of total billed charges,154.11,75,,,percent of total billed charges,75% of total billed charges,730.04,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1204.58,165,,,Fee Schedule,165% of CMS OPPS Rate,756.63,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,2096.96,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2875.81,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,3602.25,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,730.04,100,,,Fee Schedule,100% of CMS OPPS Rate,756.63,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,28.77,14,,,percent of total billed charges,14% of total billed charges,28.77,3602.25,
"Pathology Billing, Cytologic Exam add?l site",1713100,CDM,310,RC,88334,HCPCS,Outpatient,,,124.1,62.05,,93.08,75,,,percent of total billed charges,75% of total billed charges,93.08,75,,,percent of total billed charges,75% of total billed charges,39.71,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.37,14,,,percent of total billed charges,14% of total billed charges,17.37,93.08,
Pathology Billing Derm SO IHC Stain,646173,CDM,310,RC,88342,HCPCS,Outpatient,,,214.75,107.38,,161.06,75,,,percent of total billed charges,75% of total billed charges,161.06,75,,,percent of total billed charges,75% of total billed charges,147.84,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,243.93,165,,,Fee Schedule,165% of CMS OPPS Rate,153.22,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,424.65,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,582.37,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,729.48,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,147.84,100,,,Fee Schedule,100% of CMS OPPS Rate,153.22,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,30.07,14,,,percent of total billed charges,14% of total billed charges,30.07,729.48,
"Pathology Billing Immuno Cyto Chemistry, tissue,IP,ea ab Profee",3549248,CDM,971,RC,88342,HCPCS,Outpatient,,,214.75,107.38,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
88343 Bill Addtl IHC AB per block,3310560,CDM,310,RC,88343,HCPCS,Outpatient,,,273.91,136.96,,205.43,75,,,percent of total billed charges,75% of total billed charges,205.43,75,,,percent of total billed charges,75% of total billed charges,87.65,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.35,14,,,percent of total billed charges,14% of total billed charges,38.35,205.43,
88360 PD-L1 IHC,3513373,CDM,300,RC,88360,HCPCS,Outpatient,,,253.8,126.9,,190.35,75,,,percent of total billed charges,75% of total billed charges,190.35,75,,,percent of total billed charges,75% of total billed charges,147.84,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,243.93,165,,,Fee Schedule,165% of CMS OPPS Rate,153.22,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,424.65,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,582.37,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,729.48,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,147.84,100,,,Fee Schedule,100% of CMS OPPS Rate,153.22,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,35.53,14,,,percent of total billed charges,14% of total billed charges,35.53,729.48,
88360-26 IHC Manual Morph Ana Professional,3513821,CDM,971,RC,88360,HCPCS,Outpatient,,,253.8,126.9,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
Pathology Billing IHC Man Morph Anal,3561382,CDM,971,RC,88360,HCPCS,Outpatient,,,185.09,92.55,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
88361-26 IHC Morphometric Analysis Professional,3513819,CDM,971,RC,88361,HCPCS,Outpatient,,,254.94,127.47,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
"88364-26 ISH, ea. add. Professional",3513828,CDM,971,RC,88364,HCPCS,Outpatient,,,290.18,145.09,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
"88365-26 ISH, initial Professional",3513825,CDM,971,RC,88365,HCPCS,Outpatient,,,383.18,191.59,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
Pathology Billing HER 2 NEU by FISH,644637,CDM,310,RC,88365,HCPCS,Outpatient,,,318.05,159.03,,238.54,75,,,percent of total billed charges,75% of total billed charges,238.54,75,,,percent of total billed charges,75% of total billed charges,147.84,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,243.93,165,,,Fee Schedule,165% of CMS OPPS Rate,153.22,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,424.65,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,582.37,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,729.48,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,147.84,100,,,Fee Schedule,100% of CMS OPPS Rate,153.22,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,44.53,14,,,percent of total billed charges,14% of total billed charges,44.53,729.48,
88377 Global MDM2 Fish,3513398,CDM,300,RC,88377,HCPCS,Outpatient,,,833.97,416.99,,625.48,75,,,percent of total billed charges,75% of total billed charges,625.48,75,,,percent of total billed charges,75% of total billed charges,147.84,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,243.93,165,,,Fee Schedule,165% of CMS OPPS Rate,153.22,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,424.65,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,582.37,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,729.48,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,147.84,100,,,Fee Schedule,100% of CMS OPPS Rate,153.22,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,116.76,14,,,percent of total billed charges,14% of total billed charges,116.76,729.48,
88377-26 HER-2 Breast/Gastric FISH Professional,3513823,CDM,971,RC,88377,HCPCS,Outpatient,,,833.97,416.99,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
88381- Microdissection Global,3513368,CDM,300,RC,88381,HCPCS,Outpatient,,,424.16,212.08,,318.12,75,,,percent of total billed charges,75% of total billed charges,318.12,75,,,percent of total billed charges,75% of total billed charges,135.73,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,59.38,14,,,percent of total billed charges,14% of total billed charges,59.38,318.12,
"Pathology Billing, TP,FS,Consult for Chemo Assay",1565100,CDM,510,RC,88388,HCPCS,Outpatient,,,81.15,40.58,,60.86,75,,,percent of total billed charges,75% of total billed charges,60.86,75,,,percent of total billed charges,75% of total billed charges,25.97,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.36,14,,,percent of total billed charges,14% of total billed charges,11.36,60.86,
Specimen for RSV Testing,1449213,CDM,300,RC,89220,HCPCS,Outpatient,,,44.06,22.03,,33.05,75,,,percent of total billed charges,75% of total billed charges,33.05,75,,,percent of total billed charges,75% of total billed charges,147.84,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,243.93,165,,,Fee Schedule,165% of CMS OPPS Rate,153.22,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,424.65,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,582.37,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,729.48,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,147.84,100,,,Fee Schedule,100% of CMS OPPS Rate,153.22,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,6.17,14,,,percent of total billed charges,14% of total billed charges,6.17,729.48,
Sputum Induction,617719,CDM,300,RC,89220,HCPCS,Outpatient,,,44.06,22.03,,33.05,75,,,percent of total billed charges,75% of total billed charges,33.05,75,,,percent of total billed charges,75% of total billed charges,147.84,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,243.93,165,,,Fee Schedule,165% of CMS OPPS Rate,153.22,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,424.65,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,582.37,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,729.48,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,147.84,100,,,Fee Schedule,100% of CMS OPPS Rate,153.22,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,6.17,14,,,percent of total billed charges,14% of total billed charges,6.17,729.48,
0.5 mL Beyfortus Vaccine,4313727,CDM,636,RC,90380,HCPCS,Outpatient,,,14850,7425,,11137.5,75,,,percent of total billed charges,75% of total billed charges,11137.5,75,,,percent of total billed charges,75% of total billed charges,4752,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2079,14,,,percent of total billed charges,14% of total billed charges,2079,11137.5,
1 mL Beyfortus Vaccine,4313726,CDM,636,RC,90381,HCPCS,Outpatient,,,14850,7425,,11137.5,75,,,percent of total billed charges,75% of total billed charges,11137.5,75,,,percent of total billed charges,75% of total billed charges,4752,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2079,14,,,percent of total billed charges,14% of total billed charges,2079,11137.5,
90460- Vaccine admin upto 18 yrs w/couns;1st compnt,3569426,CDM,771,RC,90460,HCPCS,Outpatient,,,41.22,20.61,,30.92,75,,,percent of total billed charges,75% of total billed charges,30.92,75,,,percent of total billed charges,75% of total billed charges,13.19,32,,,percent of total billed charges,32% of total billed charges,11.06,100,,,Fee Schedule,100% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.06,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.77,14,,,percent of total billed charges,14% of total billed charges,5.77,30.92,
First Vaccine (Peds)- 90460,3574945,CDM,771,RC,90460,HCPCS,Outpatient,,,41.22,20.61,,30.92,75,,,percent of total billed charges,75% of total billed charges,30.92,75,,,percent of total billed charges,75% of total billed charges,13.19,32,,,percent of total billed charges,32% of total billed charges,11.06,100,,,Fee Schedule,100% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.06,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.77,14,,,percent of total billed charges,14% of total billed charges,5.77,30.92,
90461- Vaccine admin upto 18 yrs w/ couns;ea addl vac,3569428,CDM,771,RC,90461,HCPCS,Outpatient,,,31.48,15.74,,23.61,75,,,percent of total billed charges,75% of total billed charges,23.61,75,,,percent of total billed charges,75% of total billed charges,10.07,32,,,percent of total billed charges,32% of total billed charges,8.36,100,,,Fee Schedule,100% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.36,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.41,14,,,percent of total billed charges,14% of total billed charges,4.41,23.61,
Each additional (Peds)- 90461,3574944,CDM,771,RC,90461,HCPCS,Outpatient,,,31.48,15.74,,23.61,75,,,percent of total billed charges,75% of total billed charges,23.61,75,,,percent of total billed charges,75% of total billed charges,10.07,32,,,percent of total billed charges,32% of total billed charges,8.36,100,,,Fee Schedule,100% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.36,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.41,14,,,percent of total billed charges,14% of total billed charges,4.41,23.61,
90471 -Immunization admin,3430542,CDM,771,RC,90471,HCPCS,Outpatient,,,41.22,20.61,,30.92,75,,,percent of total billed charges,75% of total billed charges,30.92,75,,,percent of total billed charges,75% of total billed charges,63.43,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,104.66,165,,,Fee Schedule,165% of CMS OPPS Rate,65.74,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,182.2,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,249.87,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,312.99,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,63.43,100,,,Fee Schedule,100% of CMS OPPS Rate,65.74,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,5.77,14,,,percent of total billed charges,14% of total billed charges,5.77,312.99,
AMB Admin Immunization Charge:First Vaccine 90471,3444228,CDM,771,RC,90471,HCPCS,Outpatient,,,41.22,20.61,,30.92,75,,,percent of total billed charges,75% of total billed charges,30.92,75,,,percent of total billed charges,75% of total billed charges,63.43,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,104.66,165,,,Fee Schedule,165% of CMS OPPS Rate,65.74,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,182.2,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,249.87,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,312.99,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,63.43,100,,,Fee Schedule,100% of CMS OPPS Rate,65.74,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,5.77,14,,,percent of total billed charges,14% of total billed charges,5.77,312.99,
ID Admin Charge 90471,3550761,CDM,771,RC,90471,HCPCS,Outpatient,,,41.22,20.61,,30.92,75,,,percent of total billed charges,75% of total billed charges,30.92,75,,,percent of total billed charges,75% of total billed charges,63.43,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,104.66,165,,,Fee Schedule,165% of CMS OPPS Rate,65.74,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,182.2,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,249.87,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,312.99,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,63.43,100,,,Fee Schedule,100% of CMS OPPS Rate,65.74,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,5.77,14,,,percent of total billed charges,14% of total billed charges,5.77,312.99,
90472 - Immunization admin each additional,3574865,CDM,771,RC,90472,HCPCS,Outpatient,,,31.48,15.74,,23.61,75,,,percent of total billed charges,75% of total billed charges,23.61,75,,,percent of total billed charges,75% of total billed charges,10.07,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.41,14,,,percent of total billed charges,14% of total billed charges,4.41,23.61,
AMB Admin Immunization Charge:Each additional 90472,3444229,CDM,771,RC,90472,HCPCS,Outpatient,,,31.48,15.74,,23.61,75,,,percent of total billed charges,75% of total billed charges,23.61,75,,,percent of total billed charges,75% of total billed charges,10.07,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.41,14,,,percent of total billed charges,14% of total billed charges,4.41,23.61,
AMB Admin Oral Immunization Charge -> Each additional 90472,3563071,CDM,771,RC,90472,HCPCS,Outpatient,,,31.48,15.74,,23.61,75,,,percent of total billed charges,75% of total billed charges,23.61,75,,,percent of total billed charges,75% of total billed charges,10.07,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.41,14,,,percent of total billed charges,14% of total billed charges,4.41,23.61,
AMB Admin Covid-19 Charge -> Covid-19 Vaccine (12+ years) Admin Fee,4303194,CDM,771,RC,90480,HCPCS,Outpatient,,,84.8,42.4,,63.6,75,,,percent of total billed charges,75% of total billed charges,63.6,75,,,percent of total billed charges,75% of total billed charges,27.14,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.87,14,,,percent of total billed charges,14% of total billed charges,11.87,63.6,
AMB Admin Covid-19 Charge -> Covid-19 Vaccine (5y-12y) Admin Fee,4303195,CDM,771,RC,90480,HCPCS,Outpatient,,,84.8,42.4,,63.6,75,,,percent of total billed charges,75% of total billed charges,63.6,75,,,percent of total billed charges,75% of total billed charges,27.14,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.87,14,,,percent of total billed charges,14% of total billed charges,11.87,63.6,
AMB Admin Covid-19 Charge -> Covid-19 Vaccine (6m<5y) Admin Fee,4303196,CDM,771,RC,90480,HCPCS,Outpatient,,,84.8,42.4,,63.6,75,,,percent of total billed charges,75% of total billed charges,63.6,75,,,percent of total billed charges,75% of total billed charges,27.14,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.87,14,,,percent of total billed charges,14% of total billed charges,11.87,63.6,
90620 - Meningococcal (Bexsero),3918914,CDM,636,RC,90620,HCPCS,Outpatient,,,539.39,269.7,,404.54,75,,,percent of total billed charges,75% of total billed charges,404.54,75,,,percent of total billed charges,75% of total billed charges,172.6,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,75.51,14,,,percent of total billed charges,14% of total billed charges,75.51,404.54,
AMB meningococcal group B Charge:0.5 mL Bexsero Vaccine,3444353,CDM,636,RC,90620,HCPCS,Outpatient,,,543.15,271.58,,407.36,75,,,percent of total billed charges,75% of total billed charges,407.36,75,,,percent of total billed charges,75% of total billed charges,173.81,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.04,14,,,percent of total billed charges,14% of total billed charges,76.04,407.36,
AMB meningococcal group B Charge:0.5 mL Bexsero Vaccine,3581623,CDM,636,RC,90620,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
90632 - Adult Hep A,3918915,CDM,636,RC,90632,HCPCS,Outpatient,,,225.6,112.8,,169.2,75,,,percent of total billed charges,75% of total billed charges,169.2,75,,,percent of total billed charges,75% of total billed charges,72.19,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.58,14,,,percent of total billed charges,14% of total billed charges,31.58,169.2,
AMB hepatitis A Adult Charge -> 1 mL Vaqta (HepA) Adult Vaccine,3549461,CDM,636,RC,90632,HCPCS,Outpatient,,,206.73,103.37,,155.05,75,,,percent of total billed charges,75% of total billed charges,155.05,75,,,percent of total billed charges,75% of total billed charges,66.15,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.94,14,,,percent of total billed charges,14% of total billed charges,28.94,155.05,
AMB hepatitis A Adult Charge:1 mL Hepatitis A Adult Vaccine,3444307,CDM,636,RC,90632,HCPCS,Outpatient,,,206.67,103.34,,155,75,,,percent of total billed charges,75% of total billed charges,155,75,,,percent of total billed charges,75% of total billed charges,66.13,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.93,14,,,percent of total billed charges,14% of total billed charges,28.93,155,
90633 - Pediatric Hep A,3918916,CDM,636,RC,90633,HCPCS,Outpatient,,,225.6,112.8,,169.2,75,,,percent of total billed charges,75% of total billed charges,169.2,75,,,percent of total billed charges,75% of total billed charges,72.19,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.58,14,,,percent of total billed charges,14% of total billed charges,31.58,169.2,
AMB hepatitis A Ped Charge -> 0.5 mL Havrix (HepA) Ped Vaccine,3549455,CDM,636,RC,90633,HCPCS,Outpatient,,,78.73,39.37,,59.05,75,,,percent of total billed charges,75% of total billed charges,59.05,75,,,percent of total billed charges,75% of total billed charges,25.19,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.02,14,,,percent of total billed charges,14% of total billed charges,11.02,59.05,
AMB hepatitis A Ped Charge:0.5 mL Hepatitis A Ped Vaccine,3444309,CDM,636,RC,90633,HCPCS,Outpatient,,,98.64,49.32,,73.98,75,,,percent of total billed charges,75% of total billed charges,73.98,75,,,percent of total billed charges,75% of total billed charges,31.56,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.81,14,,,percent of total billed charges,14% of total billed charges,13.81,73.98,
AMB hepatitis A Ped Charge:0.5 mL Hepatitis A Ped Vaccine,3444308,CDM,636,RC,90633,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
AMB hepatitis A-hepatitis B Charge:1 mL Twinrix Vaccine,3444310,CDM,636,RC,90636,HCPCS,Outpatient,,,314.66,157.33,,236,75,,,percent of total billed charges,75% of total billed charges,236,75,,,percent of total billed charges,75% of total billed charges,100.69,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.05,14,,,percent of total billed charges,14% of total billed charges,44.05,236,
90647 - Hib PRP-OMP (PedvaxHIB),3918917,CDM,636,RC,90647,HCPCS,Outpatient,,,75.26,37.63,,56.45,75,,,percent of total billed charges,75% of total billed charges,56.45,75,,,percent of total billed charges,75% of total billed charges,24.08,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.54,14,,,percent of total billed charges,14% of total billed charges,10.54,56.45,
AMB haemophilus b Ped Charge:0.5mL PedvaxHIB Vaccine,3444306,CDM,636,RC,90647,HCPCS,Outpatient,,,77.6,38.8,,58.2,75,,,percent of total billed charges,75% of total billed charges,58.2,75,,,percent of total billed charges,75% of total billed charges,24.83,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.86,14,,,percent of total billed charges,14% of total billed charges,10.86,58.2,
AMB haemophilus b Ped Charge:0.5mL PedvaxHIB Vaccine,3444305,CDM,636,RC,90647,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
90648 - HIB,3918918,CDM,636,RC,90648,HCPCS,Outpatient,,,36.38,18.19,,27.29,75,,,percent of total billed charges,75% of total billed charges,27.29,75,,,percent of total billed charges,75% of total billed charges,11.64,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.09,14,,,percent of total billed charges,14% of total billed charges,5.09,27.29,
AMB haemophilus b Adult Charge:0.5 mL  ActHIB Vaccine,3444304,CDM,636,RC,90648,HCPCS,Outpatient,,,48.91,24.46,,36.68,75,,,percent of total billed charges,75% of total billed charges,36.68,75,,,percent of total billed charges,75% of total billed charges,15.65,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.85,14,,,percent of total billed charges,14% of total billed charges,6.85,36.68,
90651 - HPV (Gardasil),3918919,CDM,636,RC,90651,HCPCS,Outpatient,,,686.16,343.08,,514.62,75,,,percent of total billed charges,75% of total billed charges,514.62,75,,,percent of total billed charges,75% of total billed charges,219.57,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,96.06,14,,,percent of total billed charges,14% of total billed charges,96.06,514.62,
AMB HPV Charge:0.5 mL Gardasil 9 Vaccine,3444315,CDM,636,RC,90651,HCPCS,Outpatient,,,725.36,362.68,,544.02,75,,,percent of total billed charges,75% of total billed charges,544.02,75,,,percent of total billed charges,75% of total billed charges,232.12,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,101.55,14,,,percent of total billed charges,14% of total billed charges,101.55,544.02,
AMB HPV Charge:0.5 mL Gardasil 9 Vaccine,3444314,CDM,636,RC,90651,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
90653 - Flu - Fluad,3918922,CDM,636,RC,90653,HCPCS,Outpatient,,,133.11,66.56,,99.83,75,,,percent of total billed charges,75% of total billed charges,99.83,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.64,14,,,percent of total billed charges,14% of total billed charges,18.64,99.83,
"90653 - Fluad - Influenza vaccine, inactivated (IIV), subuni",3918920,CDM,636,RC,90653,HCPCS,Outpatient,,,149.35,74.68,,112.01,75,,,percent of total billed charges,75% of total billed charges,112.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.91,14,,,percent of total billed charges,14% of total billed charges,20.91,112.01,
90653 - High Dose Flu,3918921,CDM,636,RC,90653,HCPCS,Outpatient,,,133.11,66.56,,99.83,75,,,percent of total billed charges,75% of total billed charges,99.83,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.64,14,,,percent of total billed charges,14% of total billed charges,18.64,99.83,
AMB Influenza Charge:Flu Vaccine Adjuvanted 65+,3444324,CDM,636,RC,90662,HCPCS,Outpatient,,,386.3,193.15,,289.73,75,,,percent of total billed charges,75% of total billed charges,289.73,75,,,percent of total billed charges,75% of total billed charges,69.94,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,73.4,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,260.23,354.54,,,Fee Schedule,354.54% of CMS OPPS Fee Schedule Rate,314.67,428.7,,,Fee Schedule,428.7% of CMS OPPS Fee Schedule Rate,330.89,450.81,,,Fee Schedule,450.81% of CMS OPPS Fee Schedule Rate,,,,,Other,Not Separately reimbursable,73.4,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,54.08,14,,,percent of total billed charges,14% of total billed charges,54.08,330.89,
"90670 - Pneumococcal conjugate vaccine, 13 valent (PCV13), f",3918923,CDM,636,RC,90670,HCPCS,Outpatient,,,577.37,288.69,,433.03,75,,,percent of total billed charges,75% of total billed charges,433.03,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,80.83,14,,,percent of total billed charges,14% of total billed charges,80.83,433.03,
90670 - Prevnar 13,3918924,CDM,636,RC,90670,HCPCS,Outpatient,,,577.37,288.69,,433.03,75,,,percent of total billed charges,75% of total billed charges,433.03,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,80.83,14,,,percent of total billed charges,14% of total billed charges,80.83,433.03,
AMB Prevnar 13 Charge:0.5 mL Prevnar Vaccine,3444388,CDM,636,RC,90670,HCPCS,Outpatient,,,611.03,305.52,,458.27,75,,,percent of total billed charges,75% of total billed charges,458.27,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,85.54,14,,,percent of total billed charges,14% of total billed charges,85.54,458.27,
AMB Prevnar 13 Charge:0.5 mL Prevnar Vaccine,3444387,CDM,636,RC,90670,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
PCV13 VACCINE IM,3435740,CDM,636,RC,90670,HCPCS,Outpatient,,,436.53,218.27,,327.4,75,,,percent of total billed charges,75% of total billed charges,327.4,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.11,14,,,percent of total billed charges,14% of total billed charges,61.11,327.4,
0.5 mL Prevnar 20 Vaccine,3886915,CDM,636,RC,90677,HCPCS,Outpatient,,,1194.6,597.3,,895.95,75,,,percent of total billed charges,75% of total billed charges,895.95,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,167.24,14,,,percent of total billed charges,14% of total billed charges,167.24,895.95,
90677 - 0.5 mL Prevnar 20 Vaccine,4263577,CDM,636,RC,90677,HCPCS,Outpatient,,,1194.6,597.3,,895.95,75,,,percent of total billed charges,75% of total billed charges,895.95,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,167.24,14,,,percent of total billed charges,14% of total billed charges,167.24,895.95,
AMB Prevnar 20 Charge -> VFC Vaccine,4331254,CDM,636,RC,90677,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
90680 - Rotavirus,3918925,CDM,636,RC,90680,HCPCS,Outpatient,,,254.64,127.32,,190.98,75,,,percent of total billed charges,75% of total billed charges,190.98,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.65,14,,,percent of total billed charges,14% of total billed charges,35.65,190.98,
AMB rotavirus Charge:2 mL RotaTeq Vaccine,3444394,CDM,636,RC,90680,HCPCS,Outpatient,,,251.28,125.64,,188.46,75,,,percent of total billed charges,75% of total billed charges,188.46,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.18,14,,,percent of total billed charges,14% of total billed charges,35.18,188.46,
AMB rotavirus Charge:2 mL RotaTeq Vaccine,3444393,CDM,636,RC,90680,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
AMB rotavirus Charge:1 mL RotaRix Vaccine,3580928,CDM,636,RC,90681,HCPCS,Outpatient,,,352.88,176.44,,264.66,75,,,percent of total billed charges,75% of total billed charges,264.66,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.4,14,,,percent of total billed charges,14% of total billed charges,49.4,264.66,
Flu Adult Recombinant (egg-free),4183112,CDM,636,RC,90682,HCPCS,Outpatient,,,117.85,58.93,,88.39,75,,,percent of total billed charges,75% of total billed charges,88.39,75,,,percent of total billed charges,75% of total billed charges,69.94,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,73.4,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,260.23,354.54,,,Fee Schedule,354.54% of CMS OPPS Fee Schedule Rate,314.67,428.7,,,Fee Schedule,428.7% of CMS OPPS Fee Schedule Rate,330.89,450.81,,,Fee Schedule,450.81% of CMS OPPS Fee Schedule Rate,,,,,Other,Not Separately reimbursable,73.4,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,16.5,14,,,percent of total billed charges,14% of total billed charges,16.5,330.89,
90685 - Influenza (Afluria/Fluzone) Peds,3918926,CDM,636,RC,90685,HCPCS,Outpatient,,,53.01,26.51,,39.76,75,,,percent of total billed charges,75% of total billed charges,39.76,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.42,14,,,percent of total billed charges,14% of total billed charges,7.42,39.76,
"90686 - Afluria/Fluzone (adult) flu vacc, quad (IIV4), split",3918927,CDM,636,RC,90686,HCPCS,Outpatient,,,55.19,27.6,,41.39,75,,,percent of total billed charges,75% of total billed charges,41.39,75,,,percent of total billed charges,75% of total billed charges,21.52,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,22.35,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,79.24,354.54,,,Fee Schedule,354.54% of CMS OPPS Fee Schedule Rate,95.81,428.7,,,Fee Schedule,428.7% of CMS OPPS Fee Schedule Rate,100.76,450.81,,,Fee Schedule,450.81% of CMS OPPS Fee Schedule Rate,,,,,Other,Not Separately reimbursable,22.35,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,7.73,14,,,percent of total billed charges,14% of total billed charges,7.73,100.76,
AMB Influenza Charge: Flu Vaccine Adult Dose,3562705,CDM,636,RC,90686,HCPCS,Outpatient,,,117.85,58.93,,88.39,75,,,percent of total billed charges,75% of total billed charges,88.39,75,,,percent of total billed charges,75% of total billed charges,21.52,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,22.35,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,79.24,354.54,,,Fee Schedule,354.54% of CMS OPPS Fee Schedule Rate,95.81,428.7,,,Fee Schedule,428.7% of CMS OPPS Fee Schedule Rate,100.76,450.81,,,Fee Schedule,450.81% of CMS OPPS Fee Schedule Rate,,,,,Other,Not Separately reimbursable,22.35,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,16.5,14,,,percent of total billed charges,14% of total billed charges,16.5,100.76,
0.5 mL Quadracel  Vaccine,4215693,CDM,636,RC,90696,HCPCS,Outpatient,,,156.22,78.11,,117.17,75,,,percent of total billed charges,75% of total billed charges,117.17,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.87,14,,,percent of total billed charges,14% of total billed charges,21.87,117.17,
AMB DTaP/IPV Charge:0.5 mL DTaP/IPV Vaccine,3444281,CDM,636,RC,90696,HCPCS,Outpatient,,,153.14,76.57,,114.86,75,,,percent of total billed charges,75% of total billed charges,114.86,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.44,14,,,percent of total billed charges,14% of total billed charges,21.44,114.86,
AMB DTaP/IPV Charge:0.5 mL DTaP/IPV Vaccine,3581586,CDM,636,RC,90696,HCPCS,Outpatient,,,175.62,87.81,,131.72,75,,,percent of total billed charges,75% of total billed charges,131.72,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.59,14,,,percent of total billed charges,14% of total billed charges,24.59,131.72,
AMB DTaP-IPV-Hib-HepB Charge -> 0.5 mL DTaP-IPV-Hib-HepB Vaccine,4361229,CDM,636,RC,90697,HCPCS,Outpatient,,,878.11,439.06,,658.58,75,,,percent of total billed charges,75% of total billed charges,658.58,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,122.94,14,,,percent of total billed charges,14% of total billed charges,122.94,658.58,
90698 - Dtap-IPV-Hib (Pentacel),3918929,CDM,636,RC,90698,HCPCS,Outpatient,,,298.55,149.28,,223.91,75,,,percent of total billed charges,75% of total billed charges,223.91,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.8,14,,,percent of total billed charges,14% of total billed charges,41.8,223.91,
AMB DTaP-IPV-Hib Charge:0.5 mL Pentacel Vaccine,3444283,CDM,636,RC,90698,HCPCS,Outpatient,,,142.49,71.25,,106.87,75,,,percent of total billed charges,75% of total billed charges,106.87,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.95,14,,,percent of total billed charges,14% of total billed charges,19.95,106.87,
AMB DTaP-IPV-Hib Charge:0.5 mL Pentacel Vaccine,3581592,CDM,636,RC,90698,HCPCS,Outpatient,,,298.55,149.28,,223.91,75,,,percent of total billed charges,75% of total billed charges,223.91,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.8,14,,,percent of total billed charges,14% of total billed charges,41.8,223.91,
0.5 mL Daptacel (DTaP) Vaccine,4215700,CDM,636,RC,90700,HCPCS,Outpatient,,,91.19,45.6,,68.39,75,,,percent of total billed charges,75% of total billed charges,68.39,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.77,14,,,percent of total billed charges,14% of total billed charges,12.77,68.39,
90700 - Pediatric DTaP,3918930,CDM,636,RC,90700,HCPCS,Outpatient,,,82.79,41.4,,62.09,75,,,percent of total billed charges,75% of total billed charges,62.09,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.59,14,,,percent of total billed charges,14% of total billed charges,11.59,62.09,
AMB DTaP Peds Charge:0.5 mL Infanrix (DTaP) Vaccine,3444279,CDM,636,RC,90700,HCPCS,Outpatient,,,71.55,35.78,,53.66,75,,,percent of total billed charges,75% of total billed charges,53.66,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.02,14,,,percent of total billed charges,14% of total billed charges,10.02,53.66,
AMB DTaP Peds Charge:0.5 mL Infanrix (DTaP) Vaccine,3444280,CDM,636,RC,90700,HCPCS,Outpatient,,,82.79,41.4,,62.09,75,,,percent of total billed charges,75% of total billed charges,62.09,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.59,14,,,percent of total billed charges,14% of total billed charges,11.59,62.09,
90707 - MMR Vaccine,3918931,CDM,636,RC,90707,HCPCS,Outpatient,,,235.83,117.92,,176.87,75,,,percent of total billed charges,75% of total billed charges,176.87,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.02,14,,,percent of total billed charges,14% of total billed charges,33.02,176.87,
AMB MMR Charge:0.5 mL MMR Vaccine,3444365,CDM,636,RC,90707,HCPCS,Outpatient,,,241.63,120.82,,181.22,75,,,percent of total billed charges,75% of total billed charges,181.22,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.83,14,,,percent of total billed charges,14% of total billed charges,33.83,181.22,
AMB MMR Charge:0.5 mL MMR Vaccine,3444364,CDM,636,RC,90707,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
90710 - MMRV - ProQuad,3918932,CDM,636,RC,90710,HCPCS,Outpatient,,,676.12,338.06,,507.09,75,,,percent of total billed charges,75% of total billed charges,507.09,75,,,percent of total billed charges,75% of total billed charges,160,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,264,165,,,Fee Schedule,165% of CMS OPPS Rate,177.6,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,492.2,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,675.02,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,845.53,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,160,100,,,Fee Schedule,100% of CMS OPPS Rate,177.6,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,94.66,14,,,percent of total billed charges,14% of total billed charges,94.66,845.53,
AMB MMRV Charge:0.5 mL MMRV Vaccine,3444366,CDM,636,RC,90710,HCPCS,Outpatient,,,707.04,353.52,,530.28,75,,,percent of total billed charges,75% of total billed charges,530.28,75,,,percent of total billed charges,75% of total billed charges,160,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,264,165,,,Fee Schedule,165% of CMS OPPS Rate,177.6,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,492.2,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,675.02,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,845.53,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,160,100,,,Fee Schedule,100% of CMS OPPS Rate,177.6,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,98.99,14,,,percent of total billed charges,14% of total billed charges,98.99,845.53,
AMB MMRV Charge:0.5 mL MMRV Vaccine,3581634,CDM,636,RC,90710,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,160,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,264,165,,,Fee Schedule,165% of CMS OPPS Rate,177.6,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,492.2,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,675.02,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,845.53,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,160,100,,,Fee Schedule,100% of CMS OPPS Rate,177.6,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,160,845.53,
90713 - Poliovirus (IPOL),3918933,CDM,636,RC,90713,HCPCS,Outpatient,,,115.4,57.7,,86.55,75,,,percent of total billed charges,75% of total billed charges,86.55,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.16,14,,,percent of total billed charges,14% of total billed charges,16.16,86.55,
AMB IPV Charge:0.5 mL IPV Vaccine,3444329,CDM,636,RC,90713,HCPCS,Outpatient,,,104.27,52.14,,78.2,75,,,percent of total billed charges,75% of total billed charges,78.2,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.6,14,,,percent of total billed charges,14% of total billed charges,14.6,78.2,
AMB IPV Charge:0.5 mL IPV Vaccine,3444328,CDM,636,RC,90713,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
90714 - Td Adult (Tenivac),3918934,CDM,636,RC,90714,HCPCS,Outpatient,,,63.65,31.83,,47.74,75,,,percent of total billed charges,75% of total billed charges,47.74,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.91,14,,,percent of total billed charges,14% of total billed charges,8.91,47.74,
AMB Td Adult Charge:0.5 mL Tenivac Vaccine,3444407,CDM,636,RC,90714,HCPCS,Outpatient,,,101.7,50.85,,76.28,75,,,percent of total billed charges,75% of total billed charges,76.28,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.24,14,,,percent of total billed charges,14% of total billed charges,14.24,76.28,
90715 - Tdap - Adult,3918936,CDM,636,RC,90715,HCPCS,Outpatient,,,85.44,42.72,,64.08,75,,,percent of total billed charges,75% of total billed charges,64.08,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.96,14,,,percent of total billed charges,14% of total billed charges,11.96,64.08,
"90715 - Tetanus, diptheria toxoids & acellular prtussis vacc",3918935,CDM,636,RC,90715,HCPCS,Outpatient,,,85.44,42.72,,64.08,75,,,percent of total billed charges,75% of total billed charges,64.08,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.96,14,,,percent of total billed charges,14% of total billed charges,11.96,64.08,
AMB Tdap Adult Charge -> 0.5 mL Boostrix Vaccine,3546997,CDM,636,RC,90715,HCPCS,Outpatient,,,119.95,59.98,,89.96,75,,,percent of total billed charges,75% of total billed charges,89.96,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.79,14,,,percent of total billed charges,14% of total billed charges,16.79,89.96,
AMB Tdap Adult Charge -> VFC Vaccine,3581655,CDM,636,RC,90715,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
AMB Tdap Adult Charge:0.5 mL Adacel Vaccine,3444408,CDM,636,RC,90715,HCPCS,Outpatient,,,135.29,67.65,,101.47,75,,,percent of total billed charges,75% of total billed charges,101.47,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.94,14,,,percent of total billed charges,14% of total billed charges,18.94,101.47,
90716 - Varicella,3918937,CDM,636,RC,90716,HCPCS,Outpatient,,,407.68,203.84,,305.76,75,,,percent of total billed charges,75% of total billed charges,305.76,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,57.08,14,,,percent of total billed charges,14% of total billed charges,57.08,305.76,
AMB varicella virus Charge:0.5 mL Varivax Vaccine,3444421,CDM,636,RC,90716,HCPCS,Outpatient,,,431.64,215.82,,323.73,75,,,percent of total billed charges,75% of total billed charges,323.73,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.43,14,,,percent of total billed charges,14% of total billed charges,60.43,323.73,
AMB varicella virus Charge:0.5 mL Varivax Vaccine,3444420,CDM,636,RC,90716,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
90723 - Dtap-HepB-IPV (Pediarix),3918938,CDM,636,RC,90723,HCPCS,Outpatient,,,250.88,125.44,,188.16,75,,,percent of total billed charges,75% of total billed charges,188.16,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.12,14,,,percent of total billed charges,14% of total billed charges,35.12,188.16,
AMB DTaP Peds Charge:0.5 mL Infanrix (DTaP) Vaccine,3581580,CDM,636,RC,90723,HCPCS,Outpatient,,,250.88,125.44,,188.16,75,,,percent of total billed charges,75% of total billed charges,188.16,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.12,14,,,percent of total billed charges,14% of total billed charges,35.12,188.16,
AMB DTaP-HepB-IPV Charge:0.5 mL PEDIARIX Vaccine,3444282,CDM,636,RC,90723,HCPCS,Outpatient,,,223.88,111.94,,167.91,75,,,percent of total billed charges,75% of total billed charges,167.91,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.34,14,,,percent of total billed charges,14% of total billed charges,31.34,167.91,
90732 - Penumovax,3918939,CDM,636,RC,90732,HCPCS,Outpatient,,,250.88,125.44,,188.16,75,,,percent of total billed charges,75% of total billed charges,188.16,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.12,14,,,percent of total billed charges,14% of total billed charges,35.12,188.16,
"90732 - Pneumovax 23 -Pneum polysacaride vac, admin to ind 2",3918981,CDM,636,RC,90732,HCPCS,Outpatient,,,250.88,125.44,,188.16,75,,,percent of total billed charges,75% of total billed charges,188.16,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.12,14,,,percent of total billed charges,14% of total billed charges,35.12,188.16,
AMB Pneumovax 23 Charge:0.5 mL Pneumovax Vaccine,3444384,CDM,636,RC,90732,HCPCS,Outpatient,,,316.06,158.03,,237.05,75,,,percent of total billed charges,75% of total billed charges,237.05,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.25,14,,,percent of total billed charges,14% of total billed charges,44.25,237.05,
"90734 -  Menactra -Meningococcal conj vacc, A, C, W, Y, quad",3918940,CDM,636,RC,90734,HCPCS,Outpatient,,,386.36,193.18,,289.77,75,,,percent of total billed charges,75% of total billed charges,289.77,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,54.09,14,,,percent of total billed charges,14% of total billed charges,54.09,289.77,
90734 - Menactra (meningococcal),3918941,CDM,636,RC,90734,HCPCS,Outpatient,,,386.36,193.18,,289.77,75,,,percent of total billed charges,75% of total billed charges,289.77,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,54.09,14,,,percent of total billed charges,14% of total billed charges,54.09,289.77,
AMB meningococcal conjugate Charge:0.5 mL Menactra Vaccine,3444352,CDM,636,RC,90734,HCPCS,Outpatient,,,382.25,191.13,,286.69,75,,,percent of total billed charges,75% of total billed charges,286.69,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.52,14,,,percent of total billed charges,14% of total billed charges,53.52,286.69,
AMB meningococcal conjugate Charge:0.5 mL Menactra Vaccine,3444351,CDM,636,RC,90734,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
AMB Zostavax Charge:0.5 mL Zostavax Vaccine,3444423,CDM,636,RC,90736,HCPCS,Outpatient,,,656.05,328.03,,492.04,75,,,percent of total billed charges,75% of total billed charges,492.04,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,91.85,14,,,percent of total billed charges,14% of total billed charges,91.85,492.04,
90744 - Pediatric Hep B,3918942,CDM,636,RC,90744,HCPCS,Outpatient,,,225.6,112.8,,169.2,75,,,percent of total billed charges,75% of total billed charges,169.2,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.58,14,,,percent of total billed charges,14% of total billed charges,31.58,169.2,
AMB hepatitis B Ped Charge:0.5 mL HepB (Engerix-B) Ped Vacci,3546992,CDM,636,RC,90744,HCPCS,Outpatient,,,70.76,35.38,,53.07,75,,,percent of total billed charges,75% of total billed charges,53.07,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.91,14,,,percent of total billed charges,14% of total billed charges,9.91,53.07,
AMB hepatitis B Ped Charge:0.5 mL HepB (Recombivax) Ped Vacc,3444313,CDM,636,RC,90744,HCPCS,Outpatient,,,70.81,35.41,,53.11,75,,,percent of total billed charges,75% of total billed charges,53.11,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.91,14,,,percent of total billed charges,14% of total billed charges,9.91,53.11,
AMB hepatitis B Ped Charge:0.5 mL HepB (Recombivax) Ped Vacc,3444312,CDM,636,RC,90744,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
90746 - Adult Hep B,3918944,CDM,636,RC,90746,HCPCS,Outpatient,,,174.74,87.37,,131.06,75,,,percent of total billed charges,75% of total billed charges,131.06,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.46,14,,,percent of total billed charges,14% of total billed charges,24.46,131.06,
"90746 - Hepatitis B vaccine (HepB), pediatric/adolescent dos",3918943,CDM,636,RC,90746,HCPCS,Outpatient,,,174.74,87.37,,131.06,75,,,percent of total billed charges,75% of total billed charges,131.06,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.46,14,,,percent of total billed charges,14% of total billed charges,24.46,131.06,
AMB hepatitis B Adult Charge:1 mL Hepatitis B Adult Vaccine,3444311,CDM,636,RC,90746,HCPCS,Outpatient,,,173.3,86.65,,129.98,75,,,percent of total billed charges,75% of total billed charges,129.98,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.26,14,,,percent of total billed charges,14% of total billed charges,24.26,129.98,
90750 - Shingrix,3918945,CDM,636,RC,90750,HCPCS,Outpatient,,,868.25,434.13,,651.19,75,,,percent of total billed charges,75% of total billed charges,651.19,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,121.56,14,,,percent of total billed charges,14% of total billed charges,121.56,651.19,
AMB Shingrix Charge. -> 0.5 mL Shingrix Vaccine,3556762,CDM,636,RC,90750,HCPCS,Outpatient,,,463.23,231.62,,347.42,75,,,percent of total billed charges,75% of total billed charges,347.42,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.85,14,,,percent of total billed charges,14% of total billed charges,64.85,347.42,
90785- Interactive Complexity (Add-on),3437826,CDM,983,RC,90785,HCPCS,Outpatient,,,38.58,19.29,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
90791- Psych Diagnostic Eval W/O Med Mgmt,3437827,CDM,983,RC,90791,HCPCS,Outpatient,,,462.16,231.08,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
90792- Psych Diagnostic Eval With Med Mgmt,3437828,CDM,983,RC,90792,HCPCS,Outpatient,,,516.87,258.44,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
"90832- Psychotherapy, 30 Minutes",3437832,CDM,983,RC,90832,HCPCS,Outpatient,,,202.09,101.05,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
"90833- Psychotherapy, 30 Mins (E&M Add-on)",3437833,CDM,983,RC,90833,HCPCS,Outpatient,,,184.45,92.23,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
"90834- Psychotherapy, 45 Minutes",3437834,CDM,983,RC,90834,HCPCS,Outpatient,,,266.6,133.3,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
90836- Psychother/45min/pt and/or fam/E&M,3435671,CDM,510,RC,90836,HCPCS,Outpatient,,,232.65,116.33,,174.49,75,,,percent of total billed charges,75% of total billed charges,174.49,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,56.29,100,,,Fee Schedule,100% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.29,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.57,14,,,percent of total billed charges,14% of total billed charges,32.57,174.49,
90837- Psychotherapy Add-on,3437835,CDM,983,RC,90837,HCPCS,Outpatient,,,390.97,195.49,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
"90837- Psychotherapy, 60 Minutes",3437836,CDM,983,RC,90837,HCPCS,Outpatient,,,390.97,195.49,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
90838- Psychother/60min/pt and/or fam/E&M,3435672,CDM,510,RC,90838,HCPCS,Outpatient,,,305.84,152.92,,229.38,75,,,percent of total billed charges,75% of total billed charges,229.38,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,74.23,100,,,Fee Schedule,100% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,74.23,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.82,14,,,percent of total billed charges,14% of total billed charges,42.82,229.38,
90839- Crisis Psychotherapy,3437837,CDM,983,RC,90839,HCPCS,Outpatient,,,373.94,186.97,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
"90840- Crisis Psychotherapy, Additional 30 Mins",3437838,CDM,983,RC,90840,HCPCS,Outpatient,,,187.29,93.65,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
90846- Family Therapy W/O Patient,3428351,CDM,960,RC,90846,HCPCS,Outpatient,,,258.43,129.22,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
"90846- Family, Couples Psychotherapy W/O Patient",3428352,CDM,960,RC,90846,HCPCS,Outpatient,,,258.43,129.22,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
90847- Family Therapy with Patient,3428353,CDM,960,RC,90847,HCPCS,Outpatient,,,267.63,133.82,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
"90847- Family, Couples Psychotherapy With Patient",3428354,CDM,960,RC,90847,HCPCS,Outpatient,,,267.63,133.82,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
90853- Group Therapy,3428355,CDM,960,RC,90853,HCPCS,Outpatient,,,70.71,35.36,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
90863 Pharmacologic mgmt w/psytx,3430543,CDM,960,RC,90863,HCPCS,Outpatient,,,69.14,34.57,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
90870- Electroconvulsive Therapy,3437839,CDM,983,RC,90870,HCPCS,Outpatient,,,438.98,219.49,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
ESOPHAGEAL MOTILITY STUDY W/INTERP&RPT,4227186,CDM,960,RC,91010,HCPCS,Outpatient,,,424.83,212.42,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
91034-TRANSNASAL PH,3431292,CDM,750,RC,91034,HCPCS,Outpatient,,,344.57,172.29,,258.43,75,,,percent of total billed charges,75% of total billed charges,258.43,75,,,percent of total billed charges,75% of total billed charges,454.5,100,,,Fee Schedule,100% of CMS OPPS Rate,126.83,100,,,Fee Schedule,100% of WV Medicaid Rate,749.91,165,,,Fee Schedule,165% of CMS OPPS Rate,471.04,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1305.49,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1790.39,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,2242.64,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,126.83,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,454.5,100,,,Fee Schedule,100% of CMS OPPS Rate,471.04,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,48.24,14,,,percent of total billed charges,14% of total billed charges,48.24,2242.64,
"91035 Esophagus, gastroesophageal reflux test; with mucosal attached telemetry pH electrode pla",3696909,CDM,510,RC,91035,HCPCS,Outpatient,,,3205.39,1602.7,,2404.04,75,,,percent of total billed charges,75% of total billed charges,2404.04,75,,,percent of total billed charges,75% of total billed charges,454.5,100,,,Fee Schedule,100% of CMS OPPS Rate,309.22,100,,,Fee Schedule,100% of WV Medicaid Rate,749.91,165,,,Fee Schedule,165% of CMS OPPS Rate,471.04,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1305.49,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1790.39,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,2242.64,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,309.22,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,454.5,100,,,Fee Schedule,100% of CMS OPPS Rate,471.04,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,448.75,14,,,percent of total billed charges,14% of total billed charges,309.22,2404.04,
91035-BRAVO REFLUX TESTING SYSTEM,3431293,CDM,750,RC,91035,HCPCS,Outpatient,,,946.27,473.14,,709.7,75,,,percent of total billed charges,75% of total billed charges,709.7,75,,,percent of total billed charges,75% of total billed charges,454.5,100,,,Fee Schedule,100% of CMS OPPS Rate,309.22,100,,,Fee Schedule,100% of WV Medicaid Rate,749.91,165,,,Fee Schedule,165% of CMS OPPS Rate,471.04,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1305.49,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1790.39,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,2242.64,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,309.22,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,454.5,100,,,Fee Schedule,100% of CMS OPPS Rate,471.04,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,132.48,14,,,percent of total billed charges,14% of total billed charges,132.48,2242.64,
91037-IMPEDANCE,3431294,CDM,750,RC,91037,HCPCS,Outpatient,,,292.48,146.24,,219.36,75,,,percent of total billed charges,75% of total billed charges,219.36,75,,,percent of total billed charges,75% of total billed charges,263.29,100,,,Fee Schedule,100% of CMS OPPS Rate,112.08,100,,,Fee Schedule,100% of WV Medicaid Rate,434.44,165,,,Fee Schedule,165% of CMS OPPS Rate,272.88,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,756.29,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1037.2,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1299.2,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,112.08,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,263.29,100,,,Fee Schedule,100% of CMS OPPS Rate,272.88,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,40.95,14,,,percent of total billed charges,14% of total billed charges,40.95,1299.2,
91038- Esoph function test >1 hr/to 24 hr,3431442,CDM,510,RC,91038,HCPCS,Outpatient,,,875.5,437.75,,656.63,75,,,percent of total billed charges,75% of total billed charges,656.63,75,,,percent of total billed charges,75% of total billed charges,454.5,100,,,Fee Schedule,100% of CMS OPPS Rate,272.35,100,,,Fee Schedule,100% of WV Medicaid Rate,749.91,165,,,Fee Schedule,165% of CMS OPPS Rate,471.04,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1305.49,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1790.39,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,2242.64,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,272.35,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,454.5,100,,,Fee Schedule,100% of CMS OPPS Rate,471.04,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,122.57,14,,,percent of total billed charges,14% of total billed charges,122.57,2242.64,
91112- GI trans/pres meas/capsule/int/rep,3431280,CDM,510,RC,91112,HCPCS,Outpatient,,,3848.87,1924.44,,2886.65,75,,,percent of total billed charges,75% of total billed charges,2886.65,75,,,percent of total billed charges,75% of total billed charges,776.11,100,,,Fee Schedule,100% of CMS OPPS Rate,1101.92,100,,,Fee Schedule,100% of WV Medicaid Rate,1280.58,165,,,Fee Schedule,165% of CMS OPPS Rate,804.37,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,2229.28,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,3057.28,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,3829.56,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1101.92,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,776.11,100,,,Fee Schedule,100% of CMS OPPS Rate,804.37,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,538.84,14,,,percent of total billed charges,14% of total billed charges,538.84,3829.56,
91117- Colon motility stdy/6 hr/inter/rep,3431281,CDM,510,RC,91117,HCPCS,Outpatient,,,352.39,176.2,,264.29,75,,,percent of total billed charges,75% of total billed charges,264.29,75,,,percent of total billed charges,75% of total billed charges,263.29,100,,,Fee Schedule,100% of CMS OPPS Rate,94.14,100,,,Fee Schedule,100% of WV Medicaid Rate,434.44,165,,,Fee Schedule,165% of CMS OPPS Rate,272.88,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,756.29,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1037.2,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1299.2,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,94.14,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,263.29,100,,,Fee Schedule,100% of CMS OPPS Rate,272.88,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,49.33,14,,,percent of total billed charges,14% of total billed charges,49.33,1299.2,
91300 - SARSCOV2 VAC 30MCG/0.3ML IM,3997215,CDM,636,RC,91300,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
91301 - SARSCOV2 VAC 100MCG/0.5ML IM,3999146,CDM,636,RC,91301,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
91303 - SARSCOV2 VAC AD26 .5ML IM,3997216,CDM,636,RC,91303,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
91306 - SARSCOV2 VAC 50MCG/0.25ML IM,3997217,CDM,636,RC,91306,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
91307 - SARSCOV2 VAC 10 MCG TRS-SUCR,3999147,CDM,636,RC,91307,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
AMB Covid-19 Charge -> 0.3 mL Covid-19 Inj (5y-12y) CVX 310,4303192,CDM,636,RC,91319,HCPCS,Outpatient,,,428.51,214.26,,321.38,75,,,percent of total billed charges,75% of total billed charges,321.38,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,59.99,14,,,percent of total billed charges,14% of total billed charges,59.99,321.38,
AMB Covid-19 Charge -> 0.3 mL Covid-19 Inj (12+ years) CVX 309,4303193,CDM,636,RC,91320,HCPCS,Outpatient,,,667.8,333.9,,500.85,75,,,percent of total billed charges,75% of total billed charges,500.85,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.49,14,,,percent of total billed charges,14% of total billed charges,93.49,500.85,
92002- Opthal serv/exam/eval inter/new pt,3435576,CDM,962,RC,92002,HCPCS,Outpatient,,,756.81,378.41,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
92004- Opthal serv/exam/eval/comp/new pt,3435577,CDM,510,RC,92004,HCPCS,Outpatient,,,852.36,426.18,,639.27,75,,,percent of total billed charges,75% of total billed charges,639.27,75,,,percent of total billed charges,75% of total billed charges,113.62,100,,,Fee Schedule,100% of CMS OPPS Rate,65.14,100,,,Fee Schedule,100% of WV Medicaid Rate,187.47,165,,,Fee Schedule,165% of CMS OPPS Rate,117.76,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,326.38,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,447.6,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,560.66,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,65.14,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,113.62,100,,,Fee Schedule,100% of CMS OPPS Rate,117.76,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,119.33,14,,,percent of total billed charges,14% of total billed charges,65.14,639.27,
92012- Opthal serv/exam/eval/inter/est pt,3435578,CDM,962,RC,92012,HCPCS,Outpatient,,,765.88,382.94,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
92014- Opthal serv/exam/eval/comp/est pt,3435579,CDM,962,RC,92014,HCPCS,Outpatient,,,815.89,407.95,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
"92020- Gonioscopy, separate procedure",3435583,CDM,510,RC,92020,HCPCS,Outpatient,,,69.89,34.95,,52.42,75,,,percent of total billed charges,75% of total billed charges,52.42,75,,,percent of total billed charges,75% of total billed charges,109.16,100,,,Fee Schedule,100% of CMS OPPS Rate,13.76,100,,,Fee Schedule,100% of WV Medicaid Rate,180.11,165,,,Fee Schedule,165% of CMS OPPS Rate,113.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,313.55,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,430.01,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,538.63,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,13.76,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,109.16,100,,,Fee Schedule,100% of CMS OPPS Rate,113.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,9.78,14,,,percent of total billed charges,14% of total billed charges,9.78,538.63,
92025- Computer corneal topogra/uni/bi/I&,3435584,CDM,510,RC,92025,HCPCS,Outpatient,,,39.78,19.89,,29.84,75,,,percent of total billed charges,75% of total billed charges,29.84,75,,,percent of total billed charges,75% of total billed charges,54.04,100,,,Fee Schedule,100% of CMS OPPS Rate,23.6,100,,,Fee Schedule,100% of WV Medicaid Rate,89.16,165,,,Fee Schedule,165% of CMS OPPS Rate,56,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,155.22,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,212.87,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,266.65,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,23.6,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,54.04,100,,,Fee Schedule,100% of CMS OPPS Rate,56,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,5.57,14,,,percent of total billed charges,14% of total billed charges,5.57,266.65,
92060 - OCC EYE Sensorimotor Exam,3549604,CDM,983,RC,92060,HCPCS,Outpatient,,,381.05,190.53,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
92060- Sensorimotor exam/mult measure/I&R,3435585,CDM,510,RC,92060,HCPCS,Outpatient,,,381.05,190.53,,285.79,75,,,percent of total billed charges,75% of total billed charges,285.79,75,,,percent of total billed charges,75% of total billed charges,54.04,100,,,Fee Schedule,100% of CMS OPPS Rate,41.29,100,,,Fee Schedule,100% of WV Medicaid Rate,89.16,165,,,Fee Schedule,165% of CMS OPPS Rate,56,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,155.22,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,212.87,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,266.65,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,41.29,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,54.04,100,,,Fee Schedule,100% of CMS OPPS Rate,56,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,53.35,14,,,percent of total billed charges,14% of total billed charges,41.29,285.79,
92065- Orthoptic/pleoptic train/med eval,3435586,CDM,962,RC,92065,HCPCS,Outpatient,,,361.53,180.77,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
92071- Fit/cont lens/ocular surf disease,3435587,CDM,510,RC,92071,HCPCS,Outpatient,,,93.08,46.54,,69.81,75,,,percent of total billed charges,75% of total billed charges,69.81,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,22.12,100,,,Fee Schedule,100% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.12,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.03,14,,,percent of total billed charges,14% of total billed charges,13.03,69.81,
92072- Ini fit/contact lens/keratoconus,3435588,CDM,510,RC,92072,HCPCS,Outpatient,,,321.52,160.76,,241.14,75,,,percent of total billed charges,75% of total billed charges,241.14,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,65.87,100,,,Fee Schedule,100% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,65.87,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.01,14,,,percent of total billed charges,14% of total billed charges,45.01,241.14,
92081-OCC Vis field exam/uni/bi/I&R/limited,3536981,CDM,983,RC,92081,HCPCS,Outpatient,,,340.22,170.11,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
92082- Vis field exam/uni/bi/I&R/intermed,3435590,CDM,510,RC,92082,HCPCS,Outpatient,,,349.55,174.78,,262.16,75,,,percent of total billed charges,75% of total billed charges,262.16,75,,,percent of total billed charges,75% of total billed charges,54.04,100,,,Fee Schedule,100% of CMS OPPS Rate,30.23,100,,,Fee Schedule,100% of WV Medicaid Rate,89.16,165,,,Fee Schedule,165% of CMS OPPS Rate,56,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,155.22,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,212.87,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,266.65,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,30.23,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,54.04,100,,,Fee Schedule,100% of CMS OPPS Rate,56,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,48.94,14,,,percent of total billed charges,14% of total billed charges,30.23,266.65,
92083- Vis field exam/uni/bi/I&R/extended,3435591,CDM,962,RC,92083,HCPCS,Outpatient,,,697.45,348.73,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
92083-OCC Vis field exam/uni/bi/I&R/extended,3536982,CDM,983,RC,92083,HCPCS,Outpatient,,,697.45,348.73,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
92132- OCT Anterior Segment w/I+R Uni/Bi,3431345,CDM,960,RC,92132,HCPCS,Outpatient,,,340.81,170.41,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
92133- OCT/posterio seg/I & R/optic nerve,3431346,CDM,960,RC,92133,HCPCS,Outpatient,,,350.73,175.37,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
92134- OCT/posterior seg/I & R/ retina,3431347,CDM,960,RC,92134,HCPCS,Outpatient,,,357.2,178.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
92250- Fundus photography w/I&R,3435599,CDM,962,RC,92250,HCPCS,Outpatient,,,685.72,342.86,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
92250-OCC Fundus photography w/I&R,3536983,CDM,983,RC,92250,HCPCS,Outpatient,,,685.72,342.86,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
92260- Ophthalmodynamometry,3435600,CDM,962,RC,92260,HCPCS,Outpatient,,,223.9,111.95,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
92283- Color vision exam/extended,3435604,CDM,962,RC,92283,HCPCS,Outpatient,,,325.8,162.9,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
92284- Dark adaptation exam/I&R,3435605,CDM,962,RC,92284,HCPCS,Outpatient,,,2079.39,1039.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
92285- Ext ocular photo/I&R/med progress,3435606,CDM,962,RC,92285,HCPCS,Outpatient,,,208.7,104.35,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
92285-OCC Ext ocular photo/I&R/med progress,3536984,CDM,983,RC,92285,HCPCS,Outpatient,,,208.7,104.35,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
92286- Ant seg image/I & R/micro/cell ana,3435607,CDM,962,RC,92286,HCPCS,Outpatient,,,686.91,343.46,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
92287- Ant seg image/I & R/fluorescein an,3435608,CDM,962,RC,92287,HCPCS,Outpatient,,,701.29,350.65,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
92511- Nasopharyngoscopy w/endoscope,3435636,CDM,510,RC,92511,HCPCS,Outpatient,,,287.96,143.98,,215.97,75,,,percent of total billed charges,75% of total billed charges,215.97,75,,,percent of total billed charges,75% of total billed charges,168.05,100,,,Fee Schedule,100% of CMS OPPS Rate,25.81,100,,,Fee Schedule,100% of WV Medicaid Rate,277.27,165,,,Fee Schedule,165% of CMS OPPS Rate,174.17,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,482.7,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,661.99,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,829.22,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,25.81,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,168.05,100,,,Fee Schedule,100% of CMS OPPS Rate,174.17,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,40.31,14,,,percent of total billed charges,14% of total billed charges,25.81,829.22,
92526- Tx swallow dysfunc/oral func/feed,3435639,CDM,430,RC,92526,HCPCS,Outpatient,,,503.81,251.91,,377.86,75,,,percent of total billed charges,75% of total billed charges,377.86,75,,,percent of total billed charges,75% of total billed charges,80.63,100,,,Fee Schedule,100% of CMS OPPS Rate,58.01,100,,,Fee Schedule,100% of WV Medicaid Rate,133.04,165,,,Fee Schedule,165% of CMS OPPS Rate,78.67,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,285.87,354.54,,,Fee Schedule,354.54% of CMS OPPS Fee Schedule Rate,345.66,428.7,,,Fee Schedule,428.7% of CMS OPPS Fee Schedule Rate,363.49,450.81,,,Fee Schedule,450.81% of CMS OPPS Fee Schedule Rate,58.01,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,80.63,100,,,Fee Schedule,100% of CMS OPPS Rate,78.67,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,70.53,14,,,percent of total billed charges,14% of total billed charges,58.01,377.86,
92551 Audiogram,3435572,CDM,510,RC,92551,HCPCS,Outpatient,,,33.24,16.62,,24.93,75,,,percent of total billed charges,75% of total billed charges,24.93,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,7.13,100,,,Fee Schedule,100% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.13,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.65,14,,,percent of total billed charges,14% of total billed charges,4.65,24.93,
Hearing Screen POC,3444193,CDM,471,RC,92551,HCPCS,Outpatient,,,27.92,13.96,,20.94,75,,,percent of total billed charges,75% of total billed charges,20.94,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,7.13,100,,,Fee Schedule,100% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.13,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.91,14,,,percent of total billed charges,14% of total billed charges,3.91,20.94,
92552 Pure tone audiometry air,3584886,CDM,960,RC,92552,HCPCS,Outpatient,,,78.47,39.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
92553 Audiometry air & bone,3584887,CDM,960,RC,92553,HCPCS,Outpatient,,,95.07,47.54,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
92556 Speech audiometry complete,3584888,CDM,960,RC,92556,HCPCS,Outpatient,,,93.48,46.74,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
92557 Comprehensive audiometry threshold evaluation and speech recognition,3584889,CDM,960,RC,92557,HCPCS,Outpatient,,,96.75,48.38,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
92561- Bekesy audiometry/diagnostic,3435645,CDM,510,RC,92561,HCPCS,Outpatient,,,91.19,45.6,,68.39,75,,,percent of total billed charges,75% of total billed charges,68.39,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.77,14,,,percent of total billed charges,14% of total billed charges,12.77,68.39,
92562- Loudness balance test/bi/monaural,3435646,CDM,510,RC,92562,HCPCS,Outpatient,,,107.71,53.86,,80.78,75,,,percent of total billed charges,75% of total billed charges,80.78,75,,,percent of total billed charges,75% of total billed charges,136.72,100,,,Fee Schedule,100% of CMS OPPS Rate,28.76,100,,,Fee Schedule,100% of WV Medicaid Rate,225.6,165,,,Fee Schedule,165% of CMS OPPS Rate,141.7,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,392.73,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,538.6,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,674.65,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,28.76,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,136.72,100,,,Fee Schedule,100% of CMS OPPS Rate,141.7,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,15.08,14,,,percent of total billed charges,14% of total billed charges,15.08,674.65,
92564- Short increment sensitivity index,3435647,CDM,510,RC,92564,HCPCS,Outpatient,,,58.75,29.38,,44.06,75,,,percent of total billed charges,75% of total billed charges,44.06,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.23,14,,,percent of total billed charges,14% of total billed charges,8.23,44.06,
92567 Tympanometry,3584890,CDM,960,RC,92567,HCPCS,Outpatient,,,41.63,20.82,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
92572- Staggered spondaic word test,3435648,CDM,510,RC,92572,HCPCS,Outpatient,,,95.87,47.94,,71.9,75,,,percent of total billed charges,75% of total billed charges,71.9,75,,,percent of total billed charges,75% of total billed charges,136.72,100,,,Fee Schedule,100% of CMS OPPS Rate,25.56,100,,,Fee Schedule,100% of WV Medicaid Rate,225.6,165,,,Fee Schedule,165% of CMS OPPS Rate,141.7,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,392.73,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,538.6,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,674.65,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,25.56,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,136.72,100,,,Fee Schedule,100% of CMS OPPS Rate,141.7,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,13.42,14,,,percent of total billed charges,14% of total billed charges,13.42,674.65,
92575- Sensorineural acuity level test,3435649,CDM,510,RC,92575,HCPCS,Outpatient,,,164.69,82.35,,123.52,75,,,percent of total billed charges,75% of total billed charges,123.52,75,,,percent of total billed charges,75% of total billed charges,31.92,100,,,Fee Schedule,100% of CMS OPPS Rate,44,100,,,Fee Schedule,100% of WV Medicaid Rate,52.68,165,,,Fee Schedule,165% of CMS OPPS Rate,33.09,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,91.7,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,125.77,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,157.54,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,44,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,31.92,100,,,Fee Schedule,100% of CMS OPPS Rate,33.09,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,23.06,14,,,percent of total billed charges,14% of total billed charges,23.06,157.54,
92576- Synthetic sentence ID test,3435650,CDM,510,RC,92576,HCPCS,Outpatient,,,88.74,44.37,,66.56,75,,,percent of total billed charges,75% of total billed charges,66.56,75,,,percent of total billed charges,75% of total billed charges,31.92,100,,,Fee Schedule,100% of CMS OPPS Rate,23.6,100,,,Fee Schedule,100% of WV Medicaid Rate,52.68,165,,,Fee Schedule,165% of CMS OPPS Rate,33.09,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,91.7,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,125.77,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,157.54,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,23.6,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,31.92,100,,,Fee Schedule,100% of CMS OPPS Rate,33.09,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,12.42,14,,,percent of total billed charges,14% of total billed charges,12.42,157.54,
92582 Conditioning play audiometry,3585094,CDM,960,RC,92582,HCPCS,Outpatient,,,180.65,90.33,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
92583- Select picture audiometry,3435651,CDM,510,RC,92583,HCPCS,Outpatient,,,117.97,58.99,,88.48,75,,,percent of total billed charges,75% of total billed charges,88.48,75,,,percent of total billed charges,75% of total billed charges,54.04,100,,,Fee Schedule,100% of CMS OPPS Rate,31.46,100,,,Fee Schedule,100% of WV Medicaid Rate,89.16,165,,,Fee Schedule,165% of CMS OPPS Rate,56,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,155.22,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,212.87,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,266.65,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,31.46,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,54.04,100,,,Fee Schedule,100% of CMS OPPS Rate,56,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,16.52,14,,,percent of total billed charges,14% of total billed charges,16.52,266.65,
92588 Evoked auditory tst complete,3584892,CDM,960,RC,92588,HCPCS,Outpatient,,,12.95,6.48,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
92596- Ear protector attenuation measure,3435652,CDM,510,RC,92596,HCPCS,Outpatient,,,159.82,79.91,,119.87,75,,,percent of total billed charges,75% of total billed charges,119.87,75,,,percent of total billed charges,75% of total billed charges,31.92,100,,,Fee Schedule,100% of CMS OPPS Rate,42.52,100,,,Fee Schedule,100% of WV Medicaid Rate,52.68,165,,,Fee Schedule,165% of CMS OPPS Rate,33.09,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,91.7,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,125.77,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,157.54,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,42.52,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,31.92,100,,,Fee Schedule,100% of CMS OPPS Rate,33.09,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,22.37,14,,,percent of total billed charges,14% of total billed charges,22.37,157.54,
92612- Endoscop eval/swallow/cine/video,3435660,CDM,510,RC,92612,HCPCS,Outpatient,,,472.35,236.18,,354.26,75,,,percent of total billed charges,75% of total billed charges,354.26,75,,,percent of total billed charges,75% of total billed charges,64.26,100,,,Fee Schedule,100% of CMS OPPS Rate,46.46,100,,,Fee Schedule,100% of WV Medicaid Rate,106.03,165,,,Fee Schedule,165% of CMS OPPS Rate,62.69,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,227.83,354.54,,,Fee Schedule,354.54% of CMS OPPS Fee Schedule Rate,275.48,428.7,,,Fee Schedule,428.7% of CMS OPPS Fee Schedule Rate,289.69,450.81,,,Fee Schedule,450.81% of CMS OPPS Fee Schedule Rate,46.46,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,64.26,100,,,Fee Schedule,100% of CMS OPPS Rate,62.69,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,66.13,14,,,percent of total billed charges,14% of total billed charges,46.46,354.26,
92614- Endoscop eval/laryngeal sens test,3435662,CDM,510,RC,92614,HCPCS,Outpatient,,,360.21,180.11,,270.16,75,,,percent of total billed charges,75% of total billed charges,270.16,75,,,percent of total billed charges,75% of total billed charges,63.81,100,,,Fee Schedule,100% of CMS OPPS Rate,46.21,100,,,Fee Schedule,100% of WV Medicaid Rate,105.29,165,,,Fee Schedule,165% of CMS OPPS Rate,62.26,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,226.23,354.54,,,Fee Schedule,354.54% of CMS OPPS Fee Schedule Rate,273.55,428.7,,,Fee Schedule,428.7% of CMS OPPS Fee Schedule Rate,287.66,450.81,,,Fee Schedule,450.81% of CMS OPPS Fee Schedule Rate,46.21,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,63.81,100,,,Fee Schedule,100% of CMS OPPS Rate,62.26,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,50.43,14,,,percent of total billed charges,14% of total billed charges,46.21,287.66,
"92652 Auditory evoked potentials; for threshold estimation at multiple frequencies, with interpretat",3584893,CDM,960,RC,92652,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
"92653 Auditory evoked potentials; neurodiagnostic, with interpretation and report",3584894,CDM,960,RC,92653,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
Cardioversion,604545,CDM,480,RC,92960,HCPCS,Outpatient,,,3500.88,1750.44,,2625.66,75,,,percent of total billed charges,75% of total billed charges,2625.66,75,,,percent of total billed charges,75% of total billed charges,552.94,100,,,Fee Schedule,100% of CMS OPPS Rate,74.97,100,,,Fee Schedule,100% of WV Medicaid Rate,912.36,165,,,Fee Schedule,165% of CMS OPPS Rate,573.08,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1588.26,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2178.17,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,2728.39,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,74.97,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,552.94,100,,,Fee Schedule,100% of CMS OPPS Rate,573.08,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,490.12,14,,,percent of total billed charges,14% of total billed charges,74.97,2728.39,
92961- Cardioversion/elective/internal,3430928,CDM,510,RC,92961,HCPCS,Outpatient,,,3346.36,1673.18,,2509.77,75,,,percent of total billed charges,75% of total billed charges,2509.77,75,,,percent of total billed charges,75% of total billed charges,552.94,100,,,Fee Schedule,100% of CMS OPPS Rate,175.26,100,,,Fee Schedule,100% of WV Medicaid Rate,912.36,165,,,Fee Schedule,165% of CMS OPPS Rate,573.08,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1588.26,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2178.17,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,2728.39,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,175.26,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,552.94,100,,,Fee Schedule,100% of CMS OPPS Rate,573.08,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,468.49,14,,,percent of total billed charges,14% of total billed charges,175.26,2728.39,
"93000- Electrocardiogram (ECG), Routine 12-Lead, Tracing and I&R (Global)",3430947,CDM,960,RC,93000,HCPCS,Outpatient,,,28.01,14.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
Clinic EKG,3527352,CDM,731,RC,93000,HCPCS,Outpatient,,,323,161.5,,242.25,75,,,percent of total billed charges,75% of total billed charges,242.25,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,9.59,100,,,Fee Schedule,100% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.59,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.22,14,,,percent of total billed charges,14% of total billed charges,9.59,242.25,
93005- Electrocardiogram tracing,3430948,CDM,730,RC,93005,HCPCS,Outpatient,,,308.88,154.44,,231.66,75,,,percent of total billed charges,75% of total billed charges,231.66,75,,,percent of total billed charges,75% of total billed charges,54.04,100,,,Fee Schedule,100% of CMS OPPS Rate,3.93,100,,,Fee Schedule,100% of WV Medicaid Rate,89.16,165,,,Fee Schedule,165% of CMS OPPS Rate,56,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,155.22,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,212.87,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,266.65,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,3.93,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,54.04,100,,,Fee Schedule,100% of CMS OPPS Rate,56,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,43.24,14,,,percent of total billed charges,14% of total billed charges,3.93,266.65,
EKG Pre/Post Unit,645285,CDM,730,RC,93005,HCPCS,Outpatient,,,308.88,154.44,,231.66,75,,,percent of total billed charges,75% of total billed charges,231.66,75,,,percent of total billed charges,75% of total billed charges,54.04,100,,,Fee Schedule,100% of CMS OPPS Rate,3.93,100,,,Fee Schedule,100% of WV Medicaid Rate,89.16,165,,,Fee Schedule,165% of CMS OPPS Rate,56,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,155.22,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,212.87,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,266.65,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,3.93,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,54.04,100,,,Fee Schedule,100% of CMS OPPS Rate,56,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,43.24,14,,,percent of total billed charges,14% of total billed charges,3.93,266.65,
Electrocardiogram-Outpatient,604550,CDM,730,RC,93005,HCPCS,Outpatient,,,308.88,154.44,,231.66,75,,,percent of total billed charges,75% of total billed charges,231.66,75,,,percent of total billed charges,75% of total billed charges,54.04,100,,,Fee Schedule,100% of CMS OPPS Rate,3.93,100,,,Fee Schedule,100% of WV Medicaid Rate,89.16,165,,,Fee Schedule,165% of CMS OPPS Rate,56,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,155.22,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,212.87,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,266.65,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,3.93,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,54.04,100,,,Fee Schedule,100% of CMS OPPS Rate,56,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,43.24,14,,,percent of total billed charges,14% of total billed charges,3.93,266.65,
PAT EKG,653557,CDM,730,RC,93005,HCPCS,Outpatient,,,308.88,154.44,,231.66,75,,,percent of total billed charges,75% of total billed charges,231.66,75,,,percent of total billed charges,75% of total billed charges,54.04,100,,,Fee Schedule,100% of CMS OPPS Rate,3.93,100,,,Fee Schedule,100% of WV Medicaid Rate,89.16,165,,,Fee Schedule,165% of CMS OPPS Rate,56,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,155.22,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,212.87,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,266.65,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,3.93,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,54.04,100,,,Fee Schedule,100% of CMS OPPS Rate,56,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,43.24,14,,,percent of total billed charges,14% of total billed charges,3.93,266.65,
93015- Cardio stress/cont ECG/superv/I&R,3430949,CDM,960,RC,93015,HCPCS,Outpatient,,,1556.43,778.22,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
CL Stress Test,4201286,CDM,983,RC,93015,HCPCS,Outpatient,,,1556.43,778.22,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
93017- Cardio stress test/tracing only,3430951,CDM,960,RC,93017,HCPCS,Outpatient,,,1585.02,792.51,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
NM Cardiolite Stress Test,4261243,CDM,482,RC,93017,HCPCS,Outpatient,,,1585.02,792.51,,1188.77,75,,,percent of total billed charges,75% of total billed charges,1188.77,75,,,percent of total billed charges,75% of total billed charges,263.3,100,,,Fee Schedule,100% of CMS OPPS Rate,22.12,100,,,Fee Schedule,100% of WV Medicaid Rate,434.45,165,,,Fee Schedule,165% of CMS OPPS Rate,272.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,756.3,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1037.2,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1299.2,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,22.12,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,263.3,100,,,Fee Schedule,100% of CMS OPPS Rate,272.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,221.9,14,,,percent of total billed charges,14% of total billed charges,22.12,1299.2,
Stress Test,604564,CDM,482,RC,93017,HCPCS,Outpatient,,,1585.02,792.51,,1188.77,75,,,percent of total billed charges,75% of total billed charges,1188.77,75,,,percent of total billed charges,75% of total billed charges,263.3,100,,,Fee Schedule,100% of CMS OPPS Rate,22.12,100,,,Fee Schedule,100% of WV Medicaid Rate,434.45,165,,,Fee Schedule,165% of CMS OPPS Rate,272.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,756.3,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1037.2,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1299.2,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,22.12,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,263.3,100,,,Fee Schedule,100% of CMS OPPS Rate,272.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,221.9,14,,,percent of total billed charges,14% of total billed charges,22.12,1299.2,
Stress Test,,,480,RC,93017,HCPCS,Outpatient,,,1653.28,826.64,,1239.96,75,,,percent of total billed charges,75% of total billed charges,1239.96,75,,,percent of total billed charges,75% of total billed charges,263.3,100,,,Fee Schedule,100% of CMS OPPS Rate,22.12,100,,,Fee Schedule,100% of WV Medicaid Rate,434.45,165,,,Fee Schedule,165% of CMS OPPS Rate,272.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,756.3,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1037.2,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1299.2,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,22.12,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,263.3,100,,,Fee Schedule,100% of CMS OPPS Rate,272.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,231.46,14,,,percent of total billed charges,14% of total billed charges,22.12,1299.2,
93025- Microvolt T-wave alternans,3430953,CDM,510,RC,93025,HCPCS,Outpatient,,,196.45,98.23,,147.34,75,,,percent of total billed charges,75% of total billed charges,147.34,75,,,percent of total billed charges,75% of total billed charges,136.72,100,,,Fee Schedule,100% of CMS OPPS Rate,78.16,100,,,Fee Schedule,100% of WV Medicaid Rate,225.58,165,,,Fee Schedule,165% of CMS OPPS Rate,141.69,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,392.72,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,538.59,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,674.64,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,78.16,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,136.72,100,,,Fee Schedule,100% of CMS OPPS Rate,141.69,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,27.5,14,,,percent of total billed charges,14% of total billed charges,27.5,674.64,
CL Holter Monitor 24-48 hour,3430958,CDM,731,RC,93225,HCPCS,Outpatient,,,678.3,339.15,,508.73,75,,,percent of total billed charges,75% of total billed charges,508.73,75,,,percent of total billed charges,75% of total billed charges,109.16,100,,,Fee Schedule,100% of CMS OPPS Rate,12.04,100,,,Fee Schedule,100% of WV Medicaid Rate,180.11,165,,,Fee Schedule,165% of CMS OPPS Rate,113.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,313.55,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,430.01,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,538.63,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,12.04,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,109.16,100,,,Fee Schedule,100% of CMS OPPS Rate,113.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,94.96,14,,,percent of total billed charges,14% of total billed charges,12.04,538.63,
93242 - Ext ECG >48HR <7D Recording,3896947,CDM,510,RC,93242,HCPCS,Outpatient,,,224.39,112.2,,168.29,75,,,percent of total billed charges,75% of total billed charges,168.29,75,,,percent of total billed charges,75% of total billed charges,31.92,100,,,Fee Schedule,100% of CMS OPPS Rate,8.85,100,,,Fee Schedule,100% of WV Medicaid Rate,52.68,165,,,Fee Schedule,165% of CMS OPPS Rate,33.09,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,91.7,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,125.77,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,157.54,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,8.85,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,31.92,100,,,Fee Schedule,100% of CMS OPPS Rate,33.09,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,31.41,14,,,percent of total billed charges,14% of total billed charges,8.85,168.29,
CL Holter Monitor 3-7 day,4221151,CDM,731,RC,93242,HCPCS,Outpatient,,,202.51,101.26,,151.88,75,,,percent of total billed charges,75% of total billed charges,151.88,75,,,percent of total billed charges,75% of total billed charges,31.92,100,,,Fee Schedule,100% of CMS OPPS Rate,8.85,100,,,Fee Schedule,100% of WV Medicaid Rate,52.68,165,,,Fee Schedule,165% of CMS OPPS Rate,33.09,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,91.7,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,125.77,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,157.54,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,8.85,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,31.92,100,,,Fee Schedule,100% of CMS OPPS Rate,33.09,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,28.35,14,,,percent of total billed charges,14% of total billed charges,8.85,157.54,
Holter Monitor 3-7 days,4221153,CDM,731,RC,93242,HCPCS,Outpatient,,,202.51,101.26,,151.88,75,,,percent of total billed charges,75% of total billed charges,151.88,75,,,percent of total billed charges,75% of total billed charges,31.92,100,,,Fee Schedule,100% of CMS OPPS Rate,8.85,100,,,Fee Schedule,100% of WV Medicaid Rate,52.68,165,,,Fee Schedule,165% of CMS OPPS Rate,33.09,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,91.7,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,125.77,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,157.54,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,8.85,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,31.92,100,,,Fee Schedule,100% of CMS OPPS Rate,33.09,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,28.35,14,,,percent of total billed charges,14% of total billed charges,8.85,157.54,
93246 - EXT ECG>7D<15D RECORDING,3997218,CDM,510,RC,93246,HCPCS,Outpatient,,,224.39,112.2,,168.29,75,,,percent of total billed charges,75% of total billed charges,168.29,75,,,percent of total billed charges,75% of total billed charges,54.04,100,,,Fee Schedule,100% of CMS OPPS Rate,8.85,100,,,Fee Schedule,100% of WV Medicaid Rate,89.16,165,,,Fee Schedule,165% of CMS OPPS Rate,56,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,155.22,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,212.87,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,266.65,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,8.85,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,54.04,100,,,Fee Schedule,100% of CMS OPPS Rate,56,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,31.41,14,,,percent of total billed charges,14% of total billed charges,8.85,266.65,
CL Holter Monitor 8+ days,4221152,CDM,731,RC,93246,HCPCS,Outpatient,,,202.51,101.26,,151.88,75,,,percent of total billed charges,75% of total billed charges,151.88,75,,,percent of total billed charges,75% of total billed charges,54.04,100,,,Fee Schedule,100% of CMS OPPS Rate,8.85,100,,,Fee Schedule,100% of WV Medicaid Rate,89.16,165,,,Fee Schedule,165% of CMS OPPS Rate,56,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,155.22,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,212.87,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,266.65,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,8.85,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,54.04,100,,,Fee Schedule,100% of CMS OPPS Rate,56,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,28.35,14,,,percent of total billed charges,14% of total billed charges,8.85,266.65,
Holter Monitor 8+ days,4221154,CDM,731,RC,93246,HCPCS,Outpatient,,,202.51,101.26,,151.88,75,,,percent of total billed charges,75% of total billed charges,151.88,75,,,percent of total billed charges,75% of total billed charges,54.04,100,,,Fee Schedule,100% of CMS OPPS Rate,8.85,100,,,Fee Schedule,100% of WV Medicaid Rate,89.16,165,,,Fee Schedule,165% of CMS OPPS Rate,56,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,155.22,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,212.87,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,266.65,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,8.85,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,54.04,100,,,Fee Schedule,100% of CMS OPPS Rate,56,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,28.35,14,,,percent of total billed charges,14% of total billed charges,8.85,266.65,
93264-CardioMEMS recalibration,3432003,CDM,960,RC,93264,HCPCS,Outpatient,,,106.09,53.05,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
CardioMEMS recalibration,3427124,CDM,480,RC,93264,HCPCS,Outpatient,,,106.09,53.05,,79.57,75,,,percent of total billed charges,75% of total billed charges,79.57,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,24.58,100,,,Fee Schedule,100% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.58,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.85,14,,,percent of total billed charges,14% of total billed charges,14.85,79.57,
93270- Ext pt/auto ECG/30 day/MD interp,3430766,CDM,731,RC,93270,HCPCS,Outpatient,,,205.72,102.86,,154.29,75,,,percent of total billed charges,75% of total billed charges,154.29,75,,,percent of total billed charges,75% of total billed charges,32.9,100,,,Fee Schedule,100% of CMS OPPS Rate,5.41,100,,,Fee Schedule,100% of WV Medicaid Rate,54.29,165,,,Fee Schedule,165% of CMS OPPS Rate,34.1,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,94.51,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,129.62,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,162.36,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,5.41,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,32.9,100,,,Fee Schedule,100% of CMS OPPS Rate,34.1,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,28.8,14,,,percent of total billed charges,14% of total billed charges,5.41,162.36,
Event Monitoring,604570,CDM,731,RC,93270,HCPCS,Outpatient,,,205.72,102.86,,154.29,75,,,percent of total billed charges,75% of total billed charges,154.29,75,,,percent of total billed charges,75% of total billed charges,32.9,100,,,Fee Schedule,100% of CMS OPPS Rate,5.41,100,,,Fee Schedule,100% of WV Medicaid Rate,54.29,165,,,Fee Schedule,165% of CMS OPPS Rate,34.1,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,94.51,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,129.62,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,162.36,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,5.41,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,32.9,100,,,Fee Schedule,100% of CMS OPPS Rate,34.1,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,28.8,14,,,percent of total billed charges,14% of total billed charges,5.41,162.36,
93271- Event rec/to 30 days/transmis/anal,3430965,CDM,731,RC,93271,HCPCS,Outpatient,,,355.64,177.82,,266.73,75,,,percent of total billed charges,75% of total billed charges,266.73,75,,,percent of total billed charges,75% of total billed charges,93.83,100,,,Fee Schedule,100% of CMS OPPS Rate,94.88,100,,,Fee Schedule,100% of WV Medicaid Rate,154.82,165,,,Fee Schedule,165% of CMS OPPS Rate,97.24,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,269.52,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,369.64,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,463.01,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,94.88,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,93.83,100,,,Fee Schedule,100% of CMS OPPS Rate,97.24,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,49.79,14,,,percent of total billed charges,14% of total billed charges,49.79,463.01,
93278- Signal avg ECG w or w/o ECG,3430967,CDM,510,RC,93278,HCPCS,Outpatient,,,39.01,19.51,,29.26,75,,,percent of total billed charges,75% of total billed charges,29.26,75,,,percent of total billed charges,75% of total billed charges,54.04,100,,,Fee Schedule,100% of CMS OPPS Rate,18.93,100,,,Fee Schedule,100% of WV Medicaid Rate,89.16,165,,,Fee Schedule,165% of CMS OPPS Rate,56,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,155.22,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,212.87,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,266.65,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,18.93,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,54.04,100,,,Fee Schedule,100% of CMS OPPS Rate,56,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,5.46,14,,,percent of total billed charges,14% of total billed charges,5.46,266.65,
93279- PPM eval/test/program/sgn lead,3430968,CDM,480,RC,93279,HCPCS,Outpatient,,,251.76,125.88,,188.82,75,,,percent of total billed charges,75% of total billed charges,188.82,75,,,percent of total billed charges,75% of total billed charges,32.9,100,,,Fee Schedule,100% of CMS OPPS Rate,45.96,100,,,Fee Schedule,100% of WV Medicaid Rate,54.29,165,,,Fee Schedule,165% of CMS OPPS Rate,34.1,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,94.51,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,129.62,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,162.36,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,45.96,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,32.9,100,,,Fee Schedule,100% of CMS OPPS Rate,34.1,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,35.25,14,,,percent of total billed charges,14% of total billed charges,32.9,188.82,
93280- PPM eval/test/program/dual lead,3430969,CDM,480,RC,93280,HCPCS,Outpatient,,,263.08,131.54,,197.31,75,,,percent of total billed charges,75% of total billed charges,197.31,75,,,percent of total billed charges,75% of total billed charges,32.9,100,,,Fee Schedule,100% of CMS OPPS Rate,54.32,100,,,Fee Schedule,100% of WV Medicaid Rate,54.29,165,,,Fee Schedule,165% of CMS OPPS Rate,34.1,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,94.51,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,129.62,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,162.36,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,54.32,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,32.9,100,,,Fee Schedule,100% of CMS OPPS Rate,34.1,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,36.83,14,,,percent of total billed charges,14% of total billed charges,32.9,197.31,
93281- PPM eval/test/program/multi lead,3430970,CDM,480,RC,93281,HCPCS,Outpatient,,,271.97,135.99,,203.98,75,,,percent of total billed charges,75% of total billed charges,203.98,75,,,percent of total billed charges,75% of total billed charges,32.9,100,,,Fee Schedule,100% of CMS OPPS Rate,57.52,100,,,Fee Schedule,100% of WV Medicaid Rate,54.29,165,,,Fee Schedule,165% of CMS OPPS Rate,34.1,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,94.51,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,129.62,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,162.36,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,57.52,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,32.9,100,,,Fee Schedule,100% of CMS OPPS Rate,34.1,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,38.08,14,,,percent of total billed charges,14% of total billed charges,32.9,203.98,
93282- ICD eval/test/program/single lead,3430971,CDM,480,RC,93282,HCPCS,Outpatient,,,271.35,135.68,,203.51,75,,,percent of total billed charges,75% of total billed charges,203.51,75,,,percent of total billed charges,75% of total billed charges,32.9,100,,,Fee Schedule,100% of CMS OPPS Rate,55.06,100,,,Fee Schedule,100% of WV Medicaid Rate,54.29,165,,,Fee Schedule,165% of CMS OPPS Rate,34.1,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,94.51,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,129.62,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,162.36,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,55.06,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,32.9,100,,,Fee Schedule,100% of CMS OPPS Rate,34.1,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,37.99,14,,,percent of total billed charges,14% of total billed charges,32.9,203.51,
93283- ICD eval/test/program/dual lead,3430972,CDM,480,RC,93283,HCPCS,Outpatient,,,300.29,150.15,,225.22,75,,,percent of total billed charges,75% of total billed charges,225.22,75,,,percent of total billed charges,75% of total billed charges,32.9,100,,,Fee Schedule,100% of CMS OPPS Rate,67.34,100,,,Fee Schedule,100% of WV Medicaid Rate,54.29,165,,,Fee Schedule,165% of CMS OPPS Rate,34.1,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,94.51,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,129.62,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,162.36,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,67.34,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,32.9,100,,,Fee Schedule,100% of CMS OPPS Rate,34.1,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,42.04,14,,,percent of total billed charges,14% of total billed charges,32.9,225.22,
93284- ICD eval/test/program/mult lead,3430973,CDM,480,RC,93284,HCPCS,Outpatient,,,309.62,154.81,,232.22,75,,,percent of total billed charges,75% of total billed charges,232.22,75,,,percent of total billed charges,75% of total billed charges,32.9,100,,,Fee Schedule,100% of CMS OPPS Rate,72.51,100,,,Fee Schedule,100% of WV Medicaid Rate,54.29,165,,,Fee Schedule,165% of CMS OPPS Rate,34.1,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,94.51,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,129.62,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,162.36,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,72.51,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,32.9,100,,,Fee Schedule,100% of CMS OPPS Rate,34.1,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,43.35,14,,,percent of total billed charges,14% of total billed charges,32.9,232.22,
93285- ILR eval/test/program,3430974,CDM,480,RC,93285,HCPCS,Outpatient,,,240.36,120.18,,180.27,75,,,percent of total billed charges,75% of total billed charges,180.27,75,,,percent of total billed charges,75% of total billed charges,32.9,100,,,Fee Schedule,100% of CMS OPPS Rate,41.29,100,,,Fee Schedule,100% of WV Medicaid Rate,54.29,165,,,Fee Schedule,165% of CMS OPPS Rate,34.1,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,94.51,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,129.62,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,162.36,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,41.29,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,32.9,100,,,Fee Schedule,100% of CMS OPPS Rate,34.1,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,33.65,14,,,percent of total billed charges,14% of total billed charges,32.9,180.27,
Pre/Post MRI Defibrillator Interrogation,4231187,CDM,480,RC,93287,HCPCS,Outpatient,,,46.72,23.36,,35.04,75,,,percent of total billed charges,75% of total billed charges,35.04,75,,,percent of total billed charges,75% of total billed charges,14.95,32,,,percent of total billed charges,32% of total billed charges,36.61,100,,,Fee Schedule,100% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.61,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.54,14,,,percent of total billed charges,14% of total billed charges,6.54,36.61,
93288 - Interrogation Eval in Person 1/Dual/Mlt Lead Pm,3430977,CDM,480,RC,93288,HCPCS,Outpatient,,,230.77,115.39,,173.08,75,,,percent of total billed charges,75% of total billed charges,173.08,75,,,percent of total billed charges,75% of total billed charges,32.9,100,,,Fee Schedule,100% of CMS OPPS Rate,38.34,100,,,Fee Schedule,100% of WV Medicaid Rate,54.29,165,,,Fee Schedule,165% of CMS OPPS Rate,34.1,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,94.51,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,129.62,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,162.36,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,38.34,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,32.9,100,,,Fee Schedule,100% of CMS OPPS Rate,34.1,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,32.31,14,,,percent of total billed charges,14% of total billed charges,32.31,173.08,
93289- ICD interr/in person/sng/dual/mult,3430978,CDM,480,RC,93289,HCPCS,Outpatient,,,262.02,131.01,,196.52,75,,,percent of total billed charges,75% of total billed charges,196.52,75,,,percent of total billed charges,75% of total billed charges,32.9,100,,,Fee Schedule,100% of CMS OPPS Rate,49.65,100,,,Fee Schedule,100% of WV Medicaid Rate,54.29,165,,,Fee Schedule,165% of CMS OPPS Rate,34.1,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,94.51,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,129.62,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,162.36,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,49.65,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,32.9,100,,,Fee Schedule,100% of CMS OPPS Rate,34.1,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,36.68,14,,,percent of total billed charges,14% of total billed charges,32.9,196.52,
ICD Generator Testing,3427177,CDM,480,RC,93289,HCPCS,Outpatient,,,262.02,131.01,,196.52,75,,,percent of total billed charges,75% of total billed charges,196.52,75,,,percent of total billed charges,75% of total billed charges,32.9,100,,,Fee Schedule,100% of CMS OPPS Rate,49.65,100,,,Fee Schedule,100% of WV Medicaid Rate,54.29,165,,,Fee Schedule,165% of CMS OPPS Rate,34.1,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,94.51,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,129.62,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,162.36,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,49.65,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,32.9,100,,,Fee Schedule,100% of CMS OPPS Rate,34.1,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,36.68,14,,,percent of total billed charges,14% of total billed charges,32.9,196.52,
93291- Internal loop rec/interr/in person,3430980,CDM,480,RC,93291,HCPCS,Outpatient,,,185.34,92.67,,139.01,75,,,percent of total billed charges,75% of total billed charges,139.01,75,,,percent of total billed charges,75% of total billed charges,23.46,100,,,Fee Schedule,100% of CMS OPPS Rate,33.43,100,,,Fee Schedule,100% of WV Medicaid Rate,38.71,165,,,Fee Schedule,165% of CMS OPPS Rate,24.32,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,67.4,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,92.43,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,115.79,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,33.43,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,23.46,100,,,Fee Schedule,100% of CMS OPPS Rate,24.32,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,25.95,14,,,percent of total billed charges,14% of total billed charges,23.46,139.01,
93296- PM remote trans/90 day/tech review,3430985,CDM,480,RC,93296,HCPCS,Outpatient,,,229.06,114.53,,171.8,75,,,percent of total billed charges,75% of total billed charges,171.8,75,,,percent of total billed charges,75% of total billed charges,32.9,100,,,Fee Schedule,100% of CMS OPPS Rate,14.5,100,,,Fee Schedule,100% of WV Medicaid Rate,54.29,165,,,Fee Schedule,165% of CMS OPPS Rate,34.1,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,94.51,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,129.62,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,162.36,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,14.5,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,32.9,100,,,Fee Schedule,100% of CMS OPPS Rate,34.1,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,32.07,14,,,percent of total billed charges,14% of total billed charges,14.5,171.8,
93306- TTE/2D/M-mode/spec dop/color flow,3430992,CDM,483,RC,93306,HCPCS,Outpatient,,,2922.33,1461.17,,2191.75,75,,,percent of total billed charges,75% of total billed charges,2191.75,75,,,percent of total billed charges,75% of total billed charges,473.01,100,,,Fee Schedule,100% of CMS OPPS Rate,130.52,100,,,Fee Schedule,100% of WV Medicaid Rate,780.48,165,,,Fee Schedule,165% of CMS OPPS Rate,490.24,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1358.69,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1863.34,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,2334.03,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,130.52,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,473.01,100,,,Fee Schedule,100% of CMS OPPS Rate,490.24,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,409.13,14,,,percent of total billed charges,14% of total billed charges,130.52,2334.03,
CL Adult Echocardiogram,3334933,CDM,483,RC,93306,HCPCS,Outpatient,,,2922.33,1461.17,,2191.75,75,,,percent of total billed charges,75% of total billed charges,2191.75,75,,,percent of total billed charges,75% of total billed charges,473.01,100,,,Fee Schedule,100% of CMS OPPS Rate,130.52,100,,,Fee Schedule,100% of WV Medicaid Rate,780.48,165,,,Fee Schedule,165% of CMS OPPS Rate,490.24,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1358.69,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1863.34,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,2334.03,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,130.52,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,473.01,100,,,Fee Schedule,100% of CMS OPPS Rate,490.24,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,409.13,14,,,percent of total billed charges,14% of total billed charges,130.52,2334.03,
Echocardiogram,604555,CDM,483,RC,93306,HCPCS,Outpatient,,,2922.33,1461.17,,2191.75,75,,,percent of total billed charges,75% of total billed charges,2191.75,75,,,percent of total billed charges,75% of total billed charges,473.01,100,,,Fee Schedule,100% of CMS OPPS Rate,130.52,100,,,Fee Schedule,100% of WV Medicaid Rate,780.48,165,,,Fee Schedule,165% of CMS OPPS Rate,490.24,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1358.69,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1863.34,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,2334.03,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,130.52,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,473.01,100,,,Fee Schedule,100% of CMS OPPS Rate,490.24,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,409.13,14,,,percent of total billed charges,14% of total billed charges,130.52,2334.03,
MCNH Echo Transthoracic Complete,3805223,CDM,483,RC,93306,HCPCS,Outpatient,,,2922.33,1461.17,,2191.75,75,,,percent of total billed charges,75% of total billed charges,2191.75,75,,,percent of total billed charges,75% of total billed charges,473.01,100,,,Fee Schedule,100% of CMS OPPS Rate,130.52,100,,,Fee Schedule,100% of WV Medicaid Rate,780.48,165,,,Fee Schedule,165% of CMS OPPS Rate,490.24,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1358.69,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1863.34,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,2334.03,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,130.52,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,473.01,100,,,Fee Schedule,100% of CMS OPPS Rate,490.24,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,409.13,14,,,percent of total billed charges,14% of total billed charges,130.52,2334.03,
93308- TTE/2D/M-mode/follow-up/limited  (GLOBAL),3430994,CDM,483,RC,93308,HCPCS,Outpatient,,,1286.81,643.41,,965.11,75,,,percent of total billed charges,75% of total billed charges,965.11,75,,,percent of total billed charges,75% of total billed charges,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,64.15,100,,,Fee Schedule,100% of WV Medicaid Rate,362.24,165,,,Fee Schedule,165% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,630.61,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,864.84,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1083.29,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,64.15,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,180.15,14,,,percent of total billed charges,14% of total billed charges,64.15,1083.29,
CL Limited Echocardiogram,3334936,CDM,483,RC,93308,HCPCS,Outpatient,,,1286.81,643.41,,965.11,75,,,percent of total billed charges,75% of total billed charges,965.11,75,,,percent of total billed charges,75% of total billed charges,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,64.15,100,,,Fee Schedule,100% of WV Medicaid Rate,362.24,165,,,Fee Schedule,165% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,630.61,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,864.84,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1083.29,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,64.15,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,180.15,14,,,percent of total billed charges,14% of total billed charges,64.15,1083.29,
Dobutamine Valve Study,4179565,CDM,483,RC,93308,HCPCS,Outpatient,,,1286.81,643.41,,965.11,75,,,percent of total billed charges,75% of total billed charges,965.11,75,,,percent of total billed charges,75% of total billed charges,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,64.15,100,,,Fee Schedule,100% of WV Medicaid Rate,362.24,165,,,Fee Schedule,165% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,630.61,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,864.84,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1083.29,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,64.15,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,180.15,14,,,percent of total billed charges,14% of total billed charges,64.15,1083.29,
Limited Study-Echo,645295,CDM,483,RC,93308,HCPCS,Outpatient,,,1286.81,643.41,,965.11,75,,,percent of total billed charges,75% of total billed charges,965.11,75,,,percent of total billed charges,75% of total billed charges,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,64.15,100,,,Fee Schedule,100% of WV Medicaid Rate,362.24,165,,,Fee Schedule,165% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,630.61,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,864.84,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1083.29,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,64.15,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,180.15,14,,,percent of total billed charges,14% of total billed charges,64.15,1083.29,
93321- Dop echo/pulse/cont wave/spec/lim,3431005,CDM,483,RC,93321,HCPCS,Outpatient,,,494.73,247.37,,371.05,75,,,percent of total billed charges,75% of total billed charges,371.05,75,,,percent of total billed charges,75% of total billed charges,158.31,32,,,percent of total billed charges,32% of total billed charges,16.47,100,,,Fee Schedule,100% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.47,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,69.26,14,,,percent of total billed charges,14% of total billed charges,16.47,371.05,
93321 Doppler echo pulsed wave,4061246,CDM,483,RC,93321,HCPCS,Outpatient,,,494.73,247.37,,371.05,75,,,percent of total billed charges,75% of total billed charges,371.05,75,,,percent of total billed charges,75% of total billed charges,158.31,32,,,percent of total billed charges,32% of total billed charges,16.47,100,,,Fee Schedule,100% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.47,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,69.26,14,,,percent of total billed charges,14% of total billed charges,16.47,371.05,
93325 Doppler echo color flow,4061247,CDM,483,RC,93325,HCPCS,Outpatient,,,517.98,258.99,,388.49,75,,,percent of total billed charges,75% of total billed charges,388.49,75,,,percent of total billed charges,75% of total billed charges,165.75,32,,,percent of total billed charges,32% of total billed charges,15.24,100,,,Fee Schedule,100% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.24,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72.52,14,,,percent of total billed charges,14% of total billed charges,15.24,388.49,
93325- Doppler echo color flow,3431006,CDM,483,RC,93325,HCPCS,Outpatient,,,517.98,258.99,,388.49,75,,,percent of total billed charges,75% of total billed charges,388.49,75,,,percent of total billed charges,75% of total billed charges,165.75,32,,,percent of total billed charges,32% of total billed charges,15.24,100,,,Fee Schedule,100% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.24,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72.52,14,,,percent of total billed charges,14% of total billed charges,15.24,388.49,
Color Flow Mapping,604586,CDM,483,RC,93325,HCPCS,Outpatient,,,517.98,258.99,,388.49,75,,,percent of total billed charges,75% of total billed charges,388.49,75,,,percent of total billed charges,75% of total billed charges,165.75,32,,,percent of total billed charges,32% of total billed charges,15.24,100,,,Fee Schedule,100% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.24,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72.52,14,,,percent of total billed charges,14% of total billed charges,15.24,388.49,
93350 (26)- Stress Echo w/ I&R (PRO FEE),3431007,CDM,483,RC,93350,HCPCS,Outpatient,,,2922.33,1461.17,,2191.75,75,,,percent of total billed charges,75% of total billed charges,2191.75,75,,,percent of total billed charges,75% of total billed charges,473.01,100,,,Fee Schedule,100% of CMS OPPS Rate,124.13,100,,,Fee Schedule,100% of WV Medicaid Rate,780.48,165,,,Fee Schedule,165% of CMS OPPS Rate,490.24,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1358.69,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1863.34,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,2334.03,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,124.13,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,473.01,100,,,Fee Schedule,100% of CMS OPPS Rate,490.24,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,409.13,14,,,percent of total billed charges,14% of total billed charges,124.13,2334.03,
93350- Stress echo/2D/M-mode/I&R,3431008,CDM,483,RC,93350,HCPCS,Outpatient,,,2922.33,1461.17,,2191.75,75,,,percent of total billed charges,75% of total billed charges,2191.75,75,,,percent of total billed charges,75% of total billed charges,473.01,100,,,Fee Schedule,100% of CMS OPPS Rate,124.13,100,,,Fee Schedule,100% of WV Medicaid Rate,780.48,165,,,Fee Schedule,165% of CMS OPPS Rate,490.24,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1358.69,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1863.34,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,2334.03,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,124.13,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,473.01,100,,,Fee Schedule,100% of CMS OPPS Rate,490.24,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,409.13,14,,,percent of total billed charges,14% of total billed charges,124.13,2334.03,
CL Exercise Stress Echocardiogram,3334934,CDM,483,RC,93350,HCPCS,Outpatient,,,2922.33,1461.17,,2191.75,75,,,percent of total billed charges,75% of total billed charges,2191.75,75,,,percent of total billed charges,75% of total billed charges,473.01,100,,,Fee Schedule,100% of CMS OPPS Rate,124.13,100,,,Fee Schedule,100% of WV Medicaid Rate,780.48,165,,,Fee Schedule,165% of CMS OPPS Rate,490.24,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1358.69,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1863.34,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,2334.03,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,124.13,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,473.01,100,,,Fee Schedule,100% of CMS OPPS Rate,490.24,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,409.13,14,,,percent of total billed charges,14% of total billed charges,124.13,2334.03,
CVS Charge Stress Echo,1157011,CDM,483,RC,93350,HCPCS,Outpatient,,,2922.33,1461.17,,2191.75,75,,,percent of total billed charges,75% of total billed charges,2191.75,75,,,percent of total billed charges,75% of total billed charges,473.01,100,,,Fee Schedule,100% of CMS OPPS Rate,124.13,100,,,Fee Schedule,100% of WV Medicaid Rate,780.48,165,,,Fee Schedule,165% of CMS OPPS Rate,490.24,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1358.69,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1863.34,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,2334.03,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,124.13,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,473.01,100,,,Fee Schedule,100% of CMS OPPS Rate,490.24,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,409.13,14,,,percent of total billed charges,14% of total billed charges,124.13,2334.03,
Stress Echocardiogram,604568,CDM,483,RC,93350,HCPCS,Outpatient,,,2922.33,1461.17,,2191.75,75,,,percent of total billed charges,75% of total billed charges,2191.75,75,,,percent of total billed charges,75% of total billed charges,473.01,100,,,Fee Schedule,100% of CMS OPPS Rate,124.13,100,,,Fee Schedule,100% of WV Medicaid Rate,780.48,165,,,Fee Schedule,165% of CMS OPPS Rate,490.24,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1358.69,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1863.34,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,2334.03,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,124.13,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,473.01,100,,,Fee Schedule,100% of CMS OPPS Rate,490.24,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,409.13,14,,,percent of total billed charges,14% of total billed charges,124.13,2334.03,
93352- Echo contrast w/stress echo,3431010,CDM,510,RC,93352,HCPCS,Outpatient,,,81.26,40.63,,60.95,75,,,percent of total billed charges,75% of total billed charges,60.95,75,,,percent of total billed charges,75% of total billed charges,26,32,,,percent of total billed charges,32% of total billed charges,21.63,100,,,Fee Schedule,100% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.63,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.38,14,,,percent of total billed charges,14% of total billed charges,11.38,60.95,
Myocardial Strain Imaging,3824895,CDM,483,RC,93356,HCPCS,Outpatient,,,214.77,107.39,,161.08,75,,,percent of total billed charges,75% of total billed charges,161.08,75,,,percent of total billed charges,75% of total billed charges,68.73,32,,,percent of total billed charges,32% of total billed charges,8.36,100,,,Fee Schedule,100% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.36,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.07,14,,,percent of total billed charges,14% of total billed charges,8.36,161.08,
Coronary Angiography,604572,CDM,480,RC,93454,HCPCS,Outpatient,,,16943.16,8471.58,,12707.37,75,,,percent of total billed charges,75% of total billed charges,12707.37,75,,,percent of total billed charges,75% of total billed charges,2781.44,100,,,Fee Schedule,100% of CMS OPPS Rate,614.5,100,,,Fee Schedule,100% of WV Medicaid Rate,4589.37,165,,,Fee Schedule,165% of CMS OPPS Rate,2882.73,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,7989.31,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,10956.7,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13724.38,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,614.5,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2781.44,100,,,Fee Schedule,100% of CMS OPPS Rate,2882.73,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,2372.04,14,,,percent of total billed charges,14% of total billed charges,614.5,13724.38,
AV Nodal Ablation,3427172,CDM,480,RC,93650,HCPCS,Outpatient,,,38904,19452,,29178,75,,,percent of total billed charges,75% of total billed charges,29178,75,,,percent of total billed charges,75% of total billed charges,6329.89,100,,,Fee Schedule,100% of CMS OPPS Rate,420.81,100,,,Fee Schedule,100% of WV Medicaid Rate,10444.33,165,,,Fee Schedule,165% of CMS OPPS Rate,6560.4,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,18181.77,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,24934.86,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,31233.45,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,420.81,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,6329.89,100,,,Fee Schedule,100% of CMS OPPS Rate,6560.4,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,5446.56,14,,,percent of total billed charges,14% of total billed charges,420.81,31233.45,
AV Node Ablation,651265,CDM,480,RC,93650,HCPCS,Outpatient,,,38904,19452,,29178,75,,,percent of total billed charges,75% of total billed charges,29178,75,,,percent of total billed charges,75% of total billed charges,6329.89,100,,,Fee Schedule,100% of CMS OPPS Rate,420.81,100,,,Fee Schedule,100% of WV Medicaid Rate,10444.33,165,,,Fee Schedule,165% of CMS OPPS Rate,6560.4,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,18181.77,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,24934.86,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,31233.45,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,420.81,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,6329.89,100,,,Fee Schedule,100% of CMS OPPS Rate,6560.4,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,5446.56,14,,,percent of total billed charges,14% of total billed charges,420.81,31233.45,
93799 - Unlisted cardiovascular service or procedure,3783249,CDM,481,RC,93799,HCPCS,Outpatient,,,151.54,75.77,,113.66,75,,,percent of total billed charges,75% of total billed charges,113.66,75,,,percent of total billed charges,75% of total billed charges,136.72,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,225.58,165,,,Fee Schedule,165% of CMS OPPS Rate,141.69,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,392.72,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,538.59,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,674.64,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,136.72,100,,,Fee Schedule,100% of CMS OPPS Rate,141.69,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,21.22,14,,,percent of total billed charges,14% of total billed charges,21.22,674.64,
93880 - (TC) Duplex scan of extracranial arteries; complete,3898960,CDM,510,RC,93880,HCPCS,Outpatient,,,1237.39,618.7,,928.04,75,,,percent of total billed charges,75% of total billed charges,928.04,75,,,percent of total billed charges,75% of total billed charges,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,125.11,100,,,Fee Schedule,100% of WV Medicaid Rate,362.24,165,,,Fee Schedule,165% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,630.61,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,864.84,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1083.29,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,125.11,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,173.23,14,,,percent of total billed charges,14% of total billed charges,125.11,1083.29,
93880 - Duplex scan of extracranial arteries; complete bilat,3898967,CDM,510,RC,93880,HCPCS,Outpatient,,,1314.37,657.19,,985.78,75,,,percent of total billed charges,75% of total billed charges,985.78,75,,,percent of total billed charges,75% of total billed charges,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,125.11,100,,,Fee Schedule,100% of WV Medicaid Rate,362.24,165,,,Fee Schedule,165% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,630.61,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,864.84,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1083.29,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,125.11,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,184.01,14,,,percent of total billed charges,14% of total billed charges,125.11,1083.29,
93880-(TC)-Dup scan/extracran art/bilat/comp,3435542,CDM,921,RC,93880,HCPCS,Outpatient,,,1237.39,618.7,,928.04,75,,,percent of total billed charges,75% of total billed charges,928.04,75,,,percent of total billed charges,75% of total billed charges,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,125.11,100,,,Fee Schedule,100% of WV Medicaid Rate,362.24,165,,,Fee Schedule,165% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,630.61,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,864.84,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1083.29,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,125.11,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,173.23,14,,,percent of total billed charges,14% of total billed charges,125.11,1083.29,
CL Carotid Duplex Complete BILAT,3427518,CDM,921,RC,93880,HCPCS,Outpatient,,,1314.37,657.19,,985.78,75,,,percent of total billed charges,75% of total billed charges,985.78,75,,,percent of total billed charges,75% of total billed charges,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,125.11,100,,,Fee Schedule,100% of WV Medicaid Rate,362.24,165,,,Fee Schedule,165% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,630.61,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,864.84,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1083.29,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,125.11,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,184.01,14,,,percent of total billed charges,14% of total billed charges,125.11,1083.29,
CL Carotid Duplex Complete LT,3427513,CDM,921,RC,93880,HCPCS,Outpatient,,,1314.37,657.19,,985.78,75,,,percent of total billed charges,75% of total billed charges,985.78,75,,,percent of total billed charges,75% of total billed charges,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,125.11,100,,,Fee Schedule,100% of WV Medicaid Rate,362.24,165,,,Fee Schedule,165% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,630.61,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,864.84,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1083.29,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,125.11,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,184.01,14,,,percent of total billed charges,14% of total billed charges,125.11,1083.29,
CL Carotid Duplex Complete RT,3427515,CDM,921,RC,93880,HCPCS,Outpatient,,,1314.37,657.19,,985.78,75,,,percent of total billed charges,75% of total billed charges,985.78,75,,,percent of total billed charges,75% of total billed charges,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,125.11,100,,,Fee Schedule,100% of WV Medicaid Rate,362.24,165,,,Fee Schedule,165% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,630.61,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,864.84,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1083.29,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,125.11,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,184.01,14,,,percent of total billed charges,14% of total billed charges,125.11,1083.29,
SCMP US Carotid,3370902,CDM,921,RC,93880,HCPCS,Outpatient,,,1237.39,618.7,,928.04,75,,,percent of total billed charges,75% of total billed charges,928.04,75,,,percent of total billed charges,75% of total billed charges,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,125.11,100,,,Fee Schedule,100% of WV Medicaid Rate,362.24,165,,,Fee Schedule,165% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,630.61,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,864.84,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1083.29,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,125.11,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,173.23,14,,,percent of total billed charges,14% of total billed charges,125.11,1083.29,
SCMP US Carotid,3575234,CDM,921,RC,93880,HCPCS,Outpatient,,,1237.39,618.7,,928.04,75,,,percent of total billed charges,75% of total billed charges,928.04,75,,,percent of total billed charges,75% of total billed charges,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,125.11,100,,,Fee Schedule,100% of WV Medicaid Rate,362.24,165,,,Fee Schedule,165% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,630.61,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,864.84,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1083.29,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,125.11,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,173.23,14,,,percent of total billed charges,14% of total billed charges,125.11,1083.29,
SCSN US Carotid Duplex,3370940,CDM,921,RC,93880,HCPCS,Outpatient,,,1237.39,618.7,,928.04,75,,,percent of total billed charges,75% of total billed charges,928.04,75,,,percent of total billed charges,75% of total billed charges,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,125.11,100,,,Fee Schedule,100% of WV Medicaid Rate,362.24,165,,,Fee Schedule,165% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,630.61,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,864.84,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1083.29,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,125.11,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,173.23,14,,,percent of total billed charges,14% of total billed charges,125.11,1083.29,
SCSN US Exam,3575288,CDM,921,RC,93880,HCPCS,Outpatient,,,1237.39,618.7,,928.04,75,,,percent of total billed charges,75% of total billed charges,928.04,75,,,percent of total billed charges,75% of total billed charges,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,125.11,100,,,Fee Schedule,100% of WV Medicaid Rate,362.24,165,,,Fee Schedule,165% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,630.61,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,864.84,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1083.29,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,125.11,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,173.23,14,,,percent of total billed charges,14% of total billed charges,125.11,1083.29,
93882- Dup scan/extracran art/unilat/ltd,3435543,CDM,921,RC,93882,HCPCS,Outpatient,,,603.81,301.91,,452.86,75,,,percent of total billed charges,75% of total billed charges,452.86,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,82.1,100,,,Fee Schedule,100% of WV Medicaid Rate,165.79,165,,,Fee Schedule,165% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.82,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,82.1,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,84.53,14,,,percent of total billed charges,14% of total billed charges,82.1,495.81,
CL Carotid Duplex Limited BILAT,3427517,CDM,921,RC,93882,HCPCS,Outpatient,,,603.81,301.91,,452.86,75,,,percent of total billed charges,75% of total billed charges,452.86,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,82.1,100,,,Fee Schedule,100% of WV Medicaid Rate,165.79,165,,,Fee Schedule,165% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.82,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,82.1,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,84.53,14,,,percent of total billed charges,14% of total billed charges,82.1,495.81,
CL Carotid Duplex Limited LT,3427514,CDM,921,RC,93882,HCPCS,Outpatient,,,603.81,301.91,,452.86,75,,,percent of total billed charges,75% of total billed charges,452.86,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,82.1,100,,,Fee Schedule,100% of WV Medicaid Rate,165.79,165,,,Fee Schedule,165% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.82,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,82.1,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,84.53,14,,,percent of total billed charges,14% of total billed charges,82.1,495.81,
CL Carotid Duplex Limited RT,3427516,CDM,921,RC,93882,HCPCS,Outpatient,,,603.81,301.91,,452.86,75,,,percent of total billed charges,75% of total billed charges,452.86,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,82.1,100,,,Fee Schedule,100% of WV Medicaid Rate,165.79,165,,,Fee Schedule,165% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.82,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,82.1,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,84.53,14,,,percent of total billed charges,14% of total billed charges,82.1,495.81,
CL Limited Carotid Post Procedure BILAT,3427524,CDM,921,RC,93882,HCPCS,Outpatient,,,603.81,301.91,,452.86,75,,,percent of total billed charges,75% of total billed charges,452.86,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,82.1,100,,,Fee Schedule,100% of WV Medicaid Rate,165.79,165,,,Fee Schedule,165% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.82,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,82.1,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,84.53,14,,,percent of total billed charges,14% of total billed charges,82.1,495.81,
CL Limited Carotid Post Procedure LT,3427522,CDM,921,RC,93882,HCPCS,Outpatient,,,603.81,301.91,,452.86,75,,,percent of total billed charges,75% of total billed charges,452.86,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,82.1,100,,,Fee Schedule,100% of WV Medicaid Rate,165.79,165,,,Fee Schedule,165% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.82,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,82.1,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,84.53,14,,,percent of total billed charges,14% of total billed charges,82.1,495.81,
CL Limited Carotid Post Procedure RT,3427523,CDM,921,RC,93882,HCPCS,Outpatient,,,603.81,301.91,,452.86,75,,,percent of total billed charges,75% of total billed charges,452.86,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,82.1,100,,,Fee Schedule,100% of WV Medicaid Rate,165.79,165,,,Fee Schedule,165% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.82,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,82.1,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,84.53,14,,,percent of total billed charges,14% of total billed charges,82.1,495.81,
93922 Non-Invas Physiologic STD Extremity Art 2 Level,3436059,CDM,761,RC,93922,HCPCS,Outpatient,,,165.33,82.67,,124,75,,,percent of total billed charges,75% of total billed charges,124,75,,,percent of total billed charges,75% of total billed charges,109.16,100,,,Fee Schedule,100% of CMS OPPS Rate,52.85,100,,,Fee Schedule,100% of WV Medicaid Rate,180.11,165,,,Fee Schedule,165% of CMS OPPS Rate,113.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,313.55,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,430.01,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,538.63,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,52.85,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,109.16,100,,,Fee Schedule,100% of CMS OPPS Rate,113.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,23.15,14,,,percent of total billed charges,14% of total billed charges,23.15,538.63,
93922-CL US Lower Extrem Art Limited BILAT,3432069,CDM,921,RC,93922,HCPCS,Outpatient,,,165.33,82.67,,124,75,,,percent of total billed charges,75% of total billed charges,124,75,,,percent of total billed charges,75% of total billed charges,109.16,100,,,Fee Schedule,100% of CMS OPPS Rate,52.85,100,,,Fee Schedule,100% of WV Medicaid Rate,180.11,165,,,Fee Schedule,165% of CMS OPPS Rate,113.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,313.55,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,430.01,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,538.63,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,52.85,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,109.16,100,,,Fee Schedule,100% of CMS OPPS Rate,113.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,23.15,14,,,percent of total billed charges,14% of total billed charges,23.15,538.63,
93922-CL US Lower Extrem Art Limited RT,3432070,CDM,921,RC,93922,HCPCS,Outpatient,,,165.33,82.67,,124,75,,,percent of total billed charges,75% of total billed charges,124,75,,,percent of total billed charges,75% of total billed charges,109.16,100,,,Fee Schedule,100% of CMS OPPS Rate,52.85,100,,,Fee Schedule,100% of WV Medicaid Rate,180.11,165,,,Fee Schedule,165% of CMS OPPS Rate,113.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,313.55,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,430.01,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,538.63,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,52.85,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,109.16,100,,,Fee Schedule,100% of CMS OPPS Rate,113.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,23.15,14,,,percent of total billed charges,14% of total billed charges,23.15,538.63,
93922-CL US Lower Extrem Arterial Limited LT,3432071,CDM,921,RC,93922,HCPCS,Outpatient,,,165.33,82.67,,124,75,,,percent of total billed charges,75% of total billed charges,124,75,,,percent of total billed charges,75% of total billed charges,109.16,100,,,Fee Schedule,100% of CMS OPPS Rate,52.85,100,,,Fee Schedule,100% of WV Medicaid Rate,180.11,165,,,Fee Schedule,165% of CMS OPPS Rate,113.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,313.55,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,430.01,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,538.63,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,52.85,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,109.16,100,,,Fee Schedule,100% of CMS OPPS Rate,113.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,23.15,14,,,percent of total billed charges,14% of total billed charges,23.15,538.63,
SCSN US Duplex Scan,3370943,CDM,510,RC,93922,HCPCS,Outpatient,,,645.06,322.53,,483.8,75,,,percent of total billed charges,75% of total billed charges,483.8,75,,,percent of total billed charges,75% of total billed charges,109.16,100,,,Fee Schedule,100% of CMS OPPS Rate,52.85,100,,,Fee Schedule,100% of WV Medicaid Rate,180.11,165,,,Fee Schedule,165% of CMS OPPS Rate,113.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,313.55,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,430.01,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,538.63,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,52.85,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,109.16,100,,,Fee Schedule,100% of CMS OPPS Rate,113.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,90.31,14,,,percent of total billed charges,14% of total billed charges,52.85,538.63,
93923 - (TC) Non-Invasive Physiologic Study Extremity 3 Lvls,3897039,CDM,510,RC,93923,HCPCS,Outpatient,,,788.8,394.4,,591.6,75,,,percent of total billed charges,75% of total billed charges,591.6,75,,,percent of total billed charges,75% of total billed charges,136.72,100,,,Fee Schedule,100% of CMS OPPS Rate,83.33,100,,,Fee Schedule,100% of WV Medicaid Rate,225.58,165,,,Fee Schedule,165% of CMS OPPS Rate,141.69,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,392.72,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,538.59,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,674.64,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,83.33,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,136.72,100,,,Fee Schedule,100% of CMS OPPS Rate,141.69,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,110.43,14,,,percent of total billed charges,14% of total billed charges,83.33,674.64,
93923 - Non-Invasive Physiologic Study Extremity 3 Lvls,3897046,CDM,510,RC,93923,HCPCS,Outpatient,,,833.36,416.68,,625.02,75,,,percent of total billed charges,75% of total billed charges,625.02,75,,,percent of total billed charges,75% of total billed charges,136.72,100,,,Fee Schedule,100% of CMS OPPS Rate,83.33,100,,,Fee Schedule,100% of WV Medicaid Rate,225.58,165,,,Fee Schedule,165% of CMS OPPS Rate,141.69,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,392.72,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,538.59,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,674.64,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,83.33,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,136.72,100,,,Fee Schedule,100% of CMS OPPS Rate,141.69,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,116.67,14,,,percent of total billed charges,14% of total billed charges,83.33,674.64,
93923- Upr/lxtr art stdy 3+ lvls,3430796,CDM,920,RC,93923,HCPCS,Outpatient,,,833.36,416.68,,625.02,75,,,percent of total billed charges,75% of total billed charges,625.02,75,,,percent of total billed charges,75% of total billed charges,136.72,100,,,Fee Schedule,100% of CMS OPPS Rate,83.33,100,,,Fee Schedule,100% of WV Medicaid Rate,225.58,165,,,Fee Schedule,165% of CMS OPPS Rate,141.69,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,392.72,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,538.59,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,674.64,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,83.33,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,136.72,100,,,Fee Schedule,100% of CMS OPPS Rate,141.69,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,116.67,14,,,percent of total billed charges,14% of total billed charges,83.33,674.64,
CL Lower Extrem Art Physiologic BILAT,3427525,CDM,921,RC,93923,HCPCS,Outpatient,,,833.36,416.68,,625.02,75,,,percent of total billed charges,75% of total billed charges,625.02,75,,,percent of total billed charges,75% of total billed charges,136.72,100,,,Fee Schedule,100% of CMS OPPS Rate,83.33,100,,,Fee Schedule,100% of WV Medicaid Rate,225.58,165,,,Fee Schedule,165% of CMS OPPS Rate,141.69,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,392.72,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,538.59,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,674.64,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,83.33,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,136.72,100,,,Fee Schedule,100% of CMS OPPS Rate,141.69,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,116.67,14,,,percent of total billed charges,14% of total billed charges,83.33,674.64,
CL Lower Extrem Art Physiologic LT,3427526,CDM,921,RC,93923,HCPCS,Outpatient,,,833.36,416.68,,625.02,75,,,percent of total billed charges,75% of total billed charges,625.02,75,,,percent of total billed charges,75% of total billed charges,136.72,100,,,Fee Schedule,100% of CMS OPPS Rate,83.33,100,,,Fee Schedule,100% of WV Medicaid Rate,225.58,165,,,Fee Schedule,165% of CMS OPPS Rate,141.69,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,392.72,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,538.59,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,674.64,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,83.33,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,136.72,100,,,Fee Schedule,100% of CMS OPPS Rate,141.69,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,116.67,14,,,percent of total billed charges,14% of total billed charges,83.33,674.64,
CL Lower Extrem Art Physiologic RT,3427527,CDM,921,RC,93923,HCPCS,Outpatient,,,833.36,416.68,,625.02,75,,,percent of total billed charges,75% of total billed charges,625.02,75,,,percent of total billed charges,75% of total billed charges,136.72,100,,,Fee Schedule,100% of CMS OPPS Rate,83.33,100,,,Fee Schedule,100% of WV Medicaid Rate,225.58,165,,,Fee Schedule,165% of CMS OPPS Rate,141.69,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,392.72,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,538.59,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,674.64,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,83.33,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,136.72,100,,,Fee Schedule,100% of CMS OPPS Rate,141.69,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,116.67,14,,,percent of total billed charges,14% of total billed charges,83.33,674.64,
CL Lower Periph Art Duplex wo Exer BILAT,3427532,CDM,921,RC,93923,HCPCS,Outpatient,,,833.36,416.68,,625.02,75,,,percent of total billed charges,75% of total billed charges,625.02,75,,,percent of total billed charges,75% of total billed charges,136.72,100,,,Fee Schedule,100% of CMS OPPS Rate,83.33,100,,,Fee Schedule,100% of WV Medicaid Rate,225.58,165,,,Fee Schedule,165% of CMS OPPS Rate,141.69,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,392.72,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,538.59,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,674.64,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,83.33,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,136.72,100,,,Fee Schedule,100% of CMS OPPS Rate,141.69,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,116.67,14,,,percent of total billed charges,14% of total billed charges,83.33,674.64,
CL Lower Periph Art Duplex wo Exer LT,3427528,CDM,921,RC,93923,HCPCS,Outpatient,,,833.36,416.68,,625.02,75,,,percent of total billed charges,75% of total billed charges,625.02,75,,,percent of total billed charges,75% of total billed charges,136.72,100,,,Fee Schedule,100% of CMS OPPS Rate,83.33,100,,,Fee Schedule,100% of WV Medicaid Rate,225.58,165,,,Fee Schedule,165% of CMS OPPS Rate,141.69,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,392.72,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,538.59,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,674.64,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,83.33,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,136.72,100,,,Fee Schedule,100% of CMS OPPS Rate,141.69,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,116.67,14,,,percent of total billed charges,14% of total billed charges,83.33,674.64,
CL Lower Periph Art Duplex wo Exer RT,3427530,CDM,921,RC,93923,HCPCS,Outpatient,,,833.36,416.68,,625.02,75,,,percent of total billed charges,75% of total billed charges,625.02,75,,,percent of total billed charges,75% of total billed charges,136.72,100,,,Fee Schedule,100% of CMS OPPS Rate,83.33,100,,,Fee Schedule,100% of WV Medicaid Rate,225.58,165,,,Fee Schedule,165% of CMS OPPS Rate,141.69,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,392.72,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,538.59,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,674.64,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,83.33,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,136.72,100,,,Fee Schedule,100% of CMS OPPS Rate,141.69,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,116.67,14,,,percent of total billed charges,14% of total billed charges,83.33,674.64,
CL US Lower Extrem Art Comp w ABI BILAT,3427501,CDM,921,RC,93923,HCPCS,Outpatient,,,833.36,416.68,,625.02,75,,,percent of total billed charges,75% of total billed charges,625.02,75,,,percent of total billed charges,75% of total billed charges,136.72,100,,,Fee Schedule,100% of CMS OPPS Rate,83.33,100,,,Fee Schedule,100% of WV Medicaid Rate,225.58,165,,,Fee Schedule,165% of CMS OPPS Rate,141.69,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,392.72,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,538.59,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,674.64,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,83.33,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,136.72,100,,,Fee Schedule,100% of CMS OPPS Rate,141.69,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,116.67,14,,,percent of total billed charges,14% of total billed charges,83.33,674.64,
CL US Lower Extrem Art Complete LT,3427503,CDM,921,RC,93923,HCPCS,Outpatient,,,833.36,416.68,,625.02,75,,,percent of total billed charges,75% of total billed charges,625.02,75,,,percent of total billed charges,75% of total billed charges,136.72,100,,,Fee Schedule,100% of CMS OPPS Rate,83.33,100,,,Fee Schedule,100% of WV Medicaid Rate,225.58,165,,,Fee Schedule,165% of CMS OPPS Rate,141.69,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,392.72,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,538.59,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,674.64,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,83.33,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,136.72,100,,,Fee Schedule,100% of CMS OPPS Rate,141.69,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,116.67,14,,,percent of total billed charges,14% of total billed charges,83.33,674.64,
CL US Lower Extrem Art Complete RT,3427505,CDM,921,RC,93923,HCPCS,Outpatient,,,833.36,416.68,,625.02,75,,,percent of total billed charges,75% of total billed charges,625.02,75,,,percent of total billed charges,75% of total billed charges,136.72,100,,,Fee Schedule,100% of CMS OPPS Rate,83.33,100,,,Fee Schedule,100% of WV Medicaid Rate,225.58,165,,,Fee Schedule,165% of CMS OPPS Rate,141.69,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,392.72,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,538.59,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,674.64,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,83.33,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,136.72,100,,,Fee Schedule,100% of CMS OPPS Rate,141.69,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,116.67,14,,,percent of total billed charges,14% of total billed charges,83.33,674.64,
SCSN US Arterial w Seg Pressures BILAT,3569747,CDM,920,RC,93923,HCPCS,Outpatient,,,788.8,394.4,,591.6,75,,,percent of total billed charges,75% of total billed charges,591.6,75,,,percent of total billed charges,75% of total billed charges,136.72,100,,,Fee Schedule,100% of CMS OPPS Rate,83.33,100,,,Fee Schedule,100% of WV Medicaid Rate,225.58,165,,,Fee Schedule,165% of CMS OPPS Rate,141.69,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,392.72,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,538.59,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,674.64,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,83.33,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,136.72,100,,,Fee Schedule,100% of CMS OPPS Rate,141.69,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,110.43,14,,,percent of total billed charges,14% of total billed charges,83.33,674.64,
SCSN US Arterial w Seg Pressures BILAT,3569753,CDM,920,RC,93923,HCPCS,Outpatient,,,788.8,394.4,,591.6,75,,,percent of total billed charges,75% of total billed charges,591.6,75,,,percent of total billed charges,75% of total billed charges,136.72,100,,,Fee Schedule,100% of CMS OPPS Rate,83.33,100,,,Fee Schedule,100% of WV Medicaid Rate,225.58,165,,,Fee Schedule,165% of CMS OPPS Rate,141.69,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,392.72,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,538.59,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,674.64,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,83.33,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,136.72,100,,,Fee Schedule,100% of CMS OPPS Rate,141.69,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,110.43,14,,,percent of total billed charges,14% of total billed charges,83.33,674.64,
SCSN US Arterial w Seg Pressures BILAT,3575260,CDM,920,RC,93923,HCPCS,Outpatient,,,788.8,394.4,,591.6,75,,,percent of total billed charges,75% of total billed charges,591.6,75,,,percent of total billed charges,75% of total billed charges,136.72,100,,,Fee Schedule,100% of CMS OPPS Rate,83.33,100,,,Fee Schedule,100% of WV Medicaid Rate,225.58,165,,,Fee Schedule,165% of CMS OPPS Rate,141.69,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,392.72,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,538.59,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,674.64,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,83.33,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,136.72,100,,,Fee Schedule,100% of CMS OPPS Rate,141.69,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,110.43,14,,,percent of total billed charges,14% of total billed charges,83.33,674.64,
93924 - Lwr xtr vasc stdy bilat,3435544,CDM,921,RC,93924,HCPCS,Outpatient,,,837.43,418.72,,628.07,75,,,percent of total billed charges,75% of total billed charges,628.07,75,,,percent of total billed charges,75% of total billed charges,263.29,100,,,Fee Schedule,100% of CMS OPPS Rate,102.5,100,,,Fee Schedule,100% of WV Medicaid Rate,434.44,165,,,Fee Schedule,165% of CMS OPPS Rate,272.88,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,756.29,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1037.2,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1299.2,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,102.5,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,263.29,100,,,Fee Schedule,100% of CMS OPPS Rate,272.88,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,117.24,14,,,percent of total billed charges,14% of total billed charges,102.5,1299.2,
CL Lower Ext Art Physio w Exer BILAT,3569307,CDM,921,RC,93924,HCPCS,Outpatient,,,837.43,418.72,,628.07,75,,,percent of total billed charges,75% of total billed charges,628.07,75,,,percent of total billed charges,75% of total billed charges,263.29,100,,,Fee Schedule,100% of CMS OPPS Rate,102.5,100,,,Fee Schedule,100% of WV Medicaid Rate,434.44,165,,,Fee Schedule,165% of CMS OPPS Rate,272.88,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,756.29,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1037.2,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1299.2,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,102.5,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,263.29,100,,,Fee Schedule,100% of CMS OPPS Rate,272.88,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,117.24,14,,,percent of total billed charges,14% of total billed charges,102.5,1299.2,
CL Lower Periph Art Duplex w Exer BILAT,3427533,CDM,921,RC,93924,HCPCS,Outpatient,,,837.43,418.72,,628.07,75,,,percent of total billed charges,75% of total billed charges,628.07,75,,,percent of total billed charges,75% of total billed charges,263.29,100,,,Fee Schedule,100% of CMS OPPS Rate,102.5,100,,,Fee Schedule,100% of WV Medicaid Rate,434.44,165,,,Fee Schedule,165% of CMS OPPS Rate,272.88,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,756.29,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1037.2,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1299.2,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,102.5,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,263.29,100,,,Fee Schedule,100% of CMS OPPS Rate,272.88,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,117.24,14,,,percent of total billed charges,14% of total billed charges,102.5,1299.2,
CL Lower Periph Art Duplex w Exer LT,3427529,CDM,921,RC,93924,HCPCS,Outpatient,,,837.43,418.72,,628.07,75,,,percent of total billed charges,75% of total billed charges,628.07,75,,,percent of total billed charges,75% of total billed charges,263.29,100,,,Fee Schedule,100% of CMS OPPS Rate,102.5,100,,,Fee Schedule,100% of WV Medicaid Rate,434.44,165,,,Fee Schedule,165% of CMS OPPS Rate,272.88,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,756.29,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1037.2,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1299.2,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,102.5,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,263.29,100,,,Fee Schedule,100% of CMS OPPS Rate,272.88,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,117.24,14,,,percent of total billed charges,14% of total billed charges,102.5,1299.2,
CL Lower Periph Art Duplex w Exer RT,3427531,CDM,921,RC,93924,HCPCS,Outpatient,,,837.43,418.72,,628.07,75,,,percent of total billed charges,75% of total billed charges,628.07,75,,,percent of total billed charges,75% of total billed charges,263.29,100,,,Fee Schedule,100% of CMS OPPS Rate,102.5,100,,,Fee Schedule,100% of WV Medicaid Rate,434.44,165,,,Fee Schedule,165% of CMS OPPS Rate,272.88,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,756.29,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1037.2,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1299.2,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,102.5,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,263.29,100,,,Fee Schedule,100% of CMS OPPS Rate,272.88,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,117.24,14,,,percent of total billed charges,14% of total billed charges,102.5,1299.2,
SCSN US Arterial w Exercise RT Interp,3575270,CDM,920,RC,93924,HCPCS,Outpatient,,,788.8,394.4,,591.6,75,,,percent of total billed charges,75% of total billed charges,591.6,75,,,percent of total billed charges,75% of total billed charges,263.29,100,,,Fee Schedule,100% of CMS OPPS Rate,102.5,100,,,Fee Schedule,100% of WV Medicaid Rate,434.44,165,,,Fee Schedule,165% of CMS OPPS Rate,272.88,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,756.29,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1037.2,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1299.2,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,102.5,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,263.29,100,,,Fee Schedule,100% of CMS OPPS Rate,272.88,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,110.43,14,,,percent of total billed charges,14% of total billed charges,102.5,1299.2,
SCSN US Arterials w Exercise Bilat Interp,3575266,CDM,920,RC,93924,HCPCS,Outpatient,,,788.8,394.4,,591.6,75,,,percent of total billed charges,75% of total billed charges,591.6,75,,,percent of total billed charges,75% of total billed charges,263.29,100,,,Fee Schedule,100% of CMS OPPS Rate,102.5,100,,,Fee Schedule,100% of WV Medicaid Rate,434.44,165,,,Fee Schedule,165% of CMS OPPS Rate,272.88,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,756.29,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1037.2,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1299.2,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,102.5,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,263.29,100,,,Fee Schedule,100% of CMS OPPS Rate,272.88,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,110.43,14,,,percent of total billed charges,14% of total billed charges,102.5,1299.2,
SCSN US Arterials w Exercise LT,3569755,CDM,920,RC,93924,HCPCS,Outpatient,,,788.8,394.4,,591.6,75,,,percent of total billed charges,75% of total billed charges,591.6,75,,,percent of total billed charges,75% of total billed charges,263.29,100,,,Fee Schedule,100% of CMS OPPS Rate,102.5,100,,,Fee Schedule,100% of WV Medicaid Rate,434.44,165,,,Fee Schedule,165% of CMS OPPS Rate,272.88,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,756.29,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1037.2,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1299.2,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,102.5,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,263.29,100,,,Fee Schedule,100% of CMS OPPS Rate,272.88,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,110.43,14,,,percent of total billed charges,14% of total billed charges,102.5,1299.2,
SCSN US Arterials w Exercise LT Interp,3575268,CDM,920,RC,93924,HCPCS,Outpatient,,,788.8,394.4,,591.6,75,,,percent of total billed charges,75% of total billed charges,591.6,75,,,percent of total billed charges,75% of total billed charges,263.29,100,,,Fee Schedule,100% of CMS OPPS Rate,102.5,100,,,Fee Schedule,100% of WV Medicaid Rate,434.44,165,,,Fee Schedule,165% of CMS OPPS Rate,272.88,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,756.29,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1037.2,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1299.2,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,102.5,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,263.29,100,,,Fee Schedule,100% of CMS OPPS Rate,272.88,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,110.43,14,,,percent of total billed charges,14% of total billed charges,102.5,1299.2,
SCSN US Arterials w Exercise RT,3569757,CDM,920,RC,93924,HCPCS,Outpatient,,,788.8,394.4,,591.6,75,,,percent of total billed charges,75% of total billed charges,591.6,75,,,percent of total billed charges,75% of total billed charges,263.29,100,,,Fee Schedule,100% of CMS OPPS Rate,102.5,100,,,Fee Schedule,100% of WV Medicaid Rate,434.44,165,,,Fee Schedule,165% of CMS OPPS Rate,272.88,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,756.29,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1037.2,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1299.2,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,102.5,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,263.29,100,,,Fee Schedule,100% of CMS OPPS Rate,272.88,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,110.43,14,,,percent of total billed charges,14% of total billed charges,102.5,1299.2,
93925 - PF Duplex scan of lower extremity arteries or arterial bypass grafts; complete bilateral stu,3641209,CDM,510,RC,93925,HCPCS,Outpatient,,,488.44,244.22,,366.33,75,,,percent of total billed charges,75% of total billed charges,366.33,75,,,percent of total billed charges,75% of total billed charges,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,157.31,100,,,Fee Schedule,100% of WV Medicaid Rate,362.24,165,,,Fee Schedule,165% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,630.61,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,864.84,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1083.29,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,157.31,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,68.38,14,,,percent of total billed charges,14% of total billed charges,68.38,1083.29,
93925 26 Duplex scan of lower extremity arteries or arteri,3622799,CDM,510,RC,93925,HCPCS,Outpatient,,,488.44,244.22,,366.33,75,,,percent of total billed charges,75% of total billed charges,366.33,75,,,percent of total billed charges,75% of total billed charges,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,157.31,100,,,Fee Schedule,100% of WV Medicaid Rate,362.24,165,,,Fee Schedule,165% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,630.61,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,864.84,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1083.29,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,157.31,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,68.38,14,,,percent of total billed charges,14% of total billed charges,68.38,1083.29,
93925- Dup scan/LE art/graft/bilat/comp,3435545,CDM,921,RC,93925,HCPCS,Outpatient,,,488.44,244.22,,366.33,75,,,percent of total billed charges,75% of total billed charges,366.33,75,,,percent of total billed charges,75% of total billed charges,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,157.31,100,,,Fee Schedule,100% of WV Medicaid Rate,362.24,165,,,Fee Schedule,165% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,630.61,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,864.84,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1083.29,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,157.31,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,68.38,14,,,percent of total billed charges,14% of total billed charges,68.38,1083.29,
93925 TC Duplex scan of lower extremity arteries or arteri,3622802,CDM,510,RC,93925,HCPCS,Outpatient,,,488.44,244.22,,366.33,75,,,percent of total billed charges,75% of total billed charges,366.33,75,,,percent of total billed charges,75% of total billed charges,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,157.31,100,,,Fee Schedule,100% of WV Medicaid Rate,362.24,165,,,Fee Schedule,165% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,630.61,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,864.84,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1083.29,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,157.31,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,68.38,14,,,percent of total billed charges,14% of total billed charges,68.38,1083.29,
93926 - Duplex scan of lower extremity arteries or arterial bypass grafts; unilateral or limited,3620984,CDM,510,RC,93926,HCPCS,Outpatient,,,602.28,301.14,,451.71,75,,,percent of total billed charges,75% of total billed charges,451.71,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,84.58,100,,,Fee Schedule,100% of WV Medicaid Rate,165.79,165,,,Fee Schedule,165% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.82,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,84.58,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,84.32,14,,,percent of total billed charges,14% of total billed charges,84.32,495.81,
93926- Dup scan/LE art/graft/unilat/ltd,3435546,CDM,921,RC,93926,HCPCS,Outpatient,,,602.28,301.14,,451.71,75,,,percent of total billed charges,75% of total billed charges,451.71,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,84.58,100,,,Fee Schedule,100% of WV Medicaid Rate,165.79,165,,,Fee Schedule,165% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.82,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,84.58,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,84.32,14,,,percent of total billed charges,14% of total billed charges,84.32,495.81,
CL Femoral Groin Artery BILAT,3427521,CDM,921,RC,93926,HCPCS,Outpatient,,,602.28,301.14,,451.71,75,,,percent of total billed charges,75% of total billed charges,451.71,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,84.58,100,,,Fee Schedule,100% of WV Medicaid Rate,165.79,165,,,Fee Schedule,165% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.82,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,84.58,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,84.32,14,,,percent of total billed charges,14% of total billed charges,84.32,495.81,
CL Femoral Groin Artery LT,3427519,CDM,921,RC,93926,HCPCS,Outpatient,,,602.28,301.14,,451.71,75,,,percent of total billed charges,75% of total billed charges,451.71,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,84.58,100,,,Fee Schedule,100% of WV Medicaid Rate,165.79,165,,,Fee Schedule,165% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.82,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,84.58,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,84.32,14,,,percent of total billed charges,14% of total billed charges,84.32,495.81,
CL Femoral Groin Artery RT,3427520,CDM,921,RC,93926,HCPCS,Outpatient,,,602.28,301.14,,451.71,75,,,percent of total billed charges,75% of total billed charges,451.71,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,84.58,100,,,Fee Schedule,100% of WV Medicaid Rate,165.79,165,,,Fee Schedule,165% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.82,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,84.58,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,84.32,14,,,percent of total billed charges,14% of total billed charges,84.32,495.81,
SCMP US Exam,3575244,CDM,920,RC,93926,HCPCS,Outpatient,,,555.18,277.59,,416.39,75,,,percent of total billed charges,75% of total billed charges,416.39,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,84.58,100,,,Fee Schedule,100% of WV Medicaid Rate,165.79,165,,,Fee Schedule,165% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.82,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,84.58,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,77.73,14,,,percent of total billed charges,14% of total billed charges,77.73,495.81,
SCMP US Lower Extremity,3370913,CDM,920,RC,93926,HCPCS,Outpatient,,,555.18,277.59,,416.39,75,,,percent of total billed charges,75% of total billed charges,416.39,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,84.58,100,,,Fee Schedule,100% of WV Medicaid Rate,165.79,165,,,Fee Schedule,165% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.82,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,84.58,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,77.73,14,,,percent of total billed charges,14% of total billed charges,77.73,495.81,
SCSN US Arterial w Seg Pressures LT,3569749,CDM,920,RC,93926,HCPCS,Outpatient,,,555.18,277.59,,416.39,75,,,percent of total billed charges,75% of total billed charges,416.39,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,84.58,100,,,Fee Schedule,100% of WV Medicaid Rate,165.79,165,,,Fee Schedule,165% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.82,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,84.58,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,77.73,14,,,percent of total billed charges,14% of total billed charges,77.73,495.81,
SCSN US Arterial w Seg Pressures LT,3575262,CDM,920,RC,93926,HCPCS,Outpatient,,,555.18,277.59,,416.39,75,,,percent of total billed charges,75% of total billed charges,416.39,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,84.58,100,,,Fee Schedule,100% of WV Medicaid Rate,165.79,165,,,Fee Schedule,165% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.82,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,84.58,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,77.73,14,,,percent of total billed charges,14% of total billed charges,77.73,495.81,
SCSN US Arterial w Seg Pressures LT,3575264,CDM,920,RC,93926,HCPCS,Outpatient,,,555.18,277.59,,416.39,75,,,percent of total billed charges,75% of total billed charges,416.39,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,84.58,100,,,Fee Schedule,100% of WV Medicaid Rate,165.79,165,,,Fee Schedule,165% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.82,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,84.58,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,77.73,14,,,percent of total billed charges,14% of total billed charges,77.73,495.81,
SCSN US Arterial w Seg Pressures RT,3569751,CDM,920,RC,93926,HCPCS,Outpatient,,,555.18,277.59,,416.39,75,,,percent of total billed charges,75% of total billed charges,416.39,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,84.58,100,,,Fee Schedule,100% of WV Medicaid Rate,165.79,165,,,Fee Schedule,165% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.82,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,84.58,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,77.73,14,,,percent of total billed charges,14% of total billed charges,77.73,495.81,
93930- Dup scan/UE art/graft/bilat/comp,3435547,CDM,921,RC,93930,HCPCS,Outpatient,,,378.7,189.35,,284.03,75,,,percent of total billed charges,75% of total billed charges,284.03,75,,,percent of total billed charges,75% of total billed charges,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,128.55,100,,,Fee Schedule,100% of WV Medicaid Rate,362.24,165,,,Fee Schedule,165% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,630.61,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,864.84,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1083.29,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,128.55,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,53.02,14,,,percent of total billed charges,14% of total billed charges,53.02,1083.29,
93931- Dup scan/UE/art/graft/unilat/ltd,3435548,CDM,921,RC,93931,HCPCS,Outpatient,,,240.67,120.34,,180.5,75,,,percent of total billed charges,75% of total billed charges,180.5,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,81.11,100,,,Fee Schedule,100% of WV Medicaid Rate,165.79,165,,,Fee Schedule,165% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.82,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,81.11,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,33.69,14,,,percent of total billed charges,14% of total billed charges,33.69,495.81,
Clinic Selected Subclavian Artery Scan Left,3347693,CDM,921,RC,93931,HCPCS,Outpatient,,,240.67,120.34,,180.5,75,,,percent of total billed charges,75% of total billed charges,180.5,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,81.11,100,,,Fee Schedule,100% of WV Medicaid Rate,165.79,165,,,Fee Schedule,165% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.82,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,81.11,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,33.69,14,,,percent of total billed charges,14% of total billed charges,33.69,495.81,
Clinic Selected Subclavian Artery Scan Right,3347692,CDM,921,RC,93931,HCPCS,Outpatient,,,240.67,120.34,,180.5,75,,,percent of total billed charges,75% of total billed charges,180.5,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,81.11,100,,,Fee Schedule,100% of WV Medicaid Rate,165.79,165,,,Fee Schedule,165% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.82,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,81.11,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,33.69,14,,,percent of total billed charges,14% of total billed charges,33.69,495.81,
Read,3351995,CDM,972,RC,93931,HCPCS,Outpatient,,,240.67,120.34,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
Read,3351999,CDM,972,RC,93931,HCPCS,Outpatient,,,240.67,120.34,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
Read,3575247,CDM,972,RC,93931,HCPCS,Outpatient,,,240.67,120.34,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
SCMP US Exam,3575248,CDM,972,RC,93931,HCPCS,Outpatient,,,240.67,120.34,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
SCMP US Upper Extemity,3370917,CDM,972,RC,93931,HCPCS,Outpatient,,,240.67,120.34,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
93970- Dup scan/extremity vein/bilat/comp,3435549,CDM,921,RC,93970,HCPCS,Outpatient,,,1304.11,652.06,,978.08,75,,,percent of total billed charges,75% of total billed charges,978.08,75,,,percent of total billed charges,75% of total billed charges,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,122.65,100,,,Fee Schedule,100% of WV Medicaid Rate,362.24,165,,,Fee Schedule,165% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,630.61,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,864.84,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1083.29,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,122.65,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,182.58,14,,,percent of total billed charges,14% of total billed charges,122.65,1083.29,
93970 TC Duplex scan of extremity veins including response,3621411,CDM,510,RC,93970,HCPCS,Outpatient,,,1237.39,618.7,,928.04,75,,,percent of total billed charges,75% of total billed charges,928.04,75,,,percent of total billed charges,75% of total billed charges,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,122.65,100,,,Fee Schedule,100% of WV Medicaid Rate,362.24,165,,,Fee Schedule,165% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,630.61,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,864.84,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1083.29,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,122.65,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,173.23,14,,,percent of total billed charges,14% of total billed charges,122.65,1083.29,
93970-CL Periph Venous US Lower BILAT,3432087,CDM,481,RC,93970,HCPCS,Outpatient,,,369.39,184.7,,277.04,75,,,percent of total billed charges,75% of total billed charges,277.04,75,,,percent of total billed charges,75% of total billed charges,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,122.65,100,,,Fee Schedule,100% of WV Medicaid Rate,362.24,165,,,Fee Schedule,165% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,630.61,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,864.84,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1083.29,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,122.65,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,51.71,14,,,percent of total billed charges,14% of total billed charges,51.71,1083.29,
93970-CL Periph Venous US Upper BILAT,3432088,CDM,481,RC,93970,HCPCS,Outpatient,,,369.39,184.7,,277.04,75,,,percent of total billed charges,75% of total billed charges,277.04,75,,,percent of total billed charges,75% of total billed charges,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,122.65,100,,,Fee Schedule,100% of WV Medicaid Rate,362.24,165,,,Fee Schedule,165% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,630.61,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,864.84,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1083.29,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,122.65,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,51.71,14,,,percent of total billed charges,14% of total billed charges,51.71,1083.29,
93970-CL Upper Periph Arterial Duplex BILAT,3432089,CDM,481,RC,93970,HCPCS,Outpatient,,,369.39,184.7,,277.04,75,,,percent of total billed charges,75% of total billed charges,277.04,75,,,percent of total billed charges,75% of total billed charges,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,122.65,100,,,Fee Schedule,100% of WV Medicaid Rate,362.24,165,,,Fee Schedule,165% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,630.61,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,864.84,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1083.29,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,122.65,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,51.71,14,,,percent of total billed charges,14% of total billed charges,51.71,1083.29,
93970-CL US Vein Map Mark Lower Extrem BILAT,3432090,CDM,481,RC,93970,HCPCS,Outpatient,,,369.39,184.7,,277.04,75,,,percent of total billed charges,75% of total billed charges,277.04,75,,,percent of total billed charges,75% of total billed charges,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,122.65,100,,,Fee Schedule,100% of WV Medicaid Rate,362.24,165,,,Fee Schedule,165% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,630.61,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,864.84,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1083.29,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,122.65,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,51.71,14,,,percent of total billed charges,14% of total billed charges,51.71,1083.29,
93970-CL US Vein Map Mark Upper Extrem BILAT,3432091,CDM,481,RC,93970,HCPCS,Outpatient,,,369.39,184.7,,277.04,75,,,percent of total billed charges,75% of total billed charges,277.04,75,,,percent of total billed charges,75% of total billed charges,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,122.65,100,,,Fee Schedule,100% of WV Medicaid Rate,362.24,165,,,Fee Schedule,165% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,630.61,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,864.84,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1083.29,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,122.65,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,51.71,14,,,percent of total billed charges,14% of total billed charges,51.71,1083.29,
93970-CL US Venous Insuff Lower Extrem BILAT,3432092,CDM,481,RC,93970,HCPCS,Outpatient,,,369.39,184.7,,277.04,75,,,percent of total billed charges,75% of total billed charges,277.04,75,,,percent of total billed charges,75% of total billed charges,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,122.65,100,,,Fee Schedule,100% of WV Medicaid Rate,362.24,165,,,Fee Schedule,165% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,630.61,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,864.84,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1083.29,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,122.65,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,51.71,14,,,percent of total billed charges,14% of total billed charges,51.71,1083.29,
93970-CL US Venous Insuff Upper Extrem BILAT,3432093,CDM,481,RC,93970,HCPCS,Outpatient,,,369.39,184.7,,277.04,75,,,percent of total billed charges,75% of total billed charges,277.04,75,,,percent of total billed charges,75% of total billed charges,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,122.65,100,,,Fee Schedule,100% of WV Medicaid Rate,362.24,165,,,Fee Schedule,165% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,630.61,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,864.84,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1083.29,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,122.65,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,51.71,14,,,percent of total billed charges,14% of total billed charges,51.71,1083.29,
CL Periph Venous US Lower BILAT,3427536,CDM,921,RC,93970,HCPCS,Outpatient,,,1304.11,652.06,,978.08,75,,,percent of total billed charges,75% of total billed charges,978.08,75,,,percent of total billed charges,75% of total billed charges,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,122.65,100,,,Fee Schedule,100% of WV Medicaid Rate,362.24,165,,,Fee Schedule,165% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,630.61,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,864.84,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1083.29,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,122.65,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,182.58,14,,,percent of total billed charges,14% of total billed charges,122.65,1083.29,
CL Periph Venous US Upper BILAT,3427537,CDM,921,RC,93970,HCPCS,Outpatient,,,1304.11,652.06,,978.08,75,,,percent of total billed charges,75% of total billed charges,978.08,75,,,percent of total billed charges,75% of total billed charges,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,122.65,100,,,Fee Schedule,100% of WV Medicaid Rate,362.24,165,,,Fee Schedule,165% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,630.61,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,864.84,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1083.29,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,122.65,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,182.58,14,,,percent of total billed charges,14% of total billed charges,122.65,1083.29,
CL Upper Periph Arterial Duplex BILAT,3427571,CDM,921,RC,93970,HCPCS,Outpatient,,,1304.11,652.06,,978.08,75,,,percent of total billed charges,75% of total billed charges,978.08,75,,,percent of total billed charges,75% of total billed charges,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,122.65,100,,,Fee Schedule,100% of WV Medicaid Rate,362.24,165,,,Fee Schedule,165% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,630.61,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,864.84,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1083.29,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,122.65,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,182.58,14,,,percent of total billed charges,14% of total billed charges,122.65,1083.29,
CL US Vein Map Mark Lower Extrem BILAT,3427463,CDM,921,RC,93970,HCPCS,Outpatient,,,1304.11,652.06,,978.08,75,,,percent of total billed charges,75% of total billed charges,978.08,75,,,percent of total billed charges,75% of total billed charges,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,122.65,100,,,Fee Schedule,100% of WV Medicaid Rate,362.24,165,,,Fee Schedule,165% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,630.61,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,864.84,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1083.29,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,122.65,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,182.58,14,,,percent of total billed charges,14% of total billed charges,122.65,1083.29,
CL US Vein Map Mark Upper Extrem BILAT,3427498,CDM,921,RC,93970,HCPCS,Outpatient,,,1304.11,652.06,,978.08,75,,,percent of total billed charges,75% of total billed charges,978.08,75,,,percent of total billed charges,75% of total billed charges,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,122.65,100,,,Fee Schedule,100% of WV Medicaid Rate,362.24,165,,,Fee Schedule,165% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,630.61,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,864.84,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1083.29,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,122.65,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,182.58,14,,,percent of total billed charges,14% of total billed charges,122.65,1083.29,
CL US Venous Insuff Lower Extrem BILAT,3427507,CDM,921,RC,93970,HCPCS,Outpatient,,,1304.11,652.06,,978.08,75,,,percent of total billed charges,75% of total billed charges,978.08,75,,,percent of total billed charges,75% of total billed charges,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,122.65,100,,,Fee Schedule,100% of WV Medicaid Rate,362.24,165,,,Fee Schedule,165% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,630.61,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,864.84,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1083.29,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,122.65,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,182.58,14,,,percent of total billed charges,14% of total billed charges,122.65,1083.29,
CL US Venous Insuff Upper Extrem BILAT,3427510,CDM,921,RC,93970,HCPCS,Outpatient,,,1304.11,652.06,,978.08,75,,,percent of total billed charges,75% of total billed charges,978.08,75,,,percent of total billed charges,75% of total billed charges,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,122.65,100,,,Fee Schedule,100% of WV Medicaid Rate,362.24,165,,,Fee Schedule,165% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,630.61,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,864.84,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1083.29,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,122.65,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,182.58,14,,,percent of total billed charges,14% of total billed charges,122.65,1083.29,
SCMP US Exam,3575250,CDM,402,RC,93970,HCPCS,Outpatient,,,1237.39,618.7,,928.04,75,,,percent of total billed charges,75% of total billed charges,928.04,75,,,percent of total billed charges,75% of total billed charges,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,122.65,100,,,Fee Schedule,100% of WV Medicaid Rate,362.24,165,,,Fee Schedule,165% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,630.61,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,864.84,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1083.29,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,122.65,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,173.23,14,,,percent of total billed charges,14% of total billed charges,122.65,1083.29,
SCMP US Upper Extremity Vein Mapping,3370919,CDM,972,RC,93970,HCPCS,Outpatient,,,1237.39,618.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
SCMP US Vein Mapping,3370922,CDM,402,RC,93970,HCPCS,Outpatient,,,1237.39,618.7,,928.04,75,,,percent of total billed charges,75% of total billed charges,928.04,75,,,percent of total billed charges,75% of total billed charges,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,122.65,100,,,Fee Schedule,100% of WV Medicaid Rate,362.24,165,,,Fee Schedule,165% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,630.61,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,864.84,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1083.29,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,122.65,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,173.23,14,,,percent of total billed charges,14% of total billed charges,122.65,1083.29,
SCMP US Vein Mapping:Read,3575252,CDM,402,RC,93970,HCPCS,Outpatient,,,1237.39,618.7,,928.04,75,,,percent of total billed charges,75% of total billed charges,928.04,75,,,percent of total billed charges,75% of total billed charges,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,122.65,100,,,Fee Schedule,100% of WV Medicaid Rate,362.24,165,,,Fee Schedule,165% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,630.61,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,864.84,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1083.29,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,122.65,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,173.23,14,,,percent of total billed charges,14% of total billed charges,122.65,1083.29,
SCSN US Venous Lower BILAT,3569777,CDM,402,RC,93970,HCPCS,Outpatient,,,1237.39,618.7,,928.04,75,,,percent of total billed charges,75% of total billed charges,928.04,75,,,percent of total billed charges,75% of total billed charges,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,122.65,100,,,Fee Schedule,100% of WV Medicaid Rate,362.24,165,,,Fee Schedule,165% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,630.61,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,864.84,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1083.29,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,122.65,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,173.23,14,,,percent of total billed charges,14% of total billed charges,122.65,1083.29,
SCSN US Venous Lower Bilat Interp,3575318,CDM,510,RC,93970,HCPCS,Outpatient,,,1237.39,618.7,,928.04,75,,,percent of total billed charges,75% of total billed charges,928.04,75,,,percent of total billed charges,75% of total billed charges,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,122.65,100,,,Fee Schedule,100% of WV Medicaid Rate,362.24,165,,,Fee Schedule,165% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,630.61,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,864.84,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1083.29,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,122.65,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,173.23,14,,,percent of total billed charges,14% of total billed charges,122.65,1083.29,
SCSN US Venous Upper BILAT,3569783,CDM,402,RC,93970,HCPCS,Outpatient,,,1237.39,618.7,,928.04,75,,,percent of total billed charges,75% of total billed charges,928.04,75,,,percent of total billed charges,75% of total billed charges,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,122.65,100,,,Fee Schedule,100% of WV Medicaid Rate,362.24,165,,,Fee Schedule,165% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,630.61,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,864.84,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1083.29,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,122.65,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,173.23,14,,,percent of total billed charges,14% of total billed charges,122.65,1083.29,
SCSN US Venous Upper Bilat Interp,3575324,CDM,510,RC,93970,HCPCS,Outpatient,,,1237.39,618.7,,928.04,75,,,percent of total billed charges,75% of total billed charges,928.04,75,,,percent of total billed charges,75% of total billed charges,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,122.65,100,,,Fee Schedule,100% of WV Medicaid Rate,362.24,165,,,Fee Schedule,165% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,630.61,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,864.84,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1083.29,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,122.65,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,173.23,14,,,percent of total billed charges,14% of total billed charges,122.65,1083.29,
SCSN Venous Insuff Bilat,3569789,CDM,920,RC,93970,HCPCS,Outpatient,,,1237.39,618.7,,928.04,75,,,percent of total billed charges,75% of total billed charges,928.04,75,,,percent of total billed charges,75% of total billed charges,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,122.65,100,,,Fee Schedule,100% of WV Medicaid Rate,362.24,165,,,Fee Schedule,165% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,630.61,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,864.84,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1083.29,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,122.65,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,173.23,14,,,percent of total billed charges,14% of total billed charges,122.65,1083.29,
SCSN Venous Insufficiency Bilat Interp,3575330,CDM,921,RC,93970,HCPCS,Outpatient,,,1237.39,618.7,,928.04,75,,,percent of total billed charges,75% of total billed charges,928.04,75,,,percent of total billed charges,75% of total billed charges,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,122.65,100,,,Fee Schedule,100% of WV Medicaid Rate,362.24,165,,,Fee Schedule,165% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,630.61,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,864.84,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1083.29,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,122.65,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,173.23,14,,,percent of total billed charges,14% of total billed charges,122.65,1083.29,
SCSN Venous Insufficiency Bilat Interp,3575329,CDM,510,RC,93970,HCPCS,Outpatient,,,66.72,33.36,,50.04,75,,,percent of total billed charges,75% of total billed charges,50.04,75,,,percent of total billed charges,75% of total billed charges,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,66.72,100,,,Fee Schedule,100% of WV Medicaid Rate,362.24,165,,,Fee Schedule,165% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,630.61,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,864.84,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1083.29,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,66.72,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,9.34,14,,,percent of total billed charges,14% of total billed charges,9.34,1083.29,
US Extremity Complete Bilat Lower for DVT:Read,3347590,CDM,972,RC,93970,HCPCS,Outpatient,,,1237.39,618.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
US Vein Map/Marking Lower Extrem Bilat,3352012,CDM,921,RC,93970,HCPCS,Outpatient,,,1237.39,618.7,,928.04,75,,,percent of total billed charges,75% of total billed charges,928.04,75,,,percent of total billed charges,75% of total billed charges,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,122.65,100,,,Fee Schedule,100% of WV Medicaid Rate,362.24,165,,,Fee Schedule,165% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,630.61,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,864.84,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1083.29,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,122.65,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,173.23,14,,,percent of total billed charges,14% of total billed charges,122.65,1083.29,
WHC US Extremity Vein Complete,2198103,CDM,921,RC,93970,HCPCS,Outpatient,,,1237.39,618.7,,928.04,75,,,percent of total billed charges,75% of total billed charges,928.04,75,,,percent of total billed charges,75% of total billed charges,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,122.65,100,,,Fee Schedule,100% of WV Medicaid Rate,362.24,165,,,Fee Schedule,165% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,630.61,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,864.84,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1083.29,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,122.65,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,173.23,14,,,percent of total billed charges,14% of total billed charges,122.65,1083.29,
93971 (TC) Duplex scan of extremity veins including responses to compression and other maneuvers; un,3620982,CDM,510,RC,93971,HCPCS,Outpatient,,,571.2,285.6,,428.4,75,,,percent of total billed charges,75% of total billed charges,428.4,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,77.67,100,,,Fee Schedule,100% of WV Medicaid Rate,165.79,165,,,Fee Schedule,165% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.82,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,77.67,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,79.97,14,,,percent of total billed charges,14% of total billed charges,77.67,495.81,
93971- Dup scan/extremity vein/unilat/ltd,3435550,CDM,921,RC,93971,HCPCS,Outpatient,,,613.6,306.8,,460.2,75,,,percent of total billed charges,75% of total billed charges,460.2,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,77.67,100,,,Fee Schedule,100% of WV Medicaid Rate,165.79,165,,,Fee Schedule,165% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.82,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,77.67,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,85.9,14,,,percent of total billed charges,14% of total billed charges,77.67,495.81,
93971 -Duplex scan of extremity veins including responses to compression and other maneuvers; unilat,3641196,CDM,510,RC,93971,HCPCS,Outpatient,,,613.6,306.8,,460.2,75,,,percent of total billed charges,75% of total billed charges,460.2,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,77.67,100,,,Fee Schedule,100% of WV Medicaid Rate,165.79,165,,,Fee Schedule,165% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.82,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,77.67,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,85.9,14,,,percent of total billed charges,14% of total billed charges,77.67,495.81,
93971 Dup-Scan XTR Veins Unilateral/Limited Study,3436061,CDM,761,RC,93971,HCPCS,Outpatient,,,234.34,117.17,,175.76,75,,,percent of total billed charges,75% of total billed charges,175.76,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,77.67,100,,,Fee Schedule,100% of WV Medicaid Rate,165.79,165,,,Fee Schedule,165% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.82,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,77.67,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,32.81,14,,,percent of total billed charges,14% of total billed charges,32.81,495.81,
CL Periph Venous US Lower LT,3427534,CDM,921,RC,93971,HCPCS,Outpatient,,,613.6,306.8,,460.2,75,,,percent of total billed charges,75% of total billed charges,460.2,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,77.67,100,,,Fee Schedule,100% of WV Medicaid Rate,165.79,165,,,Fee Schedule,165% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.82,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,77.67,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,85.9,14,,,percent of total billed charges,14% of total billed charges,77.67,495.81,
CL Periph Venous US Lower RT,3427535,CDM,921,RC,93971,HCPCS,Outpatient,,,613.6,306.8,,460.2,75,,,percent of total billed charges,75% of total billed charges,460.2,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,77.67,100,,,Fee Schedule,100% of WV Medicaid Rate,165.79,165,,,Fee Schedule,165% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.82,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,77.67,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,85.9,14,,,percent of total billed charges,14% of total billed charges,77.67,495.81,
CL Periph Venous US Upper LT,3427538,CDM,921,RC,93971,HCPCS,Outpatient,,,613.6,306.8,,460.2,75,,,percent of total billed charges,75% of total billed charges,460.2,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,77.67,100,,,Fee Schedule,100% of WV Medicaid Rate,165.79,165,,,Fee Schedule,165% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.82,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,77.67,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,85.9,14,,,percent of total billed charges,14% of total billed charges,77.67,495.81,
CL Periph Venous US Upper RT,3427569,CDM,921,RC,93971,HCPCS,Outpatient,,,613.6,306.8,,460.2,75,,,percent of total billed charges,75% of total billed charges,460.2,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,77.67,100,,,Fee Schedule,100% of WV Medicaid Rate,165.79,165,,,Fee Schedule,165% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.82,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,77.67,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,85.9,14,,,percent of total billed charges,14% of total billed charges,77.67,495.81,
CL Upper Periph Arterial Duplex LT,3427572,CDM,921,RC,93971,HCPCS,Outpatient,,,613.6,306.8,,460.2,75,,,percent of total billed charges,75% of total billed charges,460.2,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,77.67,100,,,Fee Schedule,100% of WV Medicaid Rate,165.79,165,,,Fee Schedule,165% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.82,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,77.67,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,85.9,14,,,percent of total billed charges,14% of total billed charges,77.67,495.81,
CL Upper Periph Arterial Duplex RT,3427570,CDM,921,RC,93971,HCPCS,Outpatient,,,613.6,306.8,,460.2,75,,,percent of total billed charges,75% of total billed charges,460.2,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,77.67,100,,,Fee Schedule,100% of WV Medicaid Rate,165.79,165,,,Fee Schedule,165% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.82,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,77.67,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,85.9,14,,,percent of total billed charges,14% of total billed charges,77.67,495.81,
CL US Vein Map Mark Lower Extrem LT,3427464,CDM,921,RC,93971,HCPCS,Outpatient,,,613.6,306.8,,460.2,75,,,percent of total billed charges,75% of total billed charges,460.2,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,77.67,100,,,Fee Schedule,100% of WV Medicaid Rate,165.79,165,,,Fee Schedule,165% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.82,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,77.67,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,85.9,14,,,percent of total billed charges,14% of total billed charges,77.67,495.81,
CL US Vein Map Mark Lower Extrem RT,3427497,CDM,921,RC,93971,HCPCS,Outpatient,,,613.6,306.8,,460.2,75,,,percent of total billed charges,75% of total billed charges,460.2,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,77.67,100,,,Fee Schedule,100% of WV Medicaid Rate,165.79,165,,,Fee Schedule,165% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.82,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,77.67,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,85.9,14,,,percent of total billed charges,14% of total billed charges,77.67,495.81,
CL US Vein Map Mark Upper Extrem LT,3427499,CDM,921,RC,93971,HCPCS,Outpatient,,,613.6,306.8,,460.2,75,,,percent of total billed charges,75% of total billed charges,460.2,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,77.67,100,,,Fee Schedule,100% of WV Medicaid Rate,165.79,165,,,Fee Schedule,165% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.82,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,77.67,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,85.9,14,,,percent of total billed charges,14% of total billed charges,77.67,495.81,
CL US Vein Map Mark Upper Extrem RT,3427500,CDM,921,RC,93971,HCPCS,Outpatient,,,613.6,306.8,,460.2,75,,,percent of total billed charges,75% of total billed charges,460.2,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,77.67,100,,,Fee Schedule,100% of WV Medicaid Rate,165.79,165,,,Fee Schedule,165% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.82,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,77.67,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,85.9,14,,,percent of total billed charges,14% of total billed charges,77.67,495.81,
CL US Venous Insuff Lower Extrem LT,3427508,CDM,921,RC,93971,HCPCS,Outpatient,,,613.6,306.8,,460.2,75,,,percent of total billed charges,75% of total billed charges,460.2,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,77.67,100,,,Fee Schedule,100% of WV Medicaid Rate,165.79,165,,,Fee Schedule,165% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.82,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,77.67,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,85.9,14,,,percent of total billed charges,14% of total billed charges,77.67,495.81,
CL US Venous Insuff Lower Extrem RT,3427509,CDM,921,RC,93971,HCPCS,Outpatient,,,613.6,306.8,,460.2,75,,,percent of total billed charges,75% of total billed charges,460.2,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,77.67,100,,,Fee Schedule,100% of WV Medicaid Rate,165.79,165,,,Fee Schedule,165% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.82,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,77.67,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,85.9,14,,,percent of total billed charges,14% of total billed charges,77.67,495.81,
CL US Venous Insuff Upper Extrem LT,3427511,CDM,921,RC,93971,HCPCS,Outpatient,,,613.6,306.8,,460.2,75,,,percent of total billed charges,75% of total billed charges,460.2,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,77.67,100,,,Fee Schedule,100% of WV Medicaid Rate,165.79,165,,,Fee Schedule,165% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.82,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,77.67,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,85.9,14,,,percent of total billed charges,14% of total billed charges,77.67,495.81,
CL US Venous Insuff Upper Extrem RT,3427512,CDM,921,RC,93971,HCPCS,Outpatient,,,613.6,306.8,,460.2,75,,,percent of total billed charges,75% of total billed charges,460.2,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,77.67,100,,,Fee Schedule,100% of WV Medicaid Rate,165.79,165,,,Fee Schedule,165% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.82,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,77.67,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,85.9,14,,,percent of total billed charges,14% of total billed charges,77.67,495.81,
SCSN US Exam,3575296,CDM,972,RC,93971,HCPCS,Outpatient,,,571.2,285.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
SCSN US Exam,3575298,CDM,402,RC,93971,HCPCS,Outpatient,,,571.2,285.6,,428.4,75,,,percent of total billed charges,75% of total billed charges,428.4,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,77.67,100,,,Fee Schedule,100% of WV Medicaid Rate,165.79,165,,,Fee Schedule,165% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.82,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,77.67,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,79.97,14,,,percent of total billed charges,14% of total billed charges,77.67,495.81,
SCSN US Non Vascular Extremity Left,3370952,CDM,510,RC,93971,HCPCS,Outpatient,,,571.2,285.6,,428.4,75,,,percent of total billed charges,75% of total billed charges,428.4,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,77.67,100,,,Fee Schedule,100% of WV Medicaid Rate,165.79,165,,,Fee Schedule,165% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.82,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,77.67,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,79.97,14,,,percent of total billed charges,14% of total billed charges,77.67,495.81,
SCSN US Non Vascular Extremity Right,3370954,CDM,510,RC,93971,HCPCS,Outpatient,,,571.2,285.6,,428.4,75,,,percent of total billed charges,75% of total billed charges,428.4,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,77.67,100,,,Fee Schedule,100% of WV Medicaid Rate,165.79,165,,,Fee Schedule,165% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.82,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,77.67,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,79.97,14,,,percent of total billed charges,14% of total billed charges,77.67,495.81,
SCSN US Venous Lower LT,3569779,CDM,510,RC,93971,HCPCS,Outpatient,,,571.2,285.6,,428.4,75,,,percent of total billed charges,75% of total billed charges,428.4,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,77.67,100,,,Fee Schedule,100% of WV Medicaid Rate,165.79,165,,,Fee Schedule,165% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.82,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,77.67,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,79.97,14,,,percent of total billed charges,14% of total billed charges,77.67,495.81,
SCSN US Venous Lower LT Interp,3575320,CDM,510,RC,93971,HCPCS,Outpatient,,,571.2,285.6,,428.4,75,,,percent of total billed charges,75% of total billed charges,428.4,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,77.67,100,,,Fee Schedule,100% of WV Medicaid Rate,165.79,165,,,Fee Schedule,165% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.82,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,77.67,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,79.97,14,,,percent of total billed charges,14% of total billed charges,77.67,495.81,
SCSN US Venous Lower RT,3569781,CDM,510,RC,93971,HCPCS,Outpatient,,,571.2,285.6,,428.4,75,,,percent of total billed charges,75% of total billed charges,428.4,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,77.67,100,,,Fee Schedule,100% of WV Medicaid Rate,165.79,165,,,Fee Schedule,165% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.82,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,77.67,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,79.97,14,,,percent of total billed charges,14% of total billed charges,77.67,495.81,
SCSN US Venous Lower RT Interp,3575322,CDM,921,RC,93971,HCPCS,Outpatient,,,571.2,285.6,,428.4,75,,,percent of total billed charges,75% of total billed charges,428.4,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,77.67,100,,,Fee Schedule,100% of WV Medicaid Rate,165.79,165,,,Fee Schedule,165% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.82,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,77.67,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,79.97,14,,,percent of total billed charges,14% of total billed charges,77.67,495.81,
SCSN US Venous Upper LT,3569785,CDM,510,RC,93971,HCPCS,Outpatient,,,571.2,285.6,,428.4,75,,,percent of total billed charges,75% of total billed charges,428.4,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,77.67,100,,,Fee Schedule,100% of WV Medicaid Rate,165.79,165,,,Fee Schedule,165% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.82,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,77.67,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,79.97,14,,,percent of total billed charges,14% of total billed charges,77.67,495.81,
SCSN US Venous Upper LT,3575326,CDM,972,RC,93971,HCPCS,Outpatient,,,571.2,285.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
SCSN US Venous Upper RT,3569787,CDM,510,RC,93971,HCPCS,Outpatient,,,571.2,285.6,,428.4,75,,,percent of total billed charges,75% of total billed charges,428.4,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,77.67,100,,,Fee Schedule,100% of WV Medicaid Rate,165.79,165,,,Fee Schedule,165% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.82,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,77.67,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,79.97,14,,,percent of total billed charges,14% of total billed charges,77.67,495.81,
SCSN US Venous Upper RT Interp,3575328,CDM,510,RC,93971,HCPCS,Outpatient,,,571.2,285.6,,428.4,75,,,percent of total billed charges,75% of total billed charges,428.4,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,77.67,100,,,Fee Schedule,100% of WV Medicaid Rate,165.79,165,,,Fee Schedule,165% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.82,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,77.67,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,79.97,14,,,percent of total billed charges,14% of total billed charges,77.67,495.81,
SCSN Venous Insuff LT,3569791,CDM,510,RC,93971,HCPCS,Outpatient,,,571.2,285.6,,428.4,75,,,percent of total billed charges,75% of total billed charges,428.4,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,77.67,100,,,Fee Schedule,100% of WV Medicaid Rate,165.79,165,,,Fee Schedule,165% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.82,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,77.67,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,79.97,14,,,percent of total billed charges,14% of total billed charges,77.67,495.81,
SCSN Venous Insuff LT Interp,3575332,CDM,510,RC,93971,HCPCS,Outpatient,,,571.2,285.6,,428.4,75,,,percent of total billed charges,75% of total billed charges,428.4,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,77.67,100,,,Fee Schedule,100% of WV Medicaid Rate,165.79,165,,,Fee Schedule,165% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.82,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,77.67,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,79.97,14,,,percent of total billed charges,14% of total billed charges,77.67,495.81,
SCSN Venous Insuff RT,3569793,CDM,510,RC,93971,HCPCS,Outpatient,,,571.2,285.6,,428.4,75,,,percent of total billed charges,75% of total billed charges,428.4,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,77.67,100,,,Fee Schedule,100% of WV Medicaid Rate,165.79,165,,,Fee Schedule,165% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.82,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,77.67,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,79.97,14,,,percent of total billed charges,14% of total billed charges,77.67,495.81,
SCSN Venous Insuff RT Interp,3575334,CDM,510,RC,93971,HCPCS,Outpatient,,,571.2,285.6,,428.4,75,,,percent of total billed charges,75% of total billed charges,428.4,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,77.67,100,,,Fee Schedule,100% of WV Medicaid Rate,165.79,165,,,Fee Schedule,165% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.82,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,77.67,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,79.97,14,,,percent of total billed charges,14% of total billed charges,77.67,495.81,
US Extremity Vein Unilat Lt for DVT,1257042,CDM,921,RC,93971,HCPCS,Outpatient,,,613.6,306.8,,460.2,75,,,percent of total billed charges,75% of total billed charges,460.2,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,77.67,100,,,Fee Schedule,100% of WV Medicaid Rate,165.79,165,,,Fee Schedule,165% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.82,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,77.67,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,85.9,14,,,percent of total billed charges,14% of total billed charges,77.67,495.81,
US Extremity Vein Unilat Lt Lower for DVT,3347593,CDM,921,RC,93971,HCPCS,Outpatient,,,613.6,306.8,,460.2,75,,,percent of total billed charges,75% of total billed charges,460.2,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,77.67,100,,,Fee Schedule,100% of WV Medicaid Rate,165.79,165,,,Fee Schedule,165% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.82,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,77.67,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,85.9,14,,,percent of total billed charges,14% of total billed charges,77.67,495.81,
US Extremity Vein Unilat Lt Upper for DVT,3347595,CDM,921,RC,93971,HCPCS,Outpatient,,,613.6,306.8,,460.2,75,,,percent of total billed charges,75% of total billed charges,460.2,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,77.67,100,,,Fee Schedule,100% of WV Medicaid Rate,165.79,165,,,Fee Schedule,165% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.82,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,77.67,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,85.9,14,,,percent of total billed charges,14% of total billed charges,77.67,495.81,
US Extremity Vein Unilat Rt for DVT,1257044,CDM,921,RC,93971,HCPCS,Outpatient,,,613.6,306.8,,460.2,75,,,percent of total billed charges,75% of total billed charges,460.2,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,77.67,100,,,Fee Schedule,100% of WV Medicaid Rate,165.79,165,,,Fee Schedule,165% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.82,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,77.67,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,85.9,14,,,percent of total billed charges,14% of total billed charges,77.67,495.81,
US Extremity Vein Unilat Rt Lower for DVT,3347597,CDM,921,RC,93971,HCPCS,Outpatient,,,613.6,306.8,,460.2,75,,,percent of total billed charges,75% of total billed charges,460.2,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,77.67,100,,,Fee Schedule,100% of WV Medicaid Rate,165.79,165,,,Fee Schedule,165% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.82,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,77.67,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,85.9,14,,,percent of total billed charges,14% of total billed charges,77.67,495.81,
US Extremity Vein Unilat Rt Upper for DVT,3347599,CDM,921,RC,93971,HCPCS,Outpatient,,,613.6,306.8,,460.2,75,,,percent of total billed charges,75% of total billed charges,460.2,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,77.67,100,,,Fee Schedule,100% of WV Medicaid Rate,165.79,165,,,Fee Schedule,165% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.82,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,77.67,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,85.9,14,,,percent of total billed charges,14% of total billed charges,77.67,495.81,
US Vein Map/Marking Lower Extremity Lt,3352010,CDM,921,RC,93971,HCPCS,Outpatient,,,613.6,306.8,,460.2,75,,,percent of total billed charges,75% of total billed charges,460.2,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,77.67,100,,,Fee Schedule,100% of WV Medicaid Rate,165.79,165,,,Fee Schedule,165% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.82,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,77.67,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,85.9,14,,,percent of total billed charges,14% of total billed charges,77.67,495.81,
US Vein Map/Marking Lower Extremity Rt,3352014,CDM,921,RC,93971,HCPCS,Outpatient,,,613.6,306.8,,460.2,75,,,percent of total billed charges,75% of total billed charges,460.2,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,77.67,100,,,Fee Schedule,100% of WV Medicaid Rate,165.79,165,,,Fee Schedule,165% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.82,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,77.67,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,85.9,14,,,percent of total billed charges,14% of total billed charges,77.67,495.81,
US Vein Map/Marking Upper Extrem Bilat,3352016,CDM,921,RC,93971,HCPCS,Outpatient,,,613.6,306.8,,460.2,75,,,percent of total billed charges,75% of total billed charges,460.2,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,77.67,100,,,Fee Schedule,100% of WV Medicaid Rate,165.79,165,,,Fee Schedule,165% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.82,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,77.67,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,85.9,14,,,percent of total billed charges,14% of total billed charges,77.67,495.81,
US Vein Map/Marking Upper Extrem Lt,3352018,CDM,921,RC,93971,HCPCS,Outpatient,,,613.6,306.8,,460.2,75,,,percent of total billed charges,75% of total billed charges,460.2,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,77.67,100,,,Fee Schedule,100% of WV Medicaid Rate,165.79,165,,,Fee Schedule,165% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.82,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,77.67,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,85.9,14,,,percent of total billed charges,14% of total billed charges,77.67,495.81,
US Vein Map/Marking Upper Extrem Rt,3352020,CDM,921,RC,93971,HCPCS,Outpatient,,,613.6,306.8,,460.2,75,,,percent of total billed charges,75% of total billed charges,460.2,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,77.67,100,,,Fee Schedule,100% of WV Medicaid Rate,165.79,165,,,Fee Schedule,165% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.82,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,77.67,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,85.9,14,,,percent of total billed charges,14% of total billed charges,77.67,495.81,
US Venous Insufficiency Lower Extrem Lt,3352022,CDM,921,RC,93971,HCPCS,Outpatient,,,613.6,306.8,,460.2,75,,,percent of total billed charges,75% of total billed charges,460.2,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,77.67,100,,,Fee Schedule,100% of WV Medicaid Rate,165.79,165,,,Fee Schedule,165% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.82,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,77.67,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,85.9,14,,,percent of total billed charges,14% of total billed charges,77.67,495.81,
US Venous Insufficiency Lower Extrem Rt,3352024,CDM,921,RC,93971,HCPCS,Outpatient,,,613.6,306.8,,460.2,75,,,percent of total billed charges,75% of total billed charges,460.2,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,77.67,100,,,Fee Schedule,100% of WV Medicaid Rate,165.79,165,,,Fee Schedule,165% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.82,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,77.67,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,85.9,14,,,percent of total billed charges,14% of total billed charges,77.67,495.81,
WHC US Extremity Vein Lt,2198105,CDM,921,RC,93971,HCPCS,Outpatient,,,571.2,285.6,,428.4,75,,,percent of total billed charges,75% of total billed charges,428.4,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,77.67,100,,,Fee Schedule,100% of WV Medicaid Rate,165.79,165,,,Fee Schedule,165% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.82,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,77.67,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,79.97,14,,,percent of total billed charges,14% of total billed charges,77.67,495.81,
WHC US Extremity Vein Rt,2198107,CDM,921,RC,93971,HCPCS,Outpatient,,,571.2,285.6,,428.4,75,,,percent of total billed charges,75% of total billed charges,428.4,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,77.67,100,,,Fee Schedule,100% of WV Medicaid Rate,165.79,165,,,Fee Schedule,165% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.82,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,77.67,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,79.97,14,,,percent of total billed charges,14% of total billed charges,77.67,495.81,
93975- Dup scan/abd/pelvic/scrotal/comp,3435551,CDM,921,RC,93975,HCPCS,Outpatient,,,1237.39,618.7,,928.04,75,,,percent of total billed charges,75% of total billed charges,928.04,75,,,percent of total billed charges,75% of total billed charges,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,174.03,100,,,Fee Schedule,100% of WV Medicaid Rate,362.24,165,,,Fee Schedule,165% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,630.61,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,864.84,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1083.29,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,174.03,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,173.23,14,,,percent of total billed charges,14% of total billed charges,173.23,1083.29,
CL Renal Artery Ultrasound BILAT,3427575,CDM,921,RC,93975,HCPCS,Outpatient,,,1237.39,618.7,,928.04,75,,,percent of total billed charges,75% of total billed charges,928.04,75,,,percent of total billed charges,75% of total billed charges,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,174.03,100,,,Fee Schedule,100% of WV Medicaid Rate,362.24,165,,,Fee Schedule,165% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,630.61,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,864.84,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1083.29,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,174.03,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,173.23,14,,,percent of total billed charges,14% of total billed charges,173.23,1083.29,
Clinic Celiac Artery Ultrasound,3347690,CDM,921,RC,93975,HCPCS,Outpatient,,,1237.39,618.7,,928.04,75,,,percent of total billed charges,75% of total billed charges,928.04,75,,,percent of total billed charges,75% of total billed charges,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,174.03,100,,,Fee Schedule,100% of WV Medicaid Rate,362.24,165,,,Fee Schedule,165% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,630.61,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,864.84,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1083.29,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,174.03,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,173.23,14,,,percent of total billed charges,14% of total billed charges,173.23,1083.29,
Clinic Superior Mesenteric Artery Ultrasound,3347685,CDM,921,RC,93975,HCPCS,Outpatient,,,1237.39,618.7,,928.04,75,,,percent of total billed charges,75% of total billed charges,928.04,75,,,percent of total billed charges,75% of total billed charges,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,174.03,100,,,Fee Schedule,100% of WV Medicaid Rate,362.24,165,,,Fee Schedule,165% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,630.61,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,864.84,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1083.29,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,174.03,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,173.23,14,,,percent of total billed charges,14% of total billed charges,173.23,1083.29,
93976- Dup scan/abd/pelvic/scrotal/ltd,3435552,CDM,921,RC,93976,HCPCS,Outpatient,,,287.26,143.63,,215.45,75,,,percent of total billed charges,75% of total billed charges,215.45,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,94.82,100,,,Fee Schedule,100% of WV Medicaid Rate,165.79,165,,,Fee Schedule,165% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.82,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,94.82,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,40.22,14,,,percent of total billed charges,14% of total billed charges,40.22,495.81,
US Duplex Abd Pelvic Retro Limited:Read,596589,CDM,972,RC,93976,HCPCS,Outpatient,,,287.26,143.63,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
93978- Dup scan/aort/IVC/iliac/BP gft/com,3435553,CDM,921,RC,93978,HCPCS,Outpatient,,,1237.39,618.7,,928.04,75,,,percent of total billed charges,75% of total billed charges,928.04,75,,,percent of total billed charges,75% of total billed charges,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,118.97,100,,,Fee Schedule,100% of WV Medicaid Rate,362.24,165,,,Fee Schedule,165% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,630.61,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,864.84,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1083.29,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,118.97,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,173.23,14,,,percent of total billed charges,14% of total billed charges,118.97,1083.29,
Clinic Abdominal Aortic Ultrasound,3347684,CDM,402,RC,93978,HCPCS,Outpatient,,,1237.39,618.7,,928.04,75,,,percent of total billed charges,75% of total billed charges,928.04,75,,,percent of total billed charges,75% of total billed charges,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,118.97,100,,,Fee Schedule,100% of WV Medicaid Rate,362.24,165,,,Fee Schedule,165% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,630.61,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,864.84,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1083.29,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,118.97,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,173.23,14,,,percent of total billed charges,14% of total billed charges,118.97,1083.29,
93979- Dup scan/aort/IVC/iliac/BP gft/ltd,3435554,CDM,921,RC,93979,HCPCS,Outpatient,,,224.87,112.44,,168.65,75,,,percent of total billed charges,75% of total billed charges,168.65,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,76.69,100,,,Fee Schedule,100% of WV Medicaid Rate,165.8,165,,,Fee Schedule,165% of CMS OPPS Rate,104.14,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.83,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,76.69,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.14,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,31.48,14,,,percent of total billed charges,14% of total billed charges,31.48,495.81,
US Duplex Aorta IVC Limited:Read,596583,CDM,972,RC,93979,HCPCS,Outpatient,,,224.87,112.44,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
93980- Dup scan/art/ven/penile ves/comp,3435555,CDM,510,RC,93980,HCPCS,Outpatient,,,134.54,67.27,,100.91,75,,,percent of total billed charges,75% of total billed charges,100.91,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,77.18,100,,,Fee Schedule,100% of WV Medicaid Rate,165.79,165,,,Fee Schedule,165% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.82,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,77.18,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,18.84,14,,,percent of total billed charges,14% of total billed charges,18.84,495.81,
93981- Dup scan/art/ven/penile ves/f/u lt,3435556,CDM,510,RC,93981,HCPCS,Outpatient,,,115.59,57.8,,86.69,75,,,percent of total billed charges,75% of total billed charges,86.69,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,45.47,100,,,Fee Schedule,100% of WV Medicaid Rate,165.79,165,,,Fee Schedule,165% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.82,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,45.47,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,16.18,14,,,percent of total billed charges,14% of total billed charges,16.18,495.81,
CL US Ext AVF Comp Bilat Upper Pre-Op Wavelinq,3427458,CDM,921,RC,93985,HCPCS,Outpatient,,,508.97,254.49,,381.73,75,,,percent of total billed charges,75% of total billed charges,381.73,75,,,percent of total billed charges,75% of total billed charges,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,257.13,102,,,Fee Schedule,102% of WV Medicaid Rate,362.24,165,,,Fee Schedule,165% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,630.61,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,864.84,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1083.29,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,255.29,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,71.26,14,,,percent of total billed charges,14% of total billed charges,71.26,1083.29,
CL US Ext AVF Comp Upper Pre-Op Wavelinq LT,3427460,CDM,921,RC,93986,HCPCS,Outpatient,,,299.09,149.55,,224.32,75,,,percent of total billed charges,75% of total billed charges,224.32,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,141.78,102,,,Fee Schedule,102% of WV Medicaid Rate,165.79,165,,,Fee Schedule,165% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.82,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,140.91,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,41.87,14,,,percent of total billed charges,14% of total billed charges,41.87,495.81,
CL US Ext AVF Comp Upper Pre-Op Wavelinq RT,3427462,CDM,921,RC,93986,HCPCS,Outpatient,,,299.09,149.55,,224.32,75,,,percent of total billed charges,75% of total billed charges,224.32,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,141.78,102,,,Fee Schedule,102% of WV Medicaid Rate,165.79,165,,,Fee Schedule,165% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.82,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,140.91,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,41.87,14,,,percent of total billed charges,14% of total billed charges,41.87,495.81,
93990- Dup scan/hemodialysis access,3435559,CDM,921,RC,93990,HCPCS,Outpatient,,,295.93,147.97,,221.95,75,,,percent of total billed charges,75% of total billed charges,221.95,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,96.35,100,,,Fee Schedule,100% of WV Medicaid Rate,165.8,165,,,Fee Schedule,165% of CMS OPPS Rate,104.14,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.83,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,96.35,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.14,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,41.43,14,,,percent of total billed charges,14% of total billed charges,41.43,495.81,
Ventilator Initial,617727,CDM,410,RC,94002,HCPCS,Outpatient,,,244.53,122.27,,183.4,75,,,percent of total billed charges,75% of total billed charges,183.4,75,,,percent of total billed charges,75% of total billed charges,523.4,100,,,Fee Schedule,100% of CMS OPPS Rate,65.14,100,,,Fee Schedule,100% of WV Medicaid Rate,863.61,165,,,Fee Schedule,165% of CMS OPPS Rate,542.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1503.41,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2061.81,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,2582.64,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,65.14,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,523.4,100,,,Fee Schedule,100% of CMS OPPS Rate,542.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,34.23,14,,,percent of total billed charges,14% of total billed charges,34.23,2582.64,
Pressure Ventilator,617749,CDM,410,RC,94003,HCPCS,Outpatient,,,171.37,85.69,,128.53,75,,,percent of total billed charges,75% of total billed charges,128.53,75,,,percent of total billed charges,75% of total billed charges,523.4,100,,,Fee Schedule,100% of CMS OPPS Rate,45.72,100,,,Fee Schedule,100% of WV Medicaid Rate,863.61,165,,,Fee Schedule,165% of CMS OPPS Rate,542.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1503.41,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2061.81,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,2582.64,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,45.72,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,523.4,100,,,Fee Schedule,100% of CMS OPPS Rate,542.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,23.99,14,,,percent of total billed charges,14% of total billed charges,23.99,2582.64,
Ventilator Management,617754,CDM,410,RC,94003,HCPCS,Outpatient,,,171.37,85.69,,128.53,75,,,percent of total billed charges,75% of total billed charges,128.53,75,,,percent of total billed charges,75% of total billed charges,523.4,100,,,Fee Schedule,100% of CMS OPPS Rate,45.72,100,,,Fee Schedule,100% of WV Medicaid Rate,863.61,165,,,Fee Schedule,165% of CMS OPPS Rate,542.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1503.41,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2061.81,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,2582.64,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,45.72,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,523.4,100,,,Fee Schedule,100% of CMS OPPS Rate,542.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,23.99,14,,,percent of total billed charges,14% of total billed charges,23.99,2582.64,
94010- Spirometry/include graphic record,3435315,CDM,460,RC,94010,HCPCS,Outpatient,,,43.75,21.88,,32.81,75,,,percent of total billed charges,75% of total billed charges,32.81,75,,,percent of total billed charges,75% of total billed charges,136.72,100,,,Fee Schedule,100% of CMS OPPS Rate,17.21,100,,,Fee Schedule,100% of WV Medicaid Rate,225.6,165,,,Fee Schedule,165% of CMS OPPS Rate,141.7,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,392.73,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,538.6,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,674.65,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,17.21,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,136.72,100,,,Fee Schedule,100% of CMS OPPS Rate,141.7,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,6.13,14,,,percent of total billed charges,14% of total billed charges,6.13,674.65,
PFT (Bedside),617688,CDM,460,RC,94010,HCPCS,Outpatient,,,43.75,21.88,,32.81,75,,,percent of total billed charges,75% of total billed charges,32.81,75,,,percent of total billed charges,75% of total billed charges,136.72,100,,,Fee Schedule,100% of CMS OPPS Rate,17.21,100,,,Fee Schedule,100% of WV Medicaid Rate,225.6,165,,,Fee Schedule,165% of CMS OPPS Rate,141.7,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,392.73,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,538.6,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,674.65,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,17.21,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,136.72,100,,,Fee Schedule,100% of CMS OPPS Rate,141.7,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,6.13,14,,,percent of total billed charges,14% of total billed charges,6.13,674.65,
94011- Spirometric force exp flow/to 2yrs,3435677,CDM,510,RC,94011,HCPCS,Outpatient,,,224.5,112.25,,168.38,75,,,percent of total billed charges,75% of total billed charges,168.38,75,,,percent of total billed charges,75% of total billed charges,136.72,100,,,Fee Schedule,100% of CMS OPPS Rate,59.98,100,,,Fee Schedule,100% of WV Medicaid Rate,225.6,165,,,Fee Schedule,165% of CMS OPPS Rate,141.7,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,392.73,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,538.6,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,674.65,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,59.98,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,136.72,100,,,Fee Schedule,100% of CMS OPPS Rate,141.7,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,31.43,14,,,percent of total billed charges,14% of total billed charges,31.43,674.65,
94012- Spiro force exp flow/dilator/to 2y,3435678,CDM,510,RC,94012,HCPCS,Outpatient,,,368.02,184.01,,276.02,75,,,percent of total billed charges,75% of total billed charges,276.02,75,,,percent of total billed charges,75% of total billed charges,263.3,100,,,Fee Schedule,100% of CMS OPPS Rate,98.32,100,,,Fee Schedule,100% of WV Medicaid Rate,434.45,165,,,Fee Schedule,165% of CMS OPPS Rate,272.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,756.3,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1037.2,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1299.2,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,98.32,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,263.3,100,,,Fee Schedule,100% of CMS OPPS Rate,272.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,51.52,14,,,percent of total billed charges,14% of total billed charges,51.52,1299.2,
94015- Pt init/spiromet rec/hookup,3435681,CDM,510,RC,94015,HCPCS,Outpatient,,,71.37,35.69,,53.53,75,,,percent of total billed charges,75% of total billed charges,53.53,75,,,percent of total billed charges,75% of total billed charges,263.3,100,,,Fee Schedule,100% of CMS OPPS Rate,18.93,100,,,Fee Schedule,100% of WV Medicaid Rate,434.45,165,,,Fee Schedule,165% of CMS OPPS Rate,272.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,756.3,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1037.2,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1299.2,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,18.93,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,263.3,100,,,Fee Schedule,100% of CMS OPPS Rate,272.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,9.99,14,,,percent of total billed charges,14% of total billed charges,9.99,1299.2,
94060- Spirometry/pre/post bronchodilator,3435316,CDM,460,RC,94060,HCPCS,Outpatient,,,1605.41,802.71,,1204.06,75,,,percent of total billed charges,75% of total billed charges,1204.06,75,,,percent of total billed charges,75% of total billed charges,263.29,100,,,Fee Schedule,100% of CMS OPPS Rate,25.07,100,,,Fee Schedule,100% of WV Medicaid Rate,434.44,165,,,Fee Schedule,165% of CMS OPPS Rate,272.88,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,756.29,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1037.2,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1299.2,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,25.07,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,263.29,100,,,Fee Schedule,100% of CMS OPPS Rate,272.88,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,224.76,14,,,percent of total billed charges,14% of total billed charges,25.07,1299.2,
Clinic Spirometry w/ Diffusion Capacity,3435733,CDM,460,RC,94060,HCPCS,Outpatient,,,1605.41,802.71,,1204.06,75,,,percent of total billed charges,75% of total billed charges,1204.06,75,,,percent of total billed charges,75% of total billed charges,263.29,100,,,Fee Schedule,100% of CMS OPPS Rate,25.07,100,,,Fee Schedule,100% of WV Medicaid Rate,434.44,165,,,Fee Schedule,165% of CMS OPPS Rate,272.88,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,756.29,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1037.2,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1299.2,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,25.07,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,263.29,100,,,Fee Schedule,100% of CMS OPPS Rate,272.88,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,224.76,14,,,percent of total billed charges,14% of total billed charges,25.07,1299.2,
Clinic Spirometry with and without,3435734,CDM,460,RC,94060,HCPCS,Outpatient,,,1605.41,802.71,,1204.06,75,,,percent of total billed charges,75% of total billed charges,1204.06,75,,,percent of total billed charges,75% of total billed charges,263.29,100,,,Fee Schedule,100% of CMS OPPS Rate,25.07,100,,,Fee Schedule,100% of WV Medicaid Rate,434.44,165,,,Fee Schedule,165% of CMS OPPS Rate,272.88,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,756.29,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1037.2,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1299.2,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,25.07,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,263.29,100,,,Fee Schedule,100% of CMS OPPS Rate,272.88,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,224.76,14,,,percent of total billed charges,14% of total billed charges,25.07,1299.2,
PFT,617666,CDM,460,RC,94060,HCPCS,Outpatient,,,1605.41,802.71,,1204.06,75,,,percent of total billed charges,75% of total billed charges,1204.06,75,,,percent of total billed charges,75% of total billed charges,263.29,100,,,Fee Schedule,100% of CMS OPPS Rate,25.07,100,,,Fee Schedule,100% of WV Medicaid Rate,434.44,165,,,Fee Schedule,165% of CMS OPPS Rate,272.88,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,756.29,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1037.2,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1299.2,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,25.07,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,263.29,100,,,Fee Schedule,100% of CMS OPPS Rate,272.88,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,224.76,14,,,percent of total billed charges,14% of total billed charges,25.07,1299.2,
6 Minute Walk,658839,CDM,460,RC,94618,HCPCS,Outpatient,,,689.2,344.6,,516.9,75,,,percent of total billed charges,75% of total billed charges,516.9,75,,,percent of total billed charges,75% of total billed charges,109.16,100,,,Fee Schedule,100% of CMS OPPS Rate,22.61,100,,,Fee Schedule,100% of WV Medicaid Rate,180.11,165,,,Fee Schedule,165% of CMS OPPS Rate,113.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,313.55,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,430.01,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,538.63,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,22.61,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,109.16,100,,,Fee Schedule,100% of CMS OPPS Rate,113.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,96.49,14,,,percent of total billed charges,14% of total billed charges,22.61,538.63,
Clinic 6 min walk,3435728,CDM,460,RC,94618,HCPCS,Outpatient,,,689.2,344.6,,516.9,75,,,percent of total billed charges,75% of total billed charges,516.9,75,,,percent of total billed charges,75% of total billed charges,109.16,100,,,Fee Schedule,100% of CMS OPPS Rate,22.61,100,,,Fee Schedule,100% of WV Medicaid Rate,180.11,165,,,Fee Schedule,165% of CMS OPPS Rate,113.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,313.55,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,430.01,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,538.63,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,22.61,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,109.16,100,,,Fee Schedule,100% of CMS OPPS Rate,113.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,96.49,14,,,percent of total billed charges,14% of total billed charges,22.61,538.63,
Clinic 6 min walk with Oxygen titration,3435729,CDM,460,RC,94618,HCPCS,Outpatient,,,689.2,344.6,,516.9,75,,,percent of total billed charges,75% of total billed charges,516.9,75,,,percent of total billed charges,75% of total billed charges,109.16,100,,,Fee Schedule,100% of CMS OPPS Rate,22.61,100,,,Fee Schedule,100% of WV Medicaid Rate,180.11,165,,,Fee Schedule,165% of CMS OPPS Rate,113.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,313.55,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,430.01,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,538.63,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,22.61,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,109.16,100,,,Fee Schedule,100% of CMS OPPS Rate,113.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,96.49,14,,,percent of total billed charges,14% of total billed charges,22.61,538.63,
Six Minute Walk Test,634111,CDM,460,RC,94618,HCPCS,Outpatient,,,689.2,344.6,,516.9,75,,,percent of total billed charges,75% of total billed charges,516.9,75,,,percent of total billed charges,75% of total billed charges,109.16,100,,,Fee Schedule,100% of CMS OPPS Rate,22.61,100,,,Fee Schedule,100% of WV Medicaid Rate,180.11,165,,,Fee Schedule,165% of CMS OPPS Rate,113.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,313.55,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,430.01,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,538.63,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,22.61,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,109.16,100,,,Fee Schedule,100% of CMS OPPS Rate,113.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,96.49,14,,,percent of total billed charges,14% of total billed charges,22.61,538.63,
Phys/QHP OP Puml Rehab WO Mntr,4109131,CDM,948,RC,94625,HCPCS,Outpatient,,,44.38,22.19,,33.29,75,,,percent of total billed charges,75% of total billed charges,33.29,75,,,percent of total billed charges,75% of total billed charges,54.03,100,,,Fee Schedule,100% of CMS OPPS Rate,13.27,100,,,Fee Schedule,100% of WV Medicaid Rate,89.16,165,,,Fee Schedule,165% of CMS OPPS Rate,56,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,155.22,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,212.87,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,266.64,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,13.27,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,54.03,100,,,Fee Schedule,100% of CMS OPPS Rate,56,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,6.21,14,,,percent of total billed charges,14% of total billed charges,6.21,266.64,
94640- Inhalation tx/AAO/therapeutic/diag,3435697,CDM,410,RC,94640,HCPCS,Outpatient,,,26.38,13.19,,19.79,75,,,percent of total billed charges,75% of total billed charges,19.79,75,,,percent of total billed charges,75% of total billed charges,180.04,100,,,Fee Schedule,100% of CMS OPPS Rate,6.88,100,,,Fee Schedule,100% of WV Medicaid Rate,297.06,165,,,Fee Schedule,165% of CMS OPPS Rate,186.59,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,517.14,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,709.22,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,888.37,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,6.88,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,180.04,100,,,Fee Schedule,100% of CMS OPPS Rate,186.59,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,3.69,14,,,percent of total billed charges,14% of total billed charges,3.69,888.37,
Inhaler Treatment,617741,CDM,410,RC,94640,HCPCS,Outpatient,,,26.38,13.19,,19.79,75,,,percent of total billed charges,75% of total billed charges,19.79,75,,,percent of total billed charges,75% of total billed charges,180.04,100,,,Fee Schedule,100% of CMS OPPS Rate,6.88,100,,,Fee Schedule,100% of WV Medicaid Rate,297.06,165,,,Fee Schedule,165% of CMS OPPS Rate,186.59,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,517.14,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,709.22,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,888.37,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,6.88,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,180.04,100,,,Fee Schedule,100% of CMS OPPS Rate,186.59,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,3.69,14,,,percent of total billed charges,14% of total billed charges,3.69,888.37,
IPPB w/ Nebulized Medication,617708,CDM,410,RC,94640,HCPCS,Outpatient,,,26.38,13.19,,19.79,75,,,percent of total billed charges,75% of total billed charges,19.79,75,,,percent of total billed charges,75% of total billed charges,180.04,100,,,Fee Schedule,100% of CMS OPPS Rate,6.88,100,,,Fee Schedule,100% of WV Medicaid Rate,297.06,165,,,Fee Schedule,165% of CMS OPPS Rate,186.59,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,517.14,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,709.22,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,888.37,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,6.88,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,180.04,100,,,Fee Schedule,100% of CMS OPPS Rate,186.59,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,3.69,14,,,percent of total billed charges,14% of total billed charges,3.69,888.37,
Nebulizer,617710,CDM,410,RC,94640,HCPCS,Outpatient,,,26.38,13.19,,19.79,75,,,percent of total billed charges,75% of total billed charges,19.79,75,,,percent of total billed charges,75% of total billed charges,180.04,100,,,Fee Schedule,100% of CMS OPPS Rate,6.88,100,,,Fee Schedule,100% of WV Medicaid Rate,297.06,165,,,Fee Schedule,165% of CMS OPPS Rate,186.59,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,517.14,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,709.22,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,888.37,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,6.88,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,180.04,100,,,Fee Schedule,100% of CMS OPPS Rate,186.59,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,3.69,14,,,percent of total billed charges,14% of total billed charges,3.69,888.37,
94642- Aresol inhale/pentamidine/pneum tx,3435698,CDM,410,RC,94642,HCPCS,Outpatient,,,31.55,15.78,,23.66,75,,,percent of total billed charges,75% of total billed charges,23.66,75,,,percent of total billed charges,75% of total billed charges,180.04,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,297.06,165,,,Fee Schedule,165% of CMS OPPS Rate,186.59,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,517.14,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,709.22,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,888.37,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,180.04,100,,,Fee Schedule,100% of CMS OPPS Rate,186.59,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4.42,14,,,percent of total billed charges,14% of total billed charges,4.42,888.37,
"INH TX AERO,NEB,MDI,IPPB",3428469,CDM,981,RC,94642,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
94644- Cont inhale/aerosol med/AAO/frst h,3435699,CDM,410,RC,94644,HCPCS,Outpatient,,,144.03,72.02,,108.02,75,,,percent of total billed charges,75% of total billed charges,108.02,75,,,percent of total billed charges,75% of total billed charges,109.16,100,,,Fee Schedule,100% of CMS OPPS Rate,38.34,100,,,Fee Schedule,100% of WV Medicaid Rate,180.11,165,,,Fee Schedule,165% of CMS OPPS Rate,113.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,313.55,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,430.01,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,538.63,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,38.34,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,109.16,100,,,Fee Schedule,100% of CMS OPPS Rate,113.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,20.16,14,,,percent of total billed charges,14% of total billed charges,20.16,538.63,
94645- Cont inhale/aerosol med/AAO /ad hr,3435700,CDM,410,RC,94645,HCPCS,Outpatient,,,37.42,18.71,,28.07,75,,,percent of total billed charges,75% of total billed charges,28.07,75,,,percent of total billed charges,75% of total billed charges,11.97,32,,,percent of total billed charges,32% of total billed charges,9.83,100,,,Fee Schedule,100% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.83,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.24,14,,,percent of total billed charges,14% of total billed charges,5.24,28.07,
"94660- CPAP vent, initiat/manage",3435701,CDM,410,RC,94660,HCPCS,Outpatient,,,160.57,80.29,,120.43,75,,,percent of total billed charges,75% of total billed charges,120.43,75,,,percent of total billed charges,75% of total billed charges,180.04,100,,,Fee Schedule,100% of CMS OPPS Rate,26.55,100,,,Fee Schedule,100% of WV Medicaid Rate,297.06,165,,,Fee Schedule,165% of CMS OPPS Rate,186.59,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,517.14,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,709.22,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,888.37,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,26.55,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,180.04,100,,,Fee Schedule,100% of CMS OPPS Rate,186.59,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,22.48,14,,,percent of total billed charges,14% of total billed charges,22.48,888.37,
BIPAP,617723,CDM,410,RC,94660,HCPCS,Outpatient,,,160.57,80.29,,120.43,75,,,percent of total billed charges,75% of total billed charges,120.43,75,,,percent of total billed charges,75% of total billed charges,180.04,100,,,Fee Schedule,100% of CMS OPPS Rate,26.55,100,,,Fee Schedule,100% of WV Medicaid Rate,297.06,165,,,Fee Schedule,165% of CMS OPPS Rate,186.59,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,517.14,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,709.22,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,888.37,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,26.55,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,180.04,100,,,Fee Schedule,100% of CMS OPPS Rate,186.59,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,22.48,14,,,percent of total billed charges,14% of total billed charges,22.48,888.37,
94664- Demo/eval/pt use aerosol/neb/IPPB,3435702,CDM,410,RC,94664,HCPCS,Outpatient,,,39.78,19.89,,29.84,75,,,percent of total billed charges,75% of total billed charges,29.84,75,,,percent of total billed charges,75% of total billed charges,180.04,100,,,Fee Schedule,100% of CMS OPPS Rate,10.57,100,,,Fee Schedule,100% of WV Medicaid Rate,297.06,165,,,Fee Schedule,165% of CMS OPPS Rate,186.59,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,517.14,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,709.22,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,888.37,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,10.57,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,180.04,100,,,Fee Schedule,100% of CMS OPPS Rate,186.59,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,5.57,14,,,percent of total billed charges,14% of total billed charges,5.57,888.37,
Flutter Valve,617739,CDM,410,RC,94664,HCPCS,Outpatient,,,39.78,19.89,,29.84,75,,,percent of total billed charges,75% of total billed charges,29.84,75,,,percent of total billed charges,75% of total billed charges,180.04,100,,,Fee Schedule,100% of CMS OPPS Rate,10.57,100,,,Fee Schedule,100% of WV Medicaid Rate,297.06,165,,,Fee Schedule,165% of CMS OPPS Rate,186.59,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,517.14,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,709.22,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,888.37,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,10.57,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,180.04,100,,,Fee Schedule,100% of CMS OPPS Rate,186.59,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,5.57,14,,,percent of total billed charges,14% of total billed charges,5.57,888.37,
Inhalation Initial Demo/Evaluation,658457,CDM,410,RC,94664,HCPCS,Outpatient,,,39.78,19.89,,29.84,75,,,percent of total billed charges,75% of total billed charges,29.84,75,,,percent of total billed charges,75% of total billed charges,180.04,100,,,Fee Schedule,100% of CMS OPPS Rate,10.57,100,,,Fee Schedule,100% of WV Medicaid Rate,297.06,165,,,Fee Schedule,165% of CMS OPPS Rate,186.59,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,517.14,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,709.22,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,888.37,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,10.57,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,180.04,100,,,Fee Schedule,100% of CMS OPPS Rate,186.59,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,5.57,14,,,percent of total billed charges,14% of total billed charges,5.57,888.37,
94667- Manip chest wall/init demo/eval,3435703,CDM,410,RC,94667,HCPCS,Outpatient,,,53.53,26.77,,40.15,75,,,percent of total billed charges,75% of total billed charges,40.15,75,,,percent of total billed charges,75% of total billed charges,109.16,100,,,Fee Schedule,100% of CMS OPPS Rate,14.26,100,,,Fee Schedule,100% of WV Medicaid Rate,180.11,165,,,Fee Schedule,165% of CMS OPPS Rate,113.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,313.55,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,430.01,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,538.63,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,14.26,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,109.16,100,,,Fee Schedule,100% of CMS OPPS Rate,113.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,7.49,14,,,percent of total billed charges,14% of total billed charges,7.49,538.63,
94668- Manip chest wall/subseq demo/eval,3435704,CDM,410,RC,94668,HCPCS,Outpatient,,,82.76,41.38,,62.07,75,,,percent of total billed charges,75% of total billed charges,62.07,75,,,percent of total billed charges,75% of total billed charges,109.16,100,,,Fee Schedule,100% of CMS OPPS Rate,22.12,100,,,Fee Schedule,100% of WV Medicaid Rate,180.11,165,,,Fee Schedule,165% of CMS OPPS Rate,113.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,313.55,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,430.01,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,538.63,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,22.12,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,109.16,100,,,Fee Schedule,100% of CMS OPPS Rate,113.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,11.59,14,,,percent of total billed charges,14% of total billed charges,11.59,538.63,
IPV Treatment,1083013,CDM,410,RC,94668,HCPCS,Outpatient,,,82.76,41.38,,62.07,75,,,percent of total billed charges,75% of total billed charges,62.07,75,,,percent of total billed charges,75% of total billed charges,109.16,100,,,Fee Schedule,100% of CMS OPPS Rate,22.12,100,,,Fee Schedule,100% of WV Medicaid Rate,180.11,165,,,Fee Schedule,165% of CMS OPPS Rate,113.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,313.55,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,430.01,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,538.63,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,22.12,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,109.16,100,,,Fee Schedule,100% of CMS OPPS Rate,113.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,11.59,14,,,percent of total billed charges,14% of total billed charges,11.59,538.63,
94726 - (TC) Plethysmography Lung Volumes w/wo airway resist,3896962,CDM,460,RC,94726,HCPCS,Outpatient,,,1608.78,804.39,,1206.59,75,,,percent of total billed charges,75% of total billed charges,1206.59,75,,,percent of total billed charges,75% of total billed charges,263.3,100,,,Fee Schedule,100% of CMS OPPS Rate,35.15,100,,,Fee Schedule,100% of WV Medicaid Rate,434.45,165,,,Fee Schedule,165% of CMS OPPS Rate,272.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,756.3,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1037.2,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1299.2,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,35.15,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,263.3,100,,,Fee Schedule,100% of CMS OPPS Rate,272.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,225.23,14,,,percent of total billed charges,14% of total billed charges,35.15,1299.2,
94726 - Plethysmography Lung Volumes w/wo airway resist,3896968,CDM,510,RC,94726,HCPCS,Outpatient,,,1608.78,804.39,,1206.59,75,,,percent of total billed charges,75% of total billed charges,1206.59,75,,,percent of total billed charges,75% of total billed charges,263.3,100,,,Fee Schedule,100% of CMS OPPS Rate,35.15,100,,,Fee Schedule,100% of WV Medicaid Rate,434.45,165,,,Fee Schedule,165% of CMS OPPS Rate,272.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,756.3,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1037.2,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1299.2,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,35.15,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,263.3,100,,,Fee Schedule,100% of CMS OPPS Rate,272.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,225.23,14,,,percent of total billed charges,14% of total billed charges,35.15,1299.2,
94726- Plethysmography/lung volume,3435709,CDM,460,RC,94726,HCPCS,Outpatient,,,1608.78,804.39,,1206.59,75,,,percent of total billed charges,75% of total billed charges,1206.59,75,,,percent of total billed charges,75% of total billed charges,263.3,100,,,Fee Schedule,100% of CMS OPPS Rate,35.15,100,,,Fee Schedule,100% of WV Medicaid Rate,434.45,165,,,Fee Schedule,165% of CMS OPPS Rate,272.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,756.3,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1037.2,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1299.2,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,35.15,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,263.3,100,,,Fee Schedule,100% of CMS OPPS Rate,272.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,225.23,14,,,percent of total billed charges,14% of total billed charges,35.15,1299.2,
Clinic Lung Volumes,3435732,CDM,460,RC,94726,HCPCS,Outpatient,,,1608.78,804.39,,1206.59,75,,,percent of total billed charges,75% of total billed charges,1206.59,75,,,percent of total billed charges,75% of total billed charges,263.3,100,,,Fee Schedule,100% of CMS OPPS Rate,35.15,100,,,Fee Schedule,100% of WV Medicaid Rate,434.45,165,,,Fee Schedule,165% of CMS OPPS Rate,272.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,756.3,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1037.2,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1299.2,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,35.15,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,263.3,100,,,Fee Schedule,100% of CMS OPPS Rate,272.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,225.23,14,,,percent of total billed charges,14% of total billed charges,35.15,1299.2,
Lung Vol & Capacity,617686,CDM,460,RC,94726,HCPCS,Outpatient,,,1608.78,804.39,,1206.59,75,,,percent of total billed charges,75% of total billed charges,1206.59,75,,,percent of total billed charges,75% of total billed charges,263.3,100,,,Fee Schedule,100% of CMS OPPS Rate,35.15,100,,,Fee Schedule,100% of WV Medicaid Rate,434.45,165,,,Fee Schedule,165% of CMS OPPS Rate,272.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,756.3,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1037.2,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1299.2,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,35.15,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,263.3,100,,,Fee Schedule,100% of CMS OPPS Rate,272.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,225.23,14,,,percent of total billed charges,14% of total billed charges,35.15,1299.2,
94729- Diffusing capacity/CO2/add on,3435712,CDM,460,RC,94729,HCPCS,Outpatient,,,247.73,123.87,,185.8,75,,,percent of total billed charges,75% of total billed charges,185.8,75,,,percent of total billed charges,75% of total billed charges,79.27,32,,,percent of total billed charges,32% of total billed charges,37.11,100,,,Fee Schedule,100% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.11,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.68,14,,,percent of total billed charges,14% of total billed charges,34.68,185.8,
Carbon Monoxide Diffusing Capacity,625084,CDM,460,RC,94729,HCPCS,Outpatient,,,247.73,123.87,,185.8,75,,,percent of total billed charges,75% of total billed charges,185.8,75,,,percent of total billed charges,75% of total billed charges,79.27,32,,,percent of total billed charges,32% of total billed charges,37.11,100,,,Fee Schedule,100% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.11,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.68,14,,,percent of total billed charges,14% of total billed charges,34.68,185.8,
Clinic Diffusion Capacity,3435730,CDM,460,RC,94729,HCPCS,Outpatient,,,247.73,123.87,,185.8,75,,,percent of total billed charges,75% of total billed charges,185.8,75,,,percent of total billed charges,75% of total billed charges,79.27,32,,,percent of total billed charges,32% of total billed charges,37.11,100,,,Fee Schedule,100% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.11,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.68,14,,,percent of total billed charges,14% of total billed charges,34.68,185.8,
DLCO,617682,CDM,460,RC,94729,HCPCS,Outpatient,,,247.73,123.87,,185.8,75,,,percent of total billed charges,75% of total billed charges,185.8,75,,,percent of total billed charges,75% of total billed charges,79.27,32,,,percent of total billed charges,32% of total billed charges,37.11,100,,,Fee Schedule,100% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.11,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.68,14,,,percent of total billed charges,14% of total billed charges,34.68,185.8,
94760- Noninv ear/pulse ox/single determ,3435714,CDM,460,RC,94760,HCPCS,Outpatient,,,5.85,2.93,,4.39,75,,,percent of total billed charges,75% of total billed charges,4.39,75,,,percent of total billed charges,75% of total billed charges,1.87,32,,,percent of total billed charges,32% of total billed charges,1.47,100,,,Fee Schedule,100% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.47,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,1.47,4.39,
Ear Oximeter,617770,CDM,460,RC,94760,HCPCS,Outpatient,,,5.85,2.93,,4.39,75,,,percent of total billed charges,75% of total billed charges,4.39,75,,,percent of total billed charges,75% of total billed charges,1.87,32,,,percent of total billed charges,32% of total billed charges,1.47,100,,,Fee Schedule,100% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.47,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,1.47,4.39,
Pulse Oximetry Determination,1727099,CDM,460,RC,94760,HCPCS,Outpatient,,,5.85,2.93,,4.39,75,,,percent of total billed charges,75% of total billed charges,4.39,75,,,percent of total billed charges,75% of total billed charges,1.87,32,,,percent of total billed charges,32% of total billed charges,1.47,100,,,Fee Schedule,100% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.47,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,1.47,4.39,
94761- Noninv ear/pulse ox/multipl determ,3435715,CDM,460,RC,94761,HCPCS,Outpatient,,,8.22,4.11,,6.17,75,,,percent of total billed charges,75% of total billed charges,6.17,75,,,percent of total billed charges,75% of total billed charges,2.63,32,,,percent of total billed charges,32% of total billed charges,2.21,100,,,Fee Schedule,100% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.21,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.15,14,,,percent of total billed charges,14% of total billed charges,1.15,6.17,
"95044- Allg patch or app, # of tests",3428645,CDM,920,RC,95044,HCPCS,Outpatient,,,12.16,6.08,,9.12,75,,,percent of total billed charges,75% of total billed charges,9.12,75,,,percent of total billed charges,75% of total billed charges,878.47,100,,,Fee Schedule,100% of CMS OPPS Rate,3.2,100,,,Fee Schedule,100% of WV Medicaid Rate,1449.48,165,,,Fee Schedule,165% of CMS OPPS Rate,910.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,2523.29,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,3460.49,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,4334.61,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,3.2,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,878.47,100,,,Fee Schedule,100% of CMS OPPS Rate,910.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1.7,14,,,percent of total billed charges,14% of total billed charges,1.7,4334.61,
95060- Ophthalmic Mucous Membrane Tests,3428646,CDM,960,RC,95060,HCPCS,Outpatient,,,716,358,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
95060-OCC Ophthalmic Mucous Membrane Tests,3536985,CDM,983,RC,95060,HCPCS,Outpatient,,,716,358,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
95800- Stdy Unatnd w/Hrt Rt/O2 Sat/Resp/Slp Time,4347083,CDM,510,RC,95800,HCPCS,Outpatient,,,867.35,433.68,,650.51,75,,,percent of total billed charges,75% of total billed charges,650.51,75,,,percent of total billed charges,75% of total billed charges,136.72,100,,,Fee Schedule,100% of CMS OPPS Rate,103.24,100,,,Fee Schedule,100% of WV Medicaid Rate,225.58,165,,,Fee Schedule,165% of CMS OPPS Rate,141.69,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,392.72,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,538.59,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,674.64,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,103.24,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,136.72,100,,,Fee Schedule,100% of CMS OPPS Rate,141.69,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,121.43,14,,,percent of total billed charges,14% of total billed charges,103.24,674.64,
95801- Slp Stdy Unatnd w/Min Hrt Rt/O2 Sat/Resp Analys,4347084,CDM,510,RC,95801,HCPCS,Outpatient,,,389.8,194.9,,292.35,75,,,percent of total billed charges,75% of total billed charges,292.35,75,,,percent of total billed charges,75% of total billed charges,109.16,100,,,Fee Schedule,100% of CMS OPPS Rate,59.98,100,,,Fee Schedule,100% of WV Medicaid Rate,180.11,165,,,Fee Schedule,165% of CMS OPPS Rate,113.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,313.55,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,430.01,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,538.63,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,59.98,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,109.16,100,,,Fee Schedule,100% of CMS OPPS Rate,113.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,54.57,14,,,percent of total billed charges,14% of total billed charges,54.57,538.63,
Sleep Study - In Lab MSLT 95805,3575514,CDM,920,RC,95805,HCPCS,Outpatient,,,2819.94,1409.97,,2114.96,75,,,percent of total billed charges,75% of total billed charges,2114.96,75,,,percent of total billed charges,75% of total billed charges,454.5,100,,,Fee Schedule,100% of CMS OPPS Rate,265.7,100,,,Fee Schedule,100% of WV Medicaid Rate,749.91,165,,,Fee Schedule,165% of CMS OPPS Rate,471.04,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1305.49,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1790.39,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,2242.64,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,265.7,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,454.5,100,,,Fee Schedule,100% of CMS OPPS Rate,471.04,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,394.79,14,,,percent of total billed charges,14% of total billed charges,265.7,2242.64,
Sleep Study - Home Study 95806,3575513,CDM,920,RC,95806,HCPCS,Outpatient,,,875.89,437.95,,656.92,75,,,percent of total billed charges,75% of total billed charges,656.92,75,,,percent of total billed charges,75% of total billed charges,136.72,100,,,Fee Schedule,100% of CMS OPPS Rate,60.71,100,,,Fee Schedule,100% of WV Medicaid Rate,225.58,165,,,Fee Schedule,165% of CMS OPPS Rate,141.69,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,392.72,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,538.59,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,674.64,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,60.71,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,136.72,100,,,Fee Schedule,100% of CMS OPPS Rate,141.69,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,122.62,14,,,percent of total billed charges,14% of total billed charges,60.71,674.64,
95807 - Sleep Study - Attended,4347085,CDM,510,RC,95807,HCPCS,Outpatient,,,3168.77,1584.39,,2376.58,75,,,percent of total billed charges,75% of total billed charges,2376.58,75,,,percent of total billed charges,75% of total billed charges,454.5,100,,,Fee Schedule,100% of CMS OPPS Rate,242.11,100,,,Fee Schedule,100% of WV Medicaid Rate,749.91,165,,,Fee Schedule,165% of CMS OPPS Rate,471.04,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1305.49,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1790.39,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,2242.64,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,242.11,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,454.5,100,,,Fee Schedule,100% of CMS OPPS Rate,471.04,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,443.63,14,,,percent of total billed charges,14% of total billed charges,242.11,2376.58,
95808- Polysomnography/any age/tech,3430545,CDM,510,RC,95808,HCPCS,Outpatient,,,5444.39,2722.2,,4083.29,75,,,percent of total billed charges,75% of total billed charges,4083.29,75,,,percent of total billed charges,75% of total billed charges,878.46,100,,,Fee Schedule,100% of CMS OPPS Rate,425.48,100,,,Fee Schedule,100% of WV Medicaid Rate,1449.46,165,,,Fee Schedule,165% of CMS OPPS Rate,910.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,2523.29,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,3460.48,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,4334.6,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,425.48,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,878.46,100,,,Fee Schedule,100% of CMS OPPS Rate,910.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,762.21,14,,,percent of total billed charges,14% of total billed charges,425.48,4334.6,
Sleep Study - In Lab PSG 95810,3575515,CDM,740,RC,95810,HCPCS,Outpatient,,,5514.29,2757.15,,4135.72,75,,,percent of total billed charges,75% of total billed charges,4135.72,75,,,percent of total billed charges,75% of total billed charges,878.46,100,,,Fee Schedule,100% of CMS OPPS Rate,389.35,100,,,Fee Schedule,100% of WV Medicaid Rate,1449.46,165,,,Fee Schedule,165% of CMS OPPS Rate,910.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,2523.29,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,3460.48,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,4334.6,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,389.35,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,878.46,100,,,Fee Schedule,100% of CMS OPPS Rate,910.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,772,14,,,percent of total billed charges,14% of total billed charges,389.35,4334.6,
Sleep Study - In Lab Titration 95811,3575516,CDM,740,RC,95811,HCPCS,Outpatient,,,5523.93,2761.97,,4142.95,75,,,percent of total billed charges,75% of total billed charges,4142.95,75,,,percent of total billed charges,75% of total billed charges,878.46,100,,,Fee Schedule,100% of CMS OPPS Rate,406.55,100,,,Fee Schedule,100% of WV Medicaid Rate,1449.46,165,,,Fee Schedule,165% of CMS OPPS Rate,910.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,2523.29,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,3460.48,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,4334.6,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,406.55,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,878.46,100,,,Fee Schedule,100% of CMS OPPS Rate,910.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,773.35,14,,,percent of total billed charges,14% of total billed charges,406.55,4334.6,
Clinic EEG,3435538,CDM,740,RC,95812,HCPCS,Outpatient,,,1886.96,943.48,,1415.22,75,,,percent of total billed charges,75% of total billed charges,1415.22,75,,,percent of total billed charges,75% of total billed charges,263.29,100,,,Fee Schedule,100% of CMS OPPS Rate,221.47,100,,,Fee Schedule,100% of WV Medicaid Rate,434.44,165,,,Fee Schedule,165% of CMS OPPS Rate,272.88,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,756.29,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1037.2,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1299.2,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,221.47,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,263.29,100,,,Fee Schedule,100% of CMS OPPS Rate,272.88,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,264.17,14,,,percent of total billed charges,14% of total billed charges,221.47,1415.22,
CL EEG Routine 61- 199 Minutes 95813,4339185,CDM,740,RC,95813,HCPCS,Outpatient,,,2038.72,1019.36,,1529.04,75,,,percent of total billed charges,75% of total billed charges,1529.04,75,,,percent of total billed charges,75% of total billed charges,263.29,100,,,Fee Schedule,100% of CMS OPPS Rate,275.05,100,,,Fee Schedule,100% of WV Medicaid Rate,434.44,165,,,Fee Schedule,165% of CMS OPPS Rate,272.88,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,756.29,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1037.2,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1299.2,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,275.05,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,263.29,100,,,Fee Schedule,100% of CMS OPPS Rate,272.88,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,285.42,14,,,percent of total billed charges,14% of total billed charges,263.29,1529.04,
95816- EEG w/recording/awake/drowsy,3435465,CDM,740,RC,95816,HCPCS,Outpatient,,,1448.11,724.06,,1086.08,75,,,percent of total billed charges,75% of total billed charges,1086.08,75,,,percent of total billed charges,75% of total billed charges,263.29,100,,,Fee Schedule,100% of CMS OPPS Rate,243.83,100,,,Fee Schedule,100% of WV Medicaid Rate,434.44,165,,,Fee Schedule,165% of CMS OPPS Rate,272.88,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,756.29,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1037.2,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1299.2,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,243.83,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,263.29,100,,,Fee Schedule,100% of CMS OPPS Rate,272.88,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,202.74,14,,,percent of total billed charges,14% of total billed charges,202.74,1299.2,
95822 - (TC) Electroencephalogram (EEG); recording in coma or sleep only,3899092,CDM,983,RC,95822,HCPCS,Outpatient,,,1696.93,848.47,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
95822 - Electroencephalogram (EEG); recording in coma or sleep only,3800934,CDM,983,RC,95822,HCPCS,Outpatient,,,1696.93,848.47,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
95874- Needle EMG/chemodenervation,3435483,CDM,510,RC,95874,HCPCS,Outpatient,,,988.42,494.21,,741.32,75,,,percent of total billed charges,75% of total billed charges,741.32,75,,,percent of total billed charges,75% of total billed charges,316.29,32,,,percent of total billed charges,32% of total billed charges,51.62,100,,,Fee Schedule,100% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.62,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,138.38,14,,,percent of total billed charges,14% of total billed charges,51.62,741.32,
Clinic EMG,3435539,CDM,510,RC,95874,HCPCS,Outpatient,,,988.42,494.21,,741.32,75,,,percent of total billed charges,75% of total billed charges,741.32,75,,,percent of total billed charges,75% of total billed charges,316.29,32,,,percent of total billed charges,32% of total billed charges,51.62,100,,,Fee Schedule,100% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.62,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,138.38,14,,,percent of total billed charges,14% of total billed charges,51.62,741.32,
95905- Motor/sensory nerve conduction/I&R,3435490,CDM,510,RC,95905,HCPCS,Outpatient,,,1777.31,888.66,,1332.98,75,,,percent of total billed charges,75% of total billed charges,1332.98,75,,,percent of total billed charges,75% of total billed charges,354.97,100,,,Fee Schedule,100% of CMS OPPS Rate,24.33,100,,,Fee Schedule,100% of WV Medicaid Rate,585.71,165,,,Fee Schedule,165% of CMS OPPS Rate,367.9,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1019.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1398.33,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1751.55,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,24.33,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,354.97,100,,,Fee Schedule,100% of CMS OPPS Rate,367.9,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,248.82,14,,,percent of total billed charges,14% of total billed charges,24.33,1751.55,
95983 - Elec Anlys Implnt Brn Npgt Prgrmg 1st 15 Min,4315922,CDM,920,RC,95983,HCPCS,Outpatient,,,550.18,275.09,,412.64,75,,,percent of total billed charges,75% of total billed charges,412.64,75,,,percent of total billed charges,75% of total billed charges,93.83,100,,,Fee Schedule,100% of CMS OPPS Rate,34.9,100,,,Fee Schedule,100% of WV Medicaid Rate,154.82,165,,,Fee Schedule,165% of CMS OPPS Rate,97.24,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,269.52,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,369.64,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,463.01,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,34.9,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,93.83,100,,,Fee Schedule,100% of CMS OPPS Rate,97.24,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,77.03,14,,,percent of total billed charges,14% of total billed charges,34.9,463.01,
95984 - Elec Anlys Implnt Brn Npgt Prgrmg Ea Addl 15 Min,4315923,CDM,920,RC,95984,HCPCS,Outpatient,,,679.95,339.98,,509.96,75,,,percent of total billed charges,75% of total billed charges,509.96,75,,,percent of total billed charges,75% of total billed charges,217.58,32,,,percent of total billed charges,32% of total billed charges,30.73,100,,,Fee Schedule,100% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.73,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,95.19,14,,,percent of total billed charges,14% of total billed charges,30.73,509.96,
"96130 - Psychological Testing, first hour",3438204,CDM,983,RC,96130,HCPCS,Outpatient,,,314.04,157.02,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
96150 Health and Behavior Initial assessment each 15 min,3438181,CDM,983,RC,96150,HCPCS,Outpatient,,,61.08,30.54,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
96156 - Health Coach Assessment,3635244,CDM,510,RC,96156,HCPCS,Outpatient,,,630.86,315.43,,473.15,75,,,percent of total billed charges,75% of total billed charges,473.15,75,,,percent of total billed charges,75% of total billed charges,71.29,100,,,Fee Schedule,100% of CMS OPPS Rate,60.96,100,,,Fee Schedule,100% of WV Medicaid Rate,117.66,165,,,Fee Schedule,165% of CMS OPPS Rate,73.9,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,204.82,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,280.89,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,351.86,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,60.96,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,71.29,100,,,Fee Schedule,100% of CMS OPPS Rate,73.9,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,88.32,14,,,percent of total billed charges,14% of total billed charges,60.96,473.15,
96158 - Health Coach Initial 30 Mins,3635247,CDM,510,RC,96158,HCPCS,Outpatient,,,926.3,463.15,,694.73,75,,,percent of total billed charges,75% of total billed charges,694.73,75,,,percent of total billed charges,75% of total billed charges,71.29,100,,,Fee Schedule,100% of CMS OPPS Rate,41.79,100,,,Fee Schedule,100% of WV Medicaid Rate,117.66,165,,,Fee Schedule,165% of CMS OPPS Rate,73.9,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,204.82,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,280.89,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,351.86,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,41.79,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,71.29,100,,,Fee Schedule,100% of CMS OPPS Rate,73.9,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,129.68,14,,,percent of total billed charges,14% of total billed charges,41.79,694.73,
"96360- Hydration, first hour",3428356,CDM,981,RC,96360,HCPCS,Outpatient,,,82.6,41.3,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
"96361- Hydration, each additional hour",3428357,CDM,981,RC,96361,HCPCS,Outpatient,,,31.48,15.74,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
"96365- IV tx, first hour",3428358,CDM,483,RC,96365,HCPCS,Outpatient,,,161.93,80.97,,121.45,75,,,percent of total billed charges,75% of total billed charges,121.45,75,,,percent of total billed charges,75% of total billed charges,194.2,100,,,Fee Schedule,100% of CMS OPPS Rate,43.26,100,,,Fee Schedule,100% of WV Medicaid Rate,320.44,165,,,Fee Schedule,165% of CMS OPPS Rate,201.28,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,557.84,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,765.02,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,958.27,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,43.26,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,194.2,100,,,Fee Schedule,100% of CMS OPPS Rate,201.28,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,22.67,14,,,percent of total billed charges,14% of total billed charges,22.67,958.27,
"96366- IV tx, each additional hour",3428359,CDM,960,RC,96366,HCPCS,Outpatient,,,51.62,25.81,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
"96367- IV tx, sequential infusion",3428360,CDM,960,RC,96367,HCPCS,Outpatient,,,73.39,36.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
"96368- IV tx, concurrent infusion",3428361,CDM,960,RC,96368,HCPCS,Outpatient,,,49.9,24.95,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
96372 - IM/SQ injectin,3918946,CDM,510,RC,96372,HCPCS,Outpatient,,,391.8,195.9,,293.85,75,,,percent of total billed charges,75% of total billed charges,293.85,75,,,percent of total billed charges,75% of total billed charges,63.43,100,,,Fee Schedule,100% of CMS OPPS Rate,9.59,100,,,Fee Schedule,100% of WV Medicaid Rate,104.66,165,,,Fee Schedule,165% of CMS OPPS Rate,65.74,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,182.2,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,249.87,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,312.99,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,9.59,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,63.43,100,,,Fee Schedule,100% of CMS OPPS Rate,65.74,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,54.85,14,,,percent of total billed charges,14% of total billed charges,9.59,312.99,
96372 Injection of drug/substance under skin or into muscle,4137108,CDM,761,RC,96372,HCPCS,Outpatient,,,364.11,182.06,,273.08,75,,,percent of total billed charges,75% of total billed charges,273.08,75,,,percent of total billed charges,75% of total billed charges,63.43,100,,,Fee Schedule,100% of CMS OPPS Rate,9.59,100,,,Fee Schedule,100% of WV Medicaid Rate,104.66,165,,,Fee Schedule,165% of CMS OPPS Rate,65.74,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,182.2,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,249.87,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,312.99,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,9.59,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,63.43,100,,,Fee Schedule,100% of CMS OPPS Rate,65.74,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,50.98,14,,,percent of total billed charges,14% of total billed charges,9.59,312.99,
96372- Subq/IM Injection,3428362,CDM,761,RC,96372,HCPCS,Outpatient,,,391.8,195.9,,293.85,75,,,percent of total billed charges,75% of total billed charges,293.85,75,,,percent of total billed charges,75% of total billed charges,63.43,100,,,Fee Schedule,100% of CMS OPPS Rate,9.59,100,,,Fee Schedule,100% of WV Medicaid Rate,104.66,165,,,Fee Schedule,165% of CMS OPPS Rate,65.74,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,182.2,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,249.87,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,312.99,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,9.59,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,63.43,100,,,Fee Schedule,100% of CMS OPPS Rate,65.74,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,54.85,14,,,percent of total billed charges,14% of total billed charges,9.59,312.99,
AMB Admin Injection Charge:IM/SQ Admin Charge 96372,3444224,CDM,260,RC,96372,HCPCS,Outpatient,,,364.11,182.06,,273.08,75,,,percent of total billed charges,75% of total billed charges,273.08,75,,,percent of total billed charges,75% of total billed charges,63.43,100,,,Fee Schedule,100% of CMS OPPS Rate,9.59,100,,,Fee Schedule,100% of WV Medicaid Rate,104.66,165,,,Fee Schedule,165% of CMS OPPS Rate,65.74,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,182.2,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,249.87,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,312.99,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,9.59,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,63.43,100,,,Fee Schedule,100% of CMS OPPS Rate,65.74,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,50.98,14,,,percent of total billed charges,14% of total billed charges,9.59,312.99,
96373- Intra-Arterial Injection,3428363,CDM,940,RC,96373,HCPCS,Outpatient,,,44.39,22.2,,33.29,75,,,percent of total billed charges,75% of total billed charges,33.29,75,,,percent of total billed charges,75% of total billed charges,194.2,100,,,Fee Schedule,100% of CMS OPPS Rate,11.8,100,,,Fee Schedule,100% of WV Medicaid Rate,320.44,165,,,Fee Schedule,165% of CMS OPPS Rate,201.28,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,557.84,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,765.02,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,958.27,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,11.8,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,194.2,100,,,Fee Schedule,100% of CMS OPPS Rate,201.28,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,6.21,14,,,percent of total billed charges,14% of total billed charges,6.21,958.27,
96374 - Ther/proph/diag inj iv push,3430547,CDM,940,RC,96374,HCPCS,Outpatient,,,1082.37,541.19,,811.78,75,,,percent of total billed charges,75% of total billed charges,811.78,75,,,percent of total billed charges,75% of total billed charges,194.2,100,,,Fee Schedule,100% of CMS OPPS Rate,25.07,100,,,Fee Schedule,100% of WV Medicaid Rate,320.44,165,,,Fee Schedule,165% of CMS OPPS Rate,201.28,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,557.84,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,765.02,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,958.27,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,25.07,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,194.2,100,,,Fee Schedule,100% of CMS OPPS Rate,201.28,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,151.53,14,,,percent of total billed charges,14% of total billed charges,25.07,958.27,
"96374- IV Injection, single/initial",3428364,CDM,940,RC,96374,HCPCS,Outpatient,,,1150.57,575.29,,862.93,75,,,percent of total billed charges,75% of total billed charges,862.93,75,,,percent of total billed charges,75% of total billed charges,194.2,100,,,Fee Schedule,100% of CMS OPPS Rate,25.07,100,,,Fee Schedule,100% of WV Medicaid Rate,320.44,165,,,Fee Schedule,165% of CMS OPPS Rate,201.28,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,557.84,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,765.02,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,958.27,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,25.07,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,194.2,100,,,Fee Schedule,100% of CMS OPPS Rate,201.28,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,161.08,14,,,percent of total billed charges,14% of total billed charges,25.07,958.27,
AMB Admin Injection Charge:IV Push Admin Charge 96374,3444223,CDM,771,RC,96374,HCPCS,Outpatient,,,68.2,34.1,,51.15,75,,,percent of total billed charges,75% of total billed charges,51.15,75,,,percent of total billed charges,75% of total billed charges,194.2,100,,,Fee Schedule,100% of CMS OPPS Rate,25.07,100,,,Fee Schedule,100% of WV Medicaid Rate,320.44,165,,,Fee Schedule,165% of CMS OPPS Rate,201.28,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,557.84,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,765.02,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,958.27,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,25.07,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,194.2,100,,,Fee Schedule,100% of CMS OPPS Rate,201.28,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,9.55,14,,,percent of total billed charges,14% of total billed charges,9.55,958.27,
"96375- IV Injection, add new drug",3428365,CDM,981,RC,96375,HCPCS,Outpatient,,,38.71,19.36,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
FBC IVP New,2058177,CDM,940,RC,96375,HCPCS,Outpatient,,,38.71,19.36,,29.03,75,,,percent of total billed charges,75% of total billed charges,29.03,75,,,percent of total billed charges,75% of total billed charges,39.83,100,,,Fee Schedule,100% of CMS OPPS Rate,10.32,100,,,Fee Schedule,100% of WV Medicaid Rate,65.72,165,,,Fee Schedule,165% of CMS OPPS Rate,41.28,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,114.41,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,156.91,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,196.54,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,10.32,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,39.83,100,,,Fee Schedule,100% of CMS OPPS Rate,41.28,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,5.42,14,,,percent of total billed charges,14% of total billed charges,5.42,196.54,
Admin leuprolide Charge:INJ Admin Charge 96401,3444231,CDM,331,RC,96401,HCPCS,Outpatient,,,517.95,258.98,,388.46,75,,,percent of total billed charges,75% of total billed charges,388.46,75,,,percent of total billed charges,75% of total billed charges,63.43,100,,,Fee Schedule,100% of CMS OPPS Rate,48.67,100,,,Fee Schedule,100% of WV Medicaid Rate,104.66,165,,,Fee Schedule,165% of CMS OPPS Rate,65.74,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,182.2,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,249.87,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,312.99,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,48.67,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,63.43,100,,,Fee Schedule,100% of CMS OPPS Rate,65.74,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,72.51,14,,,percent of total billed charges,14% of total billed charges,48.67,388.46,
"96402 - Chemotherapy administration, subcutaneous or intramu",3918947,CDM,331,RC,96402,HCPCS,Outpatient,,,408.33,204.17,,306.25,75,,,percent of total billed charges,75% of total billed charges,306.25,75,,,percent of total billed charges,75% of total billed charges,63.43,100,,,Fee Schedule,100% of CMS OPPS Rate,21.38,100,,,Fee Schedule,100% of WV Medicaid Rate,104.66,165,,,Fee Schedule,165% of CMS OPPS Rate,65.74,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,182.2,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,249.87,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,312.99,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,21.38,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,63.43,100,,,Fee Schedule,100% of CMS OPPS Rate,65.74,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,57.17,14,,,percent of total billed charges,14% of total billed charges,21.38,312.99,
Admin leuprolide Charge -> INJ Admin Charge 96402,3556751,CDM,331,RC,96402,HCPCS,Outpatient,,,80.5,40.25,,60.38,75,,,percent of total billed charges,75% of total billed charges,60.38,75,,,percent of total billed charges,75% of total billed charges,63.43,100,,,Fee Schedule,100% of CMS OPPS Rate,21.38,100,,,Fee Schedule,100% of WV Medicaid Rate,104.66,165,,,Fee Schedule,165% of CMS OPPS Rate,65.74,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,182.2,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,249.87,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,312.99,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,21.38,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,63.43,100,,,Fee Schedule,100% of CMS OPPS Rate,65.74,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,11.27,14,,,percent of total billed charges,14% of total billed charges,11.27,312.99,
INJ Nonhormonal A/Neo 96402,4297300,CDM,331,RC,96402,HCPCS,Outpatient,,,408.33,204.17,,306.25,75,,,percent of total billed charges,75% of total billed charges,306.25,75,,,percent of total billed charges,75% of total billed charges,63.43,100,,,Fee Schedule,100% of CMS OPPS Rate,21.38,100,,,Fee Schedule,100% of WV Medicaid Rate,104.66,165,,,Fee Schedule,165% of CMS OPPS Rate,65.74,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,182.2,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,249.87,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,312.99,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,21.38,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,63.43,100,,,Fee Schedule,100% of CMS OPPS Rate,65.74,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,57.17,14,,,percent of total billed charges,14% of total billed charges,21.38,312.99,
96522 Refill/maint pump/resvr syst,3428367,CDM,983,RC,96522,HCPCS,Outpatient,,,291.42,145.71,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
96523  Irrig drug delivery device,3428368,CDM,983,RC,96523,HCPCS,Outpatient,,,63.53,31.77,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
96920 Excimer lsr psriasis<250sqcm,3431074,CDM,940,RC,96920,HCPCS,Outpatient,,,1136.12,568.06,,852.09,75,,,percent of total billed charges,75% of total billed charges,852.09,75,,,percent of total billed charges,75% of total billed charges,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,43.75,100,,,Fee Schedule,100% of WV Medicaid Rate,280.12,165,,,Fee Schedule,165% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,487.65,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,668.78,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,837.71,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,43.75,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,159.06,14,,,percent of total billed charges,14% of total billed charges,43.75,852.09,
96921- Excimer lsr psriasis 250-500,3431095,CDM,940,RC,96921,HCPCS,Outpatient,,,1152.85,576.43,,864.64,75,,,percent of total billed charges,75% of total billed charges,864.64,75,,,percent of total billed charges,75% of total billed charges,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,48.91,100,,,Fee Schedule,100% of WV Medicaid Rate,280.12,165,,,Fee Schedule,165% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,487.65,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,668.78,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,837.71,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,48.91,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,161.4,14,,,percent of total billed charges,14% of total billed charges,48.91,864.64,
97010 Application Modality 1/> Areas Hot/Cold Packs,3436063,CDM,761,RC,97010,HCPCS,Outpatient,,,38.12,19.06,,28.59,75,,,percent of total billed charges,75% of total billed charges,28.59,75,,,percent of total billed charges,75% of total billed charges,5.95,100,,,Fee Schedule,100% of CMS OPPS Rate,3.93,100,,,Fee Schedule,100% of WV Medicaid Rate,9.82,165,,,Fee Schedule,165% of CMS OPPS Rate,5.81,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,21.1,354.54,,,Fee Schedule,354.54% of CMS OPPS Fee Schedule Rate,25.51,428.7,,,Fee Schedule,428.7% of CMS OPPS Fee Schedule Rate,26.82,450.81,,,Fee Schedule,450.81% of CMS OPPS Fee Schedule Rate,3.93,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,5.95,100,,,Fee Schedule,100% of CMS OPPS Rate,5.81,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,5.34,14,,,percent of total billed charges,14% of total billed charges,3.93,28.59,
97010-HOT/COLD PACKS,3430549,CDM,421,RC,97010,HCPCS,Outpatient,,,50.39,25.2,,37.79,75,,,percent of total billed charges,75% of total billed charges,37.79,75,,,percent of total billed charges,75% of total billed charges,5.95,100,,,Fee Schedule,100% of CMS OPPS Rate,3.93,100,,,Fee Schedule,100% of WV Medicaid Rate,9.82,165,,,Fee Schedule,165% of CMS OPPS Rate,5.81,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,21.1,354.54,,,Fee Schedule,354.54% of CMS OPPS Fee Schedule Rate,25.51,428.7,,,Fee Schedule,428.7% of CMS OPPS Fee Schedule Rate,26.82,450.81,,,Fee Schedule,450.81% of CMS OPPS Fee Schedule Rate,3.93,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,5.95,100,,,Fee Schedule,100% of CMS OPPS Rate,5.81,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,7.05,14,,,percent of total billed charges,14% of total billed charges,3.93,37.79,
97014 Appl Modality 1/> Areas Elec Stimj Unattended,3351852,CDM,761,RC,97014,HCPCS,Outpatient,,,55.47,27.74,,41.6,75,,,percent of total billed charges,75% of total billed charges,41.6,75,,,percent of total billed charges,75% of total billed charges,17.75,32,,,percent of total billed charges,32% of total billed charges,8.36,100,,,Fee Schedule,100% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.36,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.77,14,,,percent of total billed charges,14% of total billed charges,7.77,41.6,
97014-PT E-STIM UNATTENDED(WOUND),3430550,CDM,421,RC,97014,HCPCS,Outpatient,,,229.19,114.6,,171.89,75,,,percent of total billed charges,75% of total billed charges,171.89,75,,,percent of total billed charges,75% of total billed charges,73.34,32,,,percent of total billed charges,32% of total billed charges,8.36,100,,,Fee Schedule,100% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.36,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.09,14,,,percent of total billed charges,14% of total billed charges,8.36,171.89,
97016 Appl Modality 1/> Areas Vasopneumatic Devices,3436064,CDM,761,RC,97016,HCPCS,Outpatient,,,30.28,15.14,,22.71,75,,,percent of total billed charges,75% of total billed charges,22.71,75,,,percent of total billed charges,75% of total billed charges,11.19,100,,,Fee Schedule,100% of CMS OPPS Rate,8.11,100,,,Fee Schedule,100% of WV Medicaid Rate,18.46,165,,,Fee Schedule,165% of CMS OPPS Rate,10.91,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,39.67,354.54,,,Fee Schedule,354.54% of CMS OPPS Fee Schedule Rate,47.97,428.7,,,Fee Schedule,428.7% of CMS OPPS Fee Schedule Rate,50.45,450.81,,,Fee Schedule,450.81% of CMS OPPS Fee Schedule Rate,8.11,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,11.19,100,,,Fee Schedule,100% of CMS OPPS Rate,10.91,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,4.24,14,,,percent of total billed charges,14% of total billed charges,4.24,50.45,
PT Whirlpool Extremity,633288,CDM,420,RC,97022,HCPCS,Outpatient,,,42.81,21.41,,32.11,75,,,percent of total billed charges,75% of total billed charges,32.11,75,,,percent of total billed charges,75% of total billed charges,15.8,100,,,Fee Schedule,100% of CMS OPPS Rate,11.31,100,,,Fee Schedule,100% of WV Medicaid Rate,26.07,165,,,Fee Schedule,165% of CMS OPPS Rate,15.42,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,56.02,354.54,,,Fee Schedule,354.54% of CMS OPPS Fee Schedule Rate,67.73,428.7,,,Fee Schedule,428.7% of CMS OPPS Fee Schedule Rate,71.23,450.81,,,Fee Schedule,450.81% of CMS OPPS Fee Schedule Rate,11.31,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,15.8,100,,,Fee Schedule,100% of CMS OPPS Rate,15.42,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,5.99,14,,,percent of total billed charges,14% of total billed charges,5.99,71.23,
97026 Application Modality 1/> Areas Infrared,3351933,CDM,761,RC,97026,HCPCS,Outpatient,,,16.09,8.05,,12.07,75,,,percent of total billed charges,75% of total billed charges,12.07,75,,,percent of total billed charges,75% of total billed charges,6.25,100,,,Fee Schedule,100% of CMS OPPS Rate,4.18,100,,,Fee Schedule,100% of WV Medicaid Rate,10.31,165,,,Fee Schedule,165% of CMS OPPS Rate,6.09,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,22.16,354.54,,,Fee Schedule,354.54% of CMS OPPS Fee Schedule Rate,26.79,428.7,,,Fee Schedule,428.7% of CMS OPPS Fee Schedule Rate,28.18,450.81,,,Fee Schedule,450.81% of CMS OPPS Fee Schedule Rate,4.18,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,6.25,100,,,Fee Schedule,100% of CMS OPPS Rate,6.09,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,2.25,14,,,percent of total billed charges,14% of total billed charges,2.25,28.18,
97026-INFRARED,3430551,CDM,420,RC,97026,HCPCS,Outpatient,,,44.1,22.05,,33.08,75,,,percent of total billed charges,75% of total billed charges,33.08,75,,,percent of total billed charges,75% of total billed charges,6.25,100,,,Fee Schedule,100% of CMS OPPS Rate,4.18,100,,,Fee Schedule,100% of WV Medicaid Rate,10.31,165,,,Fee Schedule,165% of CMS OPPS Rate,6.09,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,22.16,354.54,,,Fee Schedule,354.54% of CMS OPPS Fee Schedule Rate,26.79,428.7,,,Fee Schedule,428.7% of CMS OPPS Fee Schedule Rate,28.18,450.81,,,Fee Schedule,450.81% of CMS OPPS Fee Schedule Rate,4.18,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,6.25,100,,,Fee Schedule,100% of CMS OPPS Rate,6.09,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,6.17,14,,,percent of total billed charges,14% of total billed charges,4.18,33.08,
97035 Appl Modality 1/> Areas Ultrasound Ea 15 Min,3351853,CDM,761,RC,97035,HCPCS,Outpatient,,,36.22,18.11,,27.17,75,,,percent of total billed charges,75% of total billed charges,27.17,75,,,percent of total billed charges,75% of total billed charges,13.66,100,,,Fee Schedule,100% of CMS OPPS Rate,9.59,100,,,Fee Schedule,100% of WV Medicaid Rate,22.54,165,,,Fee Schedule,165% of CMS OPPS Rate,13.33,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,48.43,354.54,,,Fee Schedule,354.54% of CMS OPPS Fee Schedule Rate,58.56,428.7,,,Fee Schedule,428.7% of CMS OPPS Fee Schedule Rate,61.58,450.81,,,Fee Schedule,450.81% of CMS OPPS Fee Schedule Rate,9.59,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,13.66,100,,,Fee Schedule,100% of CMS OPPS Rate,13.33,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,5.07,14,,,percent of total billed charges,14% of total billed charges,5.07,61.58,
97035-PT ULTRASOUND(WOUND),3430552,CDM,420,RC,97035,HCPCS,Outpatient,,,242.48,121.24,,181.86,75,,,percent of total billed charges,75% of total billed charges,181.86,75,,,percent of total billed charges,75% of total billed charges,13.66,100,,,Fee Schedule,100% of CMS OPPS Rate,9.59,100,,,Fee Schedule,100% of WV Medicaid Rate,22.54,165,,,Fee Schedule,165% of CMS OPPS Rate,13.33,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,48.43,354.54,,,Fee Schedule,354.54% of CMS OPPS Fee Schedule Rate,58.56,428.7,,,Fee Schedule,428.7% of CMS OPPS Fee Schedule Rate,61.58,450.81,,,Fee Schedule,450.81% of CMS OPPS Fee Schedule Rate,9.59,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,13.66,100,,,Fee Schedule,100% of CMS OPPS Rate,13.33,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,33.95,14,,,percent of total billed charges,14% of total billed charges,9.59,181.86,
97039 Unlist Modality Spec Type&Time Constant Attend,3351932,CDM,761,RC,97039,HCPCS,Outpatient,,,159.93,79.97,,119.95,75,,,percent of total billed charges,75% of total billed charges,119.95,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.39,14,,,percent of total billed charges,14% of total billed charges,22.39,119.95,
97039-LASER/OTHER,3430553,CDM,420,RC,97039,HCPCS,Outpatient,,,222.18,111.09,,166.64,75,,,percent of total billed charges,75% of total billed charges,166.64,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.11,14,,,percent of total billed charges,14% of total billed charges,31.11,166.64,
97110 Therapeutic Px 1/> Areas Each 15 Min Exercises,3436066,CDM,761,RC,97110,HCPCS,Outpatient,,,75.21,37.61,,56.41,75,,,percent of total billed charges,75% of total billed charges,56.41,75,,,percent of total billed charges,75% of total billed charges,27.91,100,,,Fee Schedule,100% of CMS OPPS Rate,19.91,100,,,Fee Schedule,100% of WV Medicaid Rate,46.05,165,,,Fee Schedule,165% of CMS OPPS Rate,27.23,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,98.95,354.54,,,Fee Schedule,354.54% of CMS OPPS Fee Schedule Rate,119.65,428.7,,,Fee Schedule,428.7% of CMS OPPS Fee Schedule Rate,125.82,450.81,,,Fee Schedule,450.81% of CMS OPPS Fee Schedule Rate,19.91,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,27.91,100,,,Fee Schedule,100% of CMS OPPS Rate,27.23,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,10.53,14,,,percent of total billed charges,14% of total billed charges,10.53,125.82,
Chest PDP,634104,CDM,460,RC,97110,HCPCS,Outpatient,,,331.3,165.65,,248.48,75,,,percent of total billed charges,75% of total billed charges,248.48,75,,,percent of total billed charges,75% of total billed charges,27.91,100,,,Fee Schedule,100% of CMS OPPS Rate,19.91,100,,,Fee Schedule,100% of WV Medicaid Rate,46.05,165,,,Fee Schedule,165% of CMS OPPS Rate,27.23,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,98.95,354.54,,,Fee Schedule,354.54% of CMS OPPS Fee Schedule Rate,119.65,428.7,,,Fee Schedule,428.7% of CMS OPPS Fee Schedule Rate,125.82,450.81,,,Fee Schedule,450.81% of CMS OPPS Fee Schedule Rate,19.91,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,27.91,100,,,Fee Schedule,100% of CMS OPPS Rate,27.23,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,46.38,14,,,percent of total billed charges,14% of total billed charges,19.91,248.48,
OT Therapeutic Procedure 15 min,2012112,CDM,430,RC,97110,HCPCS,Outpatient,,,331.3,165.65,,248.48,75,,,percent of total billed charges,75% of total billed charges,248.48,75,,,percent of total billed charges,75% of total billed charges,27.91,100,,,Fee Schedule,100% of CMS OPPS Rate,19.91,100,,,Fee Schedule,100% of WV Medicaid Rate,46.05,165,,,Fee Schedule,165% of CMS OPPS Rate,27.23,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,98.95,354.54,,,Fee Schedule,354.54% of CMS OPPS Fee Schedule Rate,119.65,428.7,,,Fee Schedule,428.7% of CMS OPPS Fee Schedule Rate,125.82,450.81,,,Fee Schedule,450.81% of CMS OPPS Fee Schedule Rate,19.91,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,27.91,100,,,Fee Schedule,100% of CMS OPPS Rate,27.23,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,46.38,14,,,percent of total billed charges,14% of total billed charges,19.91,248.48,
PT Kinetic Leg Exerciser/CPM Application,633283,CDM,420,RC,97110,HCPCS,Outpatient,,,31.3,15.65,,23.48,75,,,percent of total billed charges,75% of total billed charges,23.48,75,,,percent of total billed charges,75% of total billed charges,27.91,100,,,Fee Schedule,100% of CMS OPPS Rate,19.91,100,,,Fee Schedule,100% of WV Medicaid Rate,46.05,165,,,Fee Schedule,165% of CMS OPPS Rate,27.23,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,98.95,354.54,,,Fee Schedule,354.54% of CMS OPPS Fee Schedule Rate,119.65,428.7,,,Fee Schedule,428.7% of CMS OPPS Fee Schedule Rate,125.82,450.81,,,Fee Schedule,450.81% of CMS OPPS Fee Schedule Rate,19.91,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,27.91,100,,,Fee Schedule,100% of CMS OPPS Rate,27.23,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,4.38,14,,,percent of total billed charges,14% of total billed charges,4.38,125.82,
Therapeutic Procedure,633286,CDM,420,RC,97110,HCPCS,Outpatient,,,331.3,165.65,,248.48,75,,,percent of total billed charges,75% of total billed charges,248.48,75,,,percent of total billed charges,75% of total billed charges,27.91,100,,,Fee Schedule,100% of CMS OPPS Rate,19.91,100,,,Fee Schedule,100% of WV Medicaid Rate,46.05,165,,,Fee Schedule,165% of CMS OPPS Rate,27.23,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,98.95,354.54,,,Fee Schedule,354.54% of CMS OPPS Fee Schedule Rate,119.65,428.7,,,Fee Schedule,428.7% of CMS OPPS Fee Schedule Rate,125.82,450.81,,,Fee Schedule,450.81% of CMS OPPS Fee Schedule Rate,19.91,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,27.91,100,,,Fee Schedule,100% of CMS OPPS Rate,27.23,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,46.38,14,,,percent of total billed charges,14% of total billed charges,19.91,248.48,
97112 Therapeutic Px 1/> Areas Each 15 Min Neuromusc ReEd,3984924,CDM,761,RC,97112,HCPCS,Outpatient,,,86.9,43.45,,65.18,75,,,percent of total billed charges,75% of total billed charges,65.18,75,,,percent of total billed charges,75% of total billed charges,31.94,100,,,Fee Schedule,100% of CMS OPPS Rate,23.11,100,,,Fee Schedule,100% of WV Medicaid Rate,52.7,165,,,Fee Schedule,165% of CMS OPPS Rate,31.16,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,113.24,354.54,,,Fee Schedule,354.54% of CMS OPPS Fee Schedule Rate,136.93,428.7,,,Fee Schedule,428.7% of CMS OPPS Fee Schedule Rate,143.99,450.81,,,Fee Schedule,450.81% of CMS OPPS Fee Schedule Rate,23.11,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,31.94,100,,,Fee Schedule,100% of CMS OPPS Rate,31.16,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,12.17,14,,,percent of total billed charges,14% of total billed charges,12.17,143.99,
OT Neuro-Muscular Re-Ed 15 min,2012113,CDM,430,RC,97112,HCPCS,Outpatient,,,268.55,134.28,,201.41,75,,,percent of total billed charges,75% of total billed charges,201.41,75,,,percent of total billed charges,75% of total billed charges,31.94,100,,,Fee Schedule,100% of CMS OPPS Rate,23.11,100,,,Fee Schedule,100% of WV Medicaid Rate,52.7,165,,,Fee Schedule,165% of CMS OPPS Rate,31.16,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,113.24,354.54,,,Fee Schedule,354.54% of CMS OPPS Fee Schedule Rate,136.93,428.7,,,Fee Schedule,428.7% of CMS OPPS Fee Schedule Rate,143.99,450.81,,,Fee Schedule,450.81% of CMS OPPS Fee Schedule Rate,23.11,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,31.94,100,,,Fee Schedule,100% of CMS OPPS Rate,31.16,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,37.6,14,,,percent of total billed charges,14% of total billed charges,23.11,201.41,
PT Gait Training,633292,CDM,420,RC,97116,HCPCS,Outpatient,,,75.21,37.61,,56.41,75,,,percent of total billed charges,75% of total billed charges,56.41,75,,,percent of total billed charges,75% of total billed charges,27.91,100,,,Fee Schedule,100% of CMS OPPS Rate,19.91,100,,,Fee Schedule,100% of WV Medicaid Rate,46.05,165,,,Fee Schedule,165% of CMS OPPS Rate,27.23,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,98.95,354.54,,,Fee Schedule,354.54% of CMS OPPS Fee Schedule Rate,119.65,428.7,,,Fee Schedule,428.7% of CMS OPPS Fee Schedule Rate,125.82,450.81,,,Fee Schedule,450.81% of CMS OPPS Fee Schedule Rate,19.91,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,27.91,100,,,Fee Schedule,100% of CMS OPPS Rate,27.23,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,10.53,14,,,percent of total billed charges,14% of total billed charges,10.53,125.82,
97124 Ther Px 1/> Areas Each 15 Min Massage,3436070,CDM,983,RC,97124,HCPCS,Outpatient,,,74.38,37.19,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
PT Massage Soft Tissue,633285,CDM,421,RC,97124,HCPCS,Outpatient,,,198.13,99.07,,148.6,75,,,percent of total billed charges,75% of total billed charges,148.6,75,,,percent of total billed charges,75% of total billed charges,28.02,100,,,Fee Schedule,100% of CMS OPPS Rate,19.91,100,,,Fee Schedule,100% of WV Medicaid Rate,46.23,165,,,Fee Schedule,165% of CMS OPPS Rate,27.34,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,99.34,354.54,,,Fee Schedule,354.54% of CMS OPPS Fee Schedule Rate,120.12,428.7,,,Fee Schedule,428.7% of CMS OPPS Fee Schedule Rate,126.32,450.81,,,Fee Schedule,450.81% of CMS OPPS Fee Schedule Rate,19.91,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,28.02,100,,,Fee Schedule,100% of CMS OPPS Rate,27.34,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,27.74,14,,,percent of total billed charges,14% of total billed charges,19.91,148.6,
97140 Manual Therapy TQS 1/> Regions Each 15 Minutes - OT,3436071,CDM,761,RC,97140,HCPCS,Outpatient,,,69.41,34.71,,52.06,75,,,percent of total billed charges,75% of total billed charges,52.06,75,,,percent of total billed charges,75% of total billed charges,25.78,100,,,Fee Schedule,100% of CMS OPPS Rate,18.44,100,,,Fee Schedule,100% of WV Medicaid Rate,42.54,165,,,Fee Schedule,165% of CMS OPPS Rate,25.15,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,91.4,354.54,,,Fee Schedule,354.54% of CMS OPPS Fee Schedule Rate,110.52,428.7,,,Fee Schedule,428.7% of CMS OPPS Fee Schedule Rate,116.22,450.81,,,Fee Schedule,450.81% of CMS OPPS Fee Schedule Rate,18.44,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,25.78,100,,,Fee Schedule,100% of CMS OPPS Rate,25.15,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,9.72,14,,,percent of total billed charges,14% of total billed charges,9.72,116.22,
OT Manual Therapy 15 min,2012116,CDM,430,RC,97140,HCPCS,Outpatient,,,282.92,141.46,,212.19,75,,,percent of total billed charges,75% of total billed charges,212.19,75,,,percent of total billed charges,75% of total billed charges,25.78,100,,,Fee Schedule,100% of CMS OPPS Rate,18.44,100,,,Fee Schedule,100% of WV Medicaid Rate,42.54,165,,,Fee Schedule,165% of CMS OPPS Rate,25.15,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,91.4,354.54,,,Fee Schedule,354.54% of CMS OPPS Fee Schedule Rate,110.52,428.7,,,Fee Schedule,428.7% of CMS OPPS Fee Schedule Rate,116.22,450.81,,,Fee Schedule,450.81% of CMS OPPS Fee Schedule Rate,18.44,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,25.78,100,,,Fee Schedule,100% of CMS OPPS Rate,25.15,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,39.61,14,,,percent of total billed charges,14% of total billed charges,18.44,212.19,
PT Joint Mobilization,605148,CDM,420,RC,97140,HCPCS,Outpatient,,,282.92,141.46,,212.19,75,,,percent of total billed charges,75% of total billed charges,212.19,75,,,percent of total billed charges,75% of total billed charges,25.78,100,,,Fee Schedule,100% of CMS OPPS Rate,18.44,100,,,Fee Schedule,100% of WV Medicaid Rate,42.54,165,,,Fee Schedule,165% of CMS OPPS Rate,25.15,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,91.4,354.54,,,Fee Schedule,354.54% of CMS OPPS Fee Schedule Rate,110.52,428.7,,,Fee Schedule,428.7% of CMS OPPS Fee Schedule Rate,116.22,450.81,,,Fee Schedule,450.81% of CMS OPPS Fee Schedule Rate,18.44,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,25.78,100,,,Fee Schedule,100% of CMS OPPS Rate,25.15,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,39.61,14,,,percent of total billed charges,14% of total billed charges,18.44,212.19,
97162-PT EVAL MOD COMPLEXITY,3430555,CDM,434,RC,97162,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,95.28,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,157.21,165,,,Fee Schedule,165% of CMS OPPS Rate,92.96,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,337.81,354.54,,,Fee Schedule,354.54% of CMS OPPS Fee Schedule Rate,408.47,428.7,,,Fee Schedule,428.7% of CMS OPPS Fee Schedule Rate,429.53,450.81,,,Fee Schedule,450.81% of CMS OPPS Fee Schedule Rate,,,,,Other,Not Separately reimbursable,95.28,100,,,Fee Schedule,100% of CMS OPPS Rate,92.96,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,,,,,Other,Not Separately reimbursable,92.96,429.53,
97163-PT EVAL HIGH COMPLEXITY,3430556,CDM,420,RC,97163,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,95.28,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,157.21,165,,,Fee Schedule,165% of CMS OPPS Rate,92.96,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,337.81,354.54,,,Fee Schedule,354.54% of CMS OPPS Fee Schedule Rate,408.47,428.7,,,Fee Schedule,428.7% of CMS OPPS Fee Schedule Rate,429.53,450.81,,,Fee Schedule,450.81% of CMS OPPS Fee Schedule Rate,,,,,Other,Not Separately reimbursable,95.28,100,,,Fee Schedule,100% of CMS OPPS Rate,92.96,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,,,,,Other,Not Separately reimbursable,92.96,429.53,
97164-PT RE-EVAL,3430557,CDM,420,RC,97164,HCPCS,Outpatient,,,307,153.5,,230.25,75,,,percent of total billed charges,75% of total billed charges,230.25,75,,,percent of total billed charges,75% of total billed charges,65.72,100,,,Fee Schedule,100% of CMS OPPS Rate,46.7,100,,,Fee Schedule,100% of WV Medicaid Rate,108.44,165,,,Fee Schedule,165% of CMS OPPS Rate,64.11,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,233,354.54,,,Fee Schedule,354.54% of CMS OPPS Fee Schedule Rate,281.74,428.7,,,Fee Schedule,428.7% of CMS OPPS Fee Schedule Rate,296.27,450.81,,,Fee Schedule,450.81% of CMS OPPS Fee Schedule Rate,46.7,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,65.72,100,,,Fee Schedule,100% of CMS OPPS Rate,64.11,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,42.98,14,,,percent of total billed charges,14% of total billed charges,42.98,296.27,
97165 OT Eval Low Complex 30 Minutes,3436073,CDM,761,RC,97165,HCPCS,Outpatient,,,257.61,128.81,,193.21,75,,,percent of total billed charges,75% of total billed charges,193.21,75,,,percent of total billed charges,75% of total billed charges,95.28,100,,,Fee Schedule,100% of CMS OPPS Rate,68.81,100,,,Fee Schedule,100% of WV Medicaid Rate,157.21,165,,,Fee Schedule,165% of CMS OPPS Rate,92.96,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,337.81,354.54,,,Fee Schedule,354.54% of CMS OPPS Fee Schedule Rate,408.47,428.7,,,Fee Schedule,428.7% of CMS OPPS Fee Schedule Rate,429.53,450.81,,,Fee Schedule,450.81% of CMS OPPS Fee Schedule Rate,68.81,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,95.28,100,,,Fee Schedule,100% of CMS OPPS Rate,92.96,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,36.07,14,,,percent of total billed charges,14% of total billed charges,36.07,429.53,
OT Evaluation Low Complexity,3334508,CDM,434,RC,97165,HCPCS,Outpatient,,,619.47,309.74,,464.6,75,,,percent of total billed charges,75% of total billed charges,464.6,75,,,percent of total billed charges,75% of total billed charges,95.28,100,,,Fee Schedule,100% of CMS OPPS Rate,68.81,100,,,Fee Schedule,100% of WV Medicaid Rate,157.21,165,,,Fee Schedule,165% of CMS OPPS Rate,92.96,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,337.81,354.54,,,Fee Schedule,354.54% of CMS OPPS Fee Schedule Rate,408.47,428.7,,,Fee Schedule,428.7% of CMS OPPS Fee Schedule Rate,429.53,450.81,,,Fee Schedule,450.81% of CMS OPPS Fee Schedule Rate,68.81,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,95.28,100,,,Fee Schedule,100% of CMS OPPS Rate,92.96,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,86.73,14,,,percent of total billed charges,14% of total billed charges,68.81,464.6,
97166 OT Eval Mod Complex 45 Minutes,3436074,CDM,761,RC,97166,HCPCS,Outpatient,,,257.61,128.81,,193.21,75,,,percent of total billed charges,75% of total billed charges,193.21,75,,,percent of total billed charges,75% of total billed charges,95.28,100,,,Fee Schedule,100% of CMS OPPS Rate,68.81,100,,,Fee Schedule,100% of WV Medicaid Rate,157.21,165,,,Fee Schedule,165% of CMS OPPS Rate,92.96,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,337.81,354.54,,,Fee Schedule,354.54% of CMS OPPS Fee Schedule Rate,408.47,428.7,,,Fee Schedule,428.7% of CMS OPPS Fee Schedule Rate,429.53,450.81,,,Fee Schedule,450.81% of CMS OPPS Fee Schedule Rate,68.81,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,95.28,100,,,Fee Schedule,100% of CMS OPPS Rate,92.96,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,36.07,14,,,percent of total billed charges,14% of total billed charges,36.07,429.53,
97167 OT Eval High Complex 60 Minutes,3436075,CDM,761,RC,97167,HCPCS,Outpatient,,,257.61,128.81,,193.21,75,,,percent of total billed charges,75% of total billed charges,193.21,75,,,percent of total billed charges,75% of total billed charges,95.28,100,,,Fee Schedule,100% of CMS OPPS Rate,68.81,100,,,Fee Schedule,100% of WV Medicaid Rate,157.21,165,,,Fee Schedule,165% of CMS OPPS Rate,92.96,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,337.81,354.54,,,Fee Schedule,354.54% of CMS OPPS Fee Schedule Rate,408.47,428.7,,,Fee Schedule,428.7% of CMS OPPS Fee Schedule Rate,429.53,450.81,,,Fee Schedule,450.81% of CMS OPPS Fee Schedule Rate,68.81,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,95.28,100,,,Fee Schedule,100% of CMS OPPS Rate,92.96,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,36.07,14,,,percent of total billed charges,14% of total billed charges,36.07,429.53,
97168 OT Re-Eval Est Plan Care 30 Minutes,3436076,CDM,761,RC,97168,HCPCS,Outpatient,,,175.67,87.84,,131.75,75,,,percent of total billed charges,75% of total billed charges,131.75,75,,,percent of total billed charges,75% of total billed charges,65.43,100,,,Fee Schedule,100% of CMS OPPS Rate,46.95,100,,,Fee Schedule,100% of WV Medicaid Rate,107.96,165,,,Fee Schedule,165% of CMS OPPS Rate,63.83,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,231.98,354.54,,,Fee Schedule,354.54% of CMS OPPS Fee Schedule Rate,280.5,428.7,,,Fee Schedule,428.7% of CMS OPPS Fee Schedule Rate,294.96,450.81,,,Fee Schedule,450.81% of CMS OPPS Fee Schedule Rate,46.95,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,65.43,100,,,Fee Schedule,100% of CMS OPPS Rate,63.83,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,24.59,14,,,percent of total billed charges,14% of total billed charges,24.59,294.96,
97530 Therapeut Activity Direct  Contact Each 15 Min,3436077,CDM,761,RC,97530,HCPCS,Outpatient,,,93.23,46.62,,69.92,75,,,percent of total billed charges,75% of total billed charges,69.92,75,,,percent of total billed charges,75% of total billed charges,34.57,100,,,Fee Schedule,100% of CMS OPPS Rate,24.83,100,,,Fee Schedule,100% of WV Medicaid Rate,57.04,165,,,Fee Schedule,165% of CMS OPPS Rate,33.73,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,122.56,354.54,,,Fee Schedule,354.54% of CMS OPPS Fee Schedule Rate,148.2,428.7,,,Fee Schedule,428.7% of CMS OPPS Fee Schedule Rate,155.85,450.81,,,Fee Schedule,450.81% of CMS OPPS Fee Schedule Rate,24.83,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,34.57,100,,,Fee Schedule,100% of CMS OPPS Rate,33.73,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,13.05,14,,,percent of total billed charges,14% of total billed charges,13.05,155.85,
OT Therapeutic Activity 15 min,2012117,CDM,430,RC,97530,HCPCS,Outpatient,,,241.86,120.93,,181.4,75,,,percent of total billed charges,75% of total billed charges,181.4,75,,,percent of total billed charges,75% of total billed charges,34.57,100,,,Fee Schedule,100% of CMS OPPS Rate,24.83,100,,,Fee Schedule,100% of WV Medicaid Rate,57.04,165,,,Fee Schedule,165% of CMS OPPS Rate,33.73,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,122.56,354.54,,,Fee Schedule,354.54% of CMS OPPS Fee Schedule Rate,148.2,428.7,,,Fee Schedule,428.7% of CMS OPPS Fee Schedule Rate,155.85,450.81,,,Fee Schedule,450.81% of CMS OPPS Fee Schedule Rate,24.83,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,34.57,100,,,Fee Schedule,100% of CMS OPPS Rate,33.73,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,33.86,14,,,percent of total billed charges,14% of total billed charges,24.83,181.4,
PT Cardiac Rehab,633290,CDM,421,RC,97530,HCPCS,Outpatient,,,241.86,120.93,,181.4,75,,,percent of total billed charges,75% of total billed charges,181.4,75,,,percent of total billed charges,75% of total billed charges,34.57,100,,,Fee Schedule,100% of CMS OPPS Rate,24.83,100,,,Fee Schedule,100% of WV Medicaid Rate,57.04,165,,,Fee Schedule,165% of CMS OPPS Rate,33.73,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,122.56,354.54,,,Fee Schedule,354.54% of CMS OPPS Fee Schedule Rate,148.2,428.7,,,Fee Schedule,428.7% of CMS OPPS Fee Schedule Rate,155.85,450.81,,,Fee Schedule,450.81% of CMS OPPS Fee Schedule Rate,24.83,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,34.57,100,,,Fee Schedule,100% of CMS OPPS Rate,33.73,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,33.86,14,,,percent of total billed charges,14% of total billed charges,24.83,181.4,
PT for Transfer Training,605155,CDM,421,RC,97530,HCPCS,Outpatient,,,241.86,120.93,,181.4,75,,,percent of total billed charges,75% of total billed charges,181.4,75,,,percent of total billed charges,75% of total billed charges,34.57,100,,,Fee Schedule,100% of CMS OPPS Rate,24.83,100,,,Fee Schedule,100% of WV Medicaid Rate,57.04,165,,,Fee Schedule,165% of CMS OPPS Rate,33.73,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,122.56,354.54,,,Fee Schedule,354.54% of CMS OPPS Fee Schedule Rate,148.2,428.7,,,Fee Schedule,428.7% of CMS OPPS Fee Schedule Rate,155.85,450.81,,,Fee Schedule,450.81% of CMS OPPS Fee Schedule Rate,24.83,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,34.57,100,,,Fee Schedule,100% of CMS OPPS Rate,33.73,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,33.86,14,,,percent of total billed charges,14% of total billed charges,24.83,181.4,
PT Functional Therapeutic Activity,605162,CDM,420,RC,97530,HCPCS,Outpatient,,,241.86,120.93,,181.4,75,,,percent of total billed charges,75% of total billed charges,181.4,75,,,percent of total billed charges,75% of total billed charges,34.57,100,,,Fee Schedule,100% of CMS OPPS Rate,24.83,100,,,Fee Schedule,100% of WV Medicaid Rate,57.04,165,,,Fee Schedule,165% of CMS OPPS Rate,33.73,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,122.56,354.54,,,Fee Schedule,354.54% of CMS OPPS Fee Schedule Rate,148.2,428.7,,,Fee Schedule,428.7% of CMS OPPS Fee Schedule Rate,155.85,450.81,,,Fee Schedule,450.81% of CMS OPPS Fee Schedule Rate,24.83,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,34.57,100,,,Fee Schedule,100% of CMS OPPS Rate,33.73,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,33.86,14,,,percent of total billed charges,14% of total billed charges,24.83,181.4,
97535 Self Care Mngment Training,3436078,CDM,761,RC,97535,HCPCS,Outpatient,,,83.1,41.55,,62.33,75,,,percent of total billed charges,75% of total billed charges,62.33,75,,,percent of total billed charges,75% of total billed charges,30.83,100,,,Fee Schedule,100% of CMS OPPS Rate,22.12,100,,,Fee Schedule,100% of WV Medicaid Rate,50.87,165,,,Fee Schedule,165% of CMS OPPS Rate,30.08,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,109.3,354.54,,,Fee Schedule,354.54% of CMS OPPS Fee Schedule Rate,132.17,428.7,,,Fee Schedule,428.7% of CMS OPPS Fee Schedule Rate,138.98,450.81,,,Fee Schedule,450.81% of CMS OPPS Fee Schedule Rate,22.12,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,30.83,100,,,Fee Schedule,100% of CMS OPPS Rate,30.08,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,11.63,14,,,percent of total billed charges,14% of total billed charges,11.63,138.98,
OT ADL's 15 min,2012120,CDM,430,RC,97535,HCPCS,Outpatient,,,237.28,118.64,,177.96,75,,,percent of total billed charges,75% of total billed charges,177.96,75,,,percent of total billed charges,75% of total billed charges,30.83,100,,,Fee Schedule,100% of CMS OPPS Rate,22.12,100,,,Fee Schedule,100% of WV Medicaid Rate,50.87,165,,,Fee Schedule,165% of CMS OPPS Rate,30.08,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,109.3,354.54,,,Fee Schedule,354.54% of CMS OPPS Fee Schedule Rate,132.17,428.7,,,Fee Schedule,428.7% of CMS OPPS Fee Schedule Rate,138.98,450.81,,,Fee Schedule,450.81% of CMS OPPS Fee Schedule Rate,22.12,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,30.83,100,,,Fee Schedule,100% of CMS OPPS Rate,30.08,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,33.22,14,,,percent of total billed charges,14% of total billed charges,22.12,177.96,
PT ADLs,633291,CDM,421,RC,97535,HCPCS,Outpatient,,,237.28,118.64,,177.96,75,,,percent of total billed charges,75% of total billed charges,177.96,75,,,percent of total billed charges,75% of total billed charges,30.83,100,,,Fee Schedule,100% of CMS OPPS Rate,22.12,100,,,Fee Schedule,100% of WV Medicaid Rate,50.87,165,,,Fee Schedule,165% of CMS OPPS Rate,30.08,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,109.3,354.54,,,Fee Schedule,354.54% of CMS OPPS Fee Schedule Rate,132.17,428.7,,,Fee Schedule,428.7% of CMS OPPS Fee Schedule Rate,138.98,450.81,,,Fee Schedule,450.81% of CMS OPPS Fee Schedule Rate,22.12,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,30.83,100,,,Fee Schedule,100% of CMS OPPS Rate,30.08,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,33.22,14,,,percent of total billed charges,14% of total billed charges,22.12,177.96,
97537 Community or Work Reint Training Ea 15 Min,4305641,CDM,761,RC,97537,HCPCS,Outpatient,,,185.71,92.86,,139.28,75,,,percent of total billed charges,75% of total billed charges,139.28,75,,,percent of total billed charges,75% of total billed charges,30.1,100,,,Fee Schedule,100% of CMS OPPS Rate,21.63,100,,,Fee Schedule,100% of WV Medicaid Rate,49.67,165,,,Fee Schedule,165% of CMS OPPS Rate,29.36,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,106.72,354.54,,,Fee Schedule,354.54% of CMS OPPS Fee Schedule Rate,129.04,428.7,,,Fee Schedule,428.7% of CMS OPPS Fee Schedule Rate,135.69,450.81,,,Fee Schedule,450.81% of CMS OPPS Fee Schedule Rate,21.63,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,30.1,100,,,Fee Schedule,100% of CMS OPPS Rate,29.36,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,26,14,,,percent of total billed charges,14% of total billed charges,21.63,139.28,
97597- Debrid/select/1st 20 sq cm or less,3430558,CDM,420,RC,97597,HCPCS,Outpatient,,,1083.14,541.57,,812.36,75,,,percent of total billed charges,75% of total billed charges,812.36,75,,,percent of total billed charges,75% of total billed charges,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,25.56,100,,,Fee Schedule,100% of WV Medicaid Rate,280.12,165,,,Fee Schedule,165% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,487.65,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,668.77,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,837.71,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,25.56,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,151.64,14,,,percent of total billed charges,14% of total billed charges,25.56,837.71,
97597 Debridement Open Wound 20 Sq Cm/<,3436079,CDM,761,RC,97597,HCPCS,Outpatient,,,251.52,125.76,,188.64,75,,,percent of total billed charges,75% of total billed charges,188.64,75,,,percent of total billed charges,75% of total billed charges,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,25.56,100,,,Fee Schedule,100% of WV Medicaid Rate,280.12,165,,,Fee Schedule,165% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,487.65,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,668.77,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,837.71,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,25.56,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,35.21,14,,,percent of total billed charges,14% of total billed charges,25.56,837.71,
Selective Debridement <20 sq centimeters,845982,CDM,420,RC,97597,HCPCS,Outpatient,,,1083.14,541.57,,812.36,75,,,percent of total billed charges,75% of total billed charges,812.36,75,,,percent of total billed charges,75% of total billed charges,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,25.56,100,,,Fee Schedule,100% of WV Medicaid Rate,280.12,165,,,Fee Schedule,165% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,487.65,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,668.77,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,837.71,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,25.56,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,151.64,14,,,percent of total billed charges,14% of total billed charges,25.56,837.71,
"97598 - Debridement (eg, high pressure waterjet with/without suction, sharp selective debridement wi",3715362,CDM,510,RC,97598,HCPCS,Outpatient,,,404.93,202.47,,303.7,75,,,percent of total billed charges,75% of total billed charges,303.7,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,17.94,100,,,Fee Schedule,100% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.94,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.69,14,,,percent of total billed charges,14% of total billed charges,17.94,303.7,
97598 Debridement Open Wound Each Addtl 20 Sq Cm,3436082,CDM,761,RC,97598,HCPCS,Outpatient,,,115.34,57.67,,86.51,75,,,percent of total billed charges,75% of total billed charges,86.51,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,17.94,100,,,Fee Schedule,100% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.94,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.15,14,,,percent of total billed charges,14% of total billed charges,16.15,86.51,
"97602 -Removal of devitalized tissue from wound(s), non-selective debridement, without anesthesia (e",3641199,CDM,510,RC,97602,HCPCS,Outpatient,,,1059.66,529.83,,794.75,75,,,percent of total billed charges,75% of total billed charges,794.75,75,,,percent of total billed charges,75% of total billed charges,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,280.12,165,,,Fee Schedule,165% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,487.65,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,668.78,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,837.71,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,148.35,14,,,percent of total billed charges,14% of total billed charges,148.35,837.71,
97602 Rmvl Devital Tiss N-Slctv Dbrdmt W/O Anes 1 Sess,3436083,CDM,761,RC,97602,HCPCS,Outpatient,,,438.79,219.4,,329.09,75,,,percent of total billed charges,75% of total billed charges,329.09,75,,,percent of total billed charges,75% of total billed charges,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,280.12,165,,,Fee Schedule,165% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,487.65,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,668.78,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,837.71,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,61.43,14,,,percent of total billed charges,14% of total billed charges,61.43,837.71,
97605 Negative Pressure Wound Therapy DME <=50 Sq Cm,3436085,CDM,761,RC,97605,HCPCS,Outpatient,,,106.51,53.26,,79.88,75,,,percent of total billed charges,75% of total billed charges,79.88,75,,,percent of total billed charges,75% of total billed charges,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,17.45,100,,,Fee Schedule,100% of WV Medicaid Rate,280.12,165,,,Fee Schedule,165% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,487.65,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,668.78,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,837.71,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,17.45,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,14.91,14,,,percent of total billed charges,14% of total billed charges,14.91,837.71,
97606- Neg press wound therapy/>50 sq cm,3430560,CDM,510,RC,97606,HCPCS,Outpatient,,,2066.92,1033.46,,1550.19,75,,,percent of total billed charges,75% of total billed charges,1550.19,75,,,percent of total billed charges,75% of total billed charges,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,18.93,100,,,Fee Schedule,100% of WV Medicaid Rate,578.73,165,,,Fee Schedule,165% of CMS OPPS Rate,363.52,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1007.47,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1381.67,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1730.68,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,18.93,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,363.52,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,289.37,14,,,percent of total billed charges,14% of total billed charges,18.93,1730.68,
97606 Negative Pressure Wound Therapy DME >50 Sq Cm,3436088,CDM,761,RC,97606,HCPCS,Outpatient,,,125.33,62.67,,94,75,,,percent of total billed charges,75% of total billed charges,94,75,,,percent of total billed charges,75% of total billed charges,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,18.93,100,,,Fee Schedule,100% of WV Medicaid Rate,578.73,165,,,Fee Schedule,165% of CMS OPPS Rate,363.52,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1007.47,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1381.67,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1730.68,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,18.93,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,363.52,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,17.55,14,,,percent of total billed charges,14% of total billed charges,17.55,1730.68,
97607 Negative Pressure Wound Therapy Non DME <=50 Sq Cm,3351838,CDM,761,RC,97607,HCPCS,Outpatient,,,913.56,456.78,,685.17,75,,,percent of total billed charges,75% of total billed charges,685.17,75,,,percent of total billed charges,75% of total billed charges,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,16.22,100,,,Fee Schedule,100% of WV Medicaid Rate,578.72,165,,,Fee Schedule,165% of CMS OPPS Rate,363.51,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1007.47,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1381.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1730.67,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,16.22,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,363.51,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,127.9,14,,,percent of total billed charges,14% of total billed charges,16.22,1730.67,
97608 Negative Pressure Wound Therapy Non DME >50 Sq Cm,3351843,CDM,761,RC,97608,HCPCS,Outpatient,,,902.65,451.33,,676.99,75,,,percent of total billed charges,75% of total billed charges,676.99,75,,,percent of total billed charges,75% of total billed charges,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,17.94,100,,,Fee Schedule,100% of WV Medicaid Rate,578.72,165,,,Fee Schedule,165% of CMS OPPS Rate,363.51,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1007.47,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1381.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1730.67,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,17.94,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,363.51,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,126.37,14,,,percent of total billed charges,14% of total billed charges,17.94,1730.67,
97750 Physical Perf Test/Meas w/ Reprt Ea 15 Min,4305640,CDM,761,RC,97750,HCPCS,Outpatient,,,199.73,99.87,,149.8,75,,,percent of total billed charges,75% of total billed charges,149.8,75,,,percent of total billed charges,75% of total billed charges,31.7,100,,,Fee Schedule,100% of CMS OPPS Rate,22.61,100,,,Fee Schedule,100% of WV Medicaid Rate,52.31,165,,,Fee Schedule,165% of CMS OPPS Rate,30.93,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,112.39,354.54,,,Fee Schedule,354.54% of CMS OPPS Fee Schedule Rate,135.9,428.7,,,Fee Schedule,428.7% of CMS OPPS Fee Schedule Rate,142.91,450.81,,,Fee Schedule,450.81% of CMS OPPS Fee Schedule Rate,22.61,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,31.7,100,,,Fee Schedule,100% of CMS OPPS Rate,30.93,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,27.96,14,,,percent of total billed charges,14% of total billed charges,22.61,149.8,
97760 Orthotics Mgmt & Traing Initial Enctr Ea 15 Mins,3436091,CDM,761,RC,97760,HCPCS,Outpatient,,,120.87,60.44,,90.65,75,,,percent of total billed charges,75% of total billed charges,90.65,75,,,percent of total billed charges,75% of total billed charges,44.76,100,,,Fee Schedule,100% of CMS OPPS Rate,32.2,100,,,Fee Schedule,100% of WV Medicaid Rate,73.85,165,,,Fee Schedule,165% of CMS OPPS Rate,43.67,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,158.69,354.54,,,Fee Schedule,354.54% of CMS OPPS Fee Schedule Rate,191.89,428.7,,,Fee Schedule,428.7% of CMS OPPS Fee Schedule Rate,201.78,450.81,,,Fee Schedule,450.81% of CMS OPPS Fee Schedule Rate,32.2,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,44.76,100,,,Fee Schedule,100% of CMS OPPS Rate,43.67,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,16.92,14,,,percent of total billed charges,14% of total billed charges,16.92,201.78,
97761- Prosthetic train/UE/LE/ea 15 min,3435932,CDM,510,RC,97761,HCPCS,Outpatient,,,104.27,52.14,,78.2,75,,,percent of total billed charges,75% of total billed charges,78.2,75,,,percent of total billed charges,75% of total billed charges,38.93,100,,,Fee Schedule,100% of CMS OPPS Rate,27.78,100,,,Fee Schedule,100% of WV Medicaid Rate,64.23,165,,,Fee Schedule,165% of CMS OPPS Rate,37.98,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,138.02,354.54,,,Fee Schedule,354.54% of CMS OPPS Fee Schedule Rate,166.89,428.7,,,Fee Schedule,428.7% of CMS OPPS Fee Schedule Rate,175.5,450.81,,,Fee Schedule,450.81% of CMS OPPS Fee Schedule Rate,27.78,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,38.93,100,,,Fee Schedule,100% of CMS OPPS Rate,37.98,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,14.6,14,,,percent of total billed charges,14% of total billed charges,14.6,175.5,
97763 Orthotics/Prosth Mgmt & Traing Sbsq Enctr 15 Min,3436092,CDM,761,RC,97763,HCPCS,Outpatient,,,133.23,66.62,,99.92,75,,,percent of total billed charges,75% of total billed charges,99.92,75,,,percent of total billed charges,75% of total billed charges,48.75,100,,,Fee Schedule,100% of CMS OPPS Rate,35.4,100,,,Fee Schedule,100% of WV Medicaid Rate,80.44,165,,,Fee Schedule,165% of CMS OPPS Rate,47.56,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,172.84,354.54,,,Fee Schedule,354.54% of CMS OPPS Fee Schedule Rate,208.99,428.7,,,Fee Schedule,428.7% of CMS OPPS Fee Schedule Rate,219.77,450.81,,,Fee Schedule,450.81% of CMS OPPS Fee Schedule Rate,35.4,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,48.75,100,,,Fee Schedule,100% of CMS OPPS Rate,47.56,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,18.65,14,,,percent of total billed charges,14% of total billed charges,18.65,219.77,
97804- Med nutri tx/re-asses/2 or>/30 min,3435563,CDM,510,RC,97804,HCPCS,Outpatient,,,43.06,21.53,,32.3,75,,,percent of total billed charges,75% of total billed charges,32.3,75,,,percent of total billed charges,75% of total billed charges,14.72,100,,,Fee Schedule,100% of CMS OPPS Rate,10.32,100,,,Fee Schedule,100% of WV Medicaid Rate,24.29,165,,,Fee Schedule,165% of CMS OPPS Rate,14.37,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,52.19,354.54,,,Fee Schedule,354.54% of CMS OPPS Fee Schedule Rate,63.1,428.7,,,Fee Schedule,428.7% of CMS OPPS Fee Schedule Rate,66.36,450.81,,,Fee Schedule,450.81% of CMS OPPS Fee Schedule Rate,10.32,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,14.72,100,,,Fee Schedule,100% of CMS OPPS Rate,14.37,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,6.03,14,,,percent of total billed charges,14% of total billed charges,6.03,66.36,
98925 Osteopathic Manipulations 1-2 body regions,3438184,CDM,510,RC,98925,HCPCS,Outpatient,,,61.75,30.88,,46.31,75,,,percent of total billed charges,75% of total billed charges,46.31,75,,,percent of total billed charges,75% of total billed charges,23.48,100,,,Fee Schedule,100% of CMS OPPS Rate,16.47,100,,,Fee Schedule,100% of WV Medicaid Rate,38.75,165,,,Fee Schedule,165% of CMS OPPS Rate,24.34,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,67.45,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,92.51,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,115.88,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,16.47,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,23.48,100,,,Fee Schedule,100% of CMS OPPS Rate,24.34,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8.65,14,,,percent of total billed charges,14% of total billed charges,8.65,115.88,
98925 Osteopathic manipulative treatment (OMT); 1-2 body regions involved,3620985,CDM,510,RC,98925,HCPCS,Outpatient,,,80.71,40.36,,60.53,75,,,percent of total billed charges,75% of total billed charges,60.53,75,,,percent of total billed charges,75% of total billed charges,23.48,100,,,Fee Schedule,100% of CMS OPPS Rate,16.47,100,,,Fee Schedule,100% of WV Medicaid Rate,38.75,165,,,Fee Schedule,165% of CMS OPPS Rate,24.34,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,67.45,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,92.51,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,115.88,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,16.47,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,23.48,100,,,Fee Schedule,100% of CMS OPPS Rate,24.34,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,11.3,14,,,percent of total billed charges,14% of total billed charges,11.3,115.88,
98926 Osteopathic Manipulations 3-4 body regions,3438185,CDM,761,RC,98926,HCPCS,Outpatient,,,82.01,41.01,,61.51,75,,,percent of total billed charges,75% of total billed charges,61.51,75,,,percent of total billed charges,75% of total billed charges,23.48,100,,,Fee Schedule,100% of CMS OPPS Rate,24.58,100,,,Fee Schedule,100% of WV Medicaid Rate,38.75,165,,,Fee Schedule,165% of CMS OPPS Rate,24.34,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,67.45,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,92.51,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,115.88,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,24.58,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,23.48,100,,,Fee Schedule,100% of CMS OPPS Rate,24.34,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,11.48,14,,,percent of total billed charges,14% of total billed charges,11.48,115.88,
98927 Osteopathic Manipulations 5-6 body regions,3438186,CDM,510,RC,98927,HCPCS,Outpatient,,,121.51,60.76,,91.13,75,,,percent of total billed charges,75% of total billed charges,91.13,75,,,percent of total billed charges,75% of total billed charges,23.48,100,,,Fee Schedule,100% of CMS OPPS Rate,32.45,100,,,Fee Schedule,100% of WV Medicaid Rate,38.75,165,,,Fee Schedule,165% of CMS OPPS Rate,24.34,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,67.45,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,92.51,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,115.88,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,32.45,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,23.48,100,,,Fee Schedule,100% of CMS OPPS Rate,24.34,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,17.01,14,,,percent of total billed charges,14% of total billed charges,17.01,115.88,
98927 Osteopathic manipulative treatment (OMT); 5-6 body regions involved,3621071,CDM,510,RC,98927,HCPCS,Outpatient,,,149.13,74.57,,111.85,75,,,percent of total billed charges,75% of total billed charges,111.85,75,,,percent of total billed charges,75% of total billed charges,23.48,100,,,Fee Schedule,100% of CMS OPPS Rate,32.45,100,,,Fee Schedule,100% of WV Medicaid Rate,38.75,165,,,Fee Schedule,165% of CMS OPPS Rate,24.34,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,67.45,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,92.51,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,115.88,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,32.45,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,23.48,100,,,Fee Schedule,100% of CMS OPPS Rate,24.34,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,20.88,14,,,percent of total billed charges,14% of total billed charges,20.88,115.88,
98928 Osteopathic Manipulations  7-8 body regions,3438187,CDM,510,RC,98928,HCPCS,Outpatient,,,153.82,76.91,,115.37,75,,,percent of total billed charges,75% of total billed charges,115.37,75,,,percent of total billed charges,75% of total billed charges,23.48,100,,,Fee Schedule,100% of CMS OPPS Rate,41.05,100,,,Fee Schedule,100% of WV Medicaid Rate,38.75,165,,,Fee Schedule,165% of CMS OPPS Rate,24.34,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,67.45,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,92.51,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,115.88,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,41.05,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,23.48,100,,,Fee Schedule,100% of CMS OPPS Rate,24.34,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,21.53,14,,,percent of total billed charges,14% of total billed charges,21.53,115.88,
98928 Osteopathic manipulative treatment (OMT); 7-8 body regions involved,3621072,CDM,510,RC,98928,HCPCS,Outpatient,,,183.81,91.91,,137.86,75,,,percent of total billed charges,75% of total billed charges,137.86,75,,,percent of total billed charges,75% of total billed charges,23.48,100,,,Fee Schedule,100% of CMS OPPS Rate,41.05,100,,,Fee Schedule,100% of WV Medicaid Rate,38.75,165,,,Fee Schedule,165% of CMS OPPS Rate,24.34,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,67.45,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,92.51,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,115.88,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,41.05,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,23.48,100,,,Fee Schedule,100% of CMS OPPS Rate,24.34,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,25.73,14,,,percent of total billed charges,14% of total billed charges,23.48,137.86,
98929 Osteopathic Manipulations 9-10 body regions,3438188,CDM,510,RC,98929,HCPCS,Outpatient,,,185.36,92.68,,139.02,75,,,percent of total billed charges,75% of total billed charges,139.02,75,,,percent of total billed charges,75% of total billed charges,23.48,100,,,Fee Schedule,100% of CMS OPPS Rate,49.65,100,,,Fee Schedule,100% of WV Medicaid Rate,38.75,165,,,Fee Schedule,165% of CMS OPPS Rate,24.34,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,67.45,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,92.51,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,115.88,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,49.65,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,23.48,100,,,Fee Schedule,100% of CMS OPPS Rate,24.34,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,25.95,14,,,percent of total billed charges,14% of total billed charges,23.48,139.02,
98960 - Education Training for self-mgmt,4323185,CDM,761,RC,98960,HCPCS,Outpatient,,,52.56,26.28,,39.42,75,,,percent of total billed charges,75% of total billed charges,39.42,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,18.19,100,,,Fee Schedule,100% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.19,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.36,14,,,percent of total billed charges,14% of total billed charges,7.36,39.42,
98966- Phone assess/nonMD/est pt/5-10 min,3437859,CDM,983,RC,98966,HCPCS,Outpatient,,,33.58,16.79,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
98967- Phone assess/nonMD/est pt/11-20min,3437860,CDM,983,RC,98967,HCPCS,Outpatient,,,62.44,31.22,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
98968- Phone assess/nonMD/est pt/21-30min,3437861,CDM,983,RC,98968,HCPCS,Outpatient,,,89.22,44.61,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
99000- Handle/convey/specimen/office-lab,3437863,CDM,983,RC,99000,HCPCS,Outpatient,,,63.82,31.91,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
99070- Supply/mat over & above for OV,3430564,CDM,960,RC,99070,HCPCS,Outpatient,,,13.29,6.65,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
99080- Special Reports Physical Form,3437877,CDM,983,RC,99080,HCPCS,Outpatient,,,39.89,19.95,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
99091- Clin data/dig transmit/interp/30mi,3437879,CDM,983,RC,99091,HCPCS,Outpatient,,,145.9,72.95,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
99152 - MOD SED SAME PHYS/QHP 5/>YRS,3997219,CDM,370,RC,99152,HCPCS,Outpatient,,,123.74,61.87,,92.81,75,,,percent of total billed charges,75% of total billed charges,92.81,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,9.09,100,,,Fee Schedule,100% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.09,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.32,14,,,percent of total billed charges,14% of total billed charges,9.09,92.81,
99153 - MOD SED SAME PHYS/QHP EA,3997220,CDM,370,RC,99153,HCPCS,Outpatient,,,25.91,12.96,,19.43,75,,,percent of total billed charges,75% of total billed charges,19.43,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,6.88,100,,,Fee Schedule,100% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.88,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.63,14,,,percent of total billed charges,14% of total billed charges,3.63,19.43,
Sedation Each Additional 15 Minutes,3428519,CDM,981,RC,99156,HCPCS,Outpatient,,,203.29,101.65,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
Sedation First 30 Minutes,3428520,CDM,981,RC,99157,HCPCS,Outpatient,,,163.51,81.76,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
99173 Vision Screening,3435573,CDM,510,RC,99173,HCPCS,Outpatient,,,13.29,6.65,,9.97,75,,,percent of total billed charges,75% of total billed charges,9.97,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,1.97,100,,,Fee Schedule,100% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.97,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.86,14,,,percent of total billed charges,14% of total billed charges,1.86,9.97,
Vision Testing POC,3444212,CDM,920,RC,99173,HCPCS,Outpatient,,,6.65,3.33,,4.99,75,,,percent of total billed charges,75% of total billed charges,4.99,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,1.97,100,,,Fee Schedule,100% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.97,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,1.97,4.99,
99183 Phys/QHP Attn&Supvj Hyprbaric Oxygen Tx/Session,3436093,CDM,761,RC,99183,HCPCS,Outpatient,,,283.33,141.67,,212.5,75,,,percent of total billed charges,75% of total billed charges,212.5,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,75.7,100,,,Fee Schedule,100% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,75.7,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.67,14,,,percent of total billed charges,14% of total billed charges,39.67,212.5,
99190- Assem/op pump/O2 or heat exch/60mi,3437890,CDM,983,RC,99190,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
99202 Office Outpt visist new StrFrwd or 15 to 29 mins,3726908,CDM,983,RC,99202,HCPCS,Outpatient,,,334.16,167.08,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
99202 Office Outpt visist new StrFrwd or 15 to 29 mins,3572774,CDM,510,RC,99202,HCPCS,Outpatient,,,334.16,167.08,,250.62,75,,,percent of total billed charges,75% of total billed charges,250.62,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,34.17,100,,,Fee Schedule,100% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.17,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.78,14,,,percent of total billed charges,14% of total billed charges,34.17,250.62,
99203 Office Outpt visit new Low or 30 to 44 mins,3726914,CDM,983,RC,99203,HCPCS,Outpatient,,,404.84,202.42,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
99203 Office Outpt visit new Low or 30 to 44 mins,3572775,CDM,510,RC,99203,HCPCS,Outpatient,,,404.84,202.42,,303.63,75,,,percent of total billed charges,75% of total billed charges,303.63,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,58.25,100,,,Fee Schedule,100% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,58.25,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.68,14,,,percent of total billed charges,14% of total billed charges,56.68,303.63,
99204 Office Outpt visit new Mod or 45 to 59 mins,3726901,CDM,983,RC,99204,HCPCS,Outpatient,,,508.59,254.3,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
99204 Office Outpt visit new Mod or 45 to 59 mins,3572776,CDM,510,RC,99204,HCPCS,Outpatient,,,508.59,254.3,,381.44,75,,,percent of total billed charges,75% of total billed charges,381.44,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,94.39,100,,,Fee Schedule,100% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,94.39,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,71.2,14,,,percent of total billed charges,14% of total billed charges,71.2,381.44,
99205 Office Outpt visist new High 60 to 74 mins,3572777,CDM,510,RC,99205,HCPCS,Outpatient,,,605.71,302.86,,454.28,75,,,percent of total billed charges,75% of total billed charges,454.28,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,127.82,100,,,Fee Schedule,100% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,127.82,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,84.8,14,,,percent of total billed charges,14% of total billed charges,84.8,454.28,
99205 Office Outpt visit new High 60 to 74 mins,3726920,CDM,983,RC,99205,HCPCS,Outpatient,,,605.71,302.86,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
99211 Office outpatient visit est  nursing visit only,3572778,CDM,510,RC,99211,HCPCS,Outpatient,,,255.89,127.95,,191.92,75,,,percent of total billed charges,75% of total billed charges,191.92,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.82,14,,,percent of total billed charges,14% of total billed charges,35.82,191.92,
99211 Office Outpt visit Est nursing visit only,3726926,CDM,983,RC,99211,HCPCS,Outpatient,,,255.89,127.95,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
99212 Office Outpt visit Est Straightforward 10 to 19 mins,3726932,CDM,983,RC,99212,HCPCS,Outpatient,,,309.78,154.89,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
99212 Office Outpt visit est Strtforward or 10 to 19 mins,3572779,CDM,510,RC,99212,HCPCS,Outpatient,,,309.78,154.89,,232.34,75,,,percent of total billed charges,75% of total billed charges,232.34,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.37,14,,,percent of total billed charges,14% of total billed charges,43.37,232.34,
99213 Office Outpt visit Est Low 20 to 29 mins,3726938,CDM,983,RC,99213,HCPCS,Outpatient,,,371.28,185.64,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
99213- Office/OP Est SF 20 Minutes,3572780,CDM,510,RC,99213,HCPCS,Outpatient,,,371.28,185.64,,278.46,75,,,percent of total billed charges,75% of total billed charges,278.46,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.98,14,,,percent of total billed charges,14% of total billed charges,51.98,278.46,
99214 Office Outpt visit Est Moderate 30 to 39 mins,3726944,CDM,983,RC,99214,HCPCS,Outpatient,,,434.18,217.09,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
99214- Office/OP Est Mod 30 Minutes,3572781,CDM,510,RC,99214,HCPCS,Outpatient,,,434.18,217.09,,325.64,75,,,percent of total billed charges,75% of total billed charges,325.64,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.79,14,,,percent of total billed charges,14% of total billed charges,60.79,325.64,
99215 Office Outpatient visit est High or 40 to 54 minutes,3572782,CDM,510,RC,99215,HCPCS,Outpatient,,,528.99,264.5,,396.74,75,,,percent of total billed charges,75% of total billed charges,396.74,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,74.06,14,,,percent of total billed charges,14% of total billed charges,74.06,396.74,
99215 Office Outpt vist Est High 40 to 54 mins,3726950,CDM,983,RC,99215,HCPCS,Outpatient,,,528.99,264.5,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
99288- Direct advanced life support,3437955,CDM,983,RC,99288,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
Direct Advanced Life Support,3428415,CDM,981,RC,99288,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
99341- Home visit new patient,3437990,CDM,983,RC,99341,HCPCS,Outpatient,,,137.94,68.97,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
99342- Home visit new patient,3437991,CDM,983,RC,99342,HCPCS,Outpatient,,,197.67,98.84,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
99344- Home visit new patient,3437993,CDM,983,RC,99344,HCPCS,Outpatient,,,461.65,230.83,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
99345- Home visit new patient,3437994,CDM,983,RC,99345,HCPCS,Outpatient,,,559.66,279.83,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
99347- Home visit est patient,3437995,CDM,983,RC,99347,HCPCS,Outpatient,,,139.4,69.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
99348- Home visit est patient,3437996,CDM,983,RC,99348,HCPCS,Outpatient,,,212.72,106.36,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
99349- Home visit est patient,3437997,CDM,983,RC,99349,HCPCS,Outpatient,,,326.99,163.5,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
99350- Home visit est patient,3437998,CDM,983,RC,99350,HCPCS,Outpatient,,,455.15,227.58,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
99360- Phys Standby Svc Prolng Phys Attn Ea 30 Min,3438009,CDM,983,RC,99360,HCPCS,Outpatient,,,134.29,67.15,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
99363- Anticoagulant Mgmt Outpatient Init 90 Days,3438012,CDM,983,RC,99363,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
99364- Anticoagulant Mgmt Outpatient Ea Sbsq 90 Days,3438013,CDM,983,RC,99364,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
99374- Home health care supervision,3438021,CDM,983,RC,99374,HCPCS,Outpatient,,,132.97,66.49,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
99375- Home health care supervision,3438022,CDM,983,RC,99375,HCPCS,Outpatient,,,43.88,21.94,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
99377- Hospice care supervision,3438023,CDM,983,RC,99377,HCPCS,Outpatient,,,187.48,93.74,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
99381- Initial Comp Preventive Med less than 1 year New,3438027,CDM,510,RC,99381,HCPCS,Outpatient,,,281.89,140.95,,211.42,75,,,percent of total billed charges,75% of total billed charges,211.42,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,52.36,100,,,Fee Schedule,100% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.36,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.46,14,,,percent of total billed charges,14% of total billed charges,39.46,211.42,
99382- Initial Comp Preventive Med 1 to 4 years New,3438028,CDM,510,RC,99382,HCPCS,Outpatient,,,295.19,147.6,,221.39,75,,,percent of total billed charges,75% of total billed charges,221.39,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,55.8,100,,,Fee Schedule,100% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55.8,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.33,14,,,percent of total billed charges,14% of total billed charges,41.33,221.39,
99383- Initial Comp Preventive Med 5 to 11 years New,3438029,CDM,510,RC,99383,HCPCS,Outpatient,,,307.16,153.58,,230.37,75,,,percent of total billed charges,75% of total billed charges,230.37,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,59.24,100,,,Fee Schedule,100% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,59.24,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43,14,,,percent of total billed charges,14% of total billed charges,43,230.37,
99384- Initial Comp Preventive Med 12 to 17 years New,3438030,CDM,983,RC,99384,HCPCS,Outpatient,,,340.95,170.48,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
99385- Initial Comp Preventive Med 18 to 39 years New,3438031,CDM,983,RC,99385,HCPCS,Outpatient,,,329.86,164.93,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
99386- Initial Comp Preventive Med 40 to 64 years New,3438032,CDM,983,RC,99386,HCPCS,Outpatient,,,384.62,192.31,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
99387- Initial Comp Preventive Med 65+ yrs New,3438033,CDM,983,RC,99387,HCPCS,Outpatient,,,514,257,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
99391- Periodic Comp Preventive Med less than 1 year Est,3438035,CDM,983,RC,99391,HCPCS,Outpatient,,,248.64,124.32,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
99392- Periodic Comp Preventive Med 1 to 4 years Est,3438037,CDM,983,RC,99392,HCPCS,Outpatient,,,265.93,132.97,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
99393- Periodic Comp Preventive Med 5 to 11 years Est,3438038,CDM,983,RC,99393,HCPCS,Outpatient,,,276.58,138.29,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
99394- Periodic Comp Preventive Med 12 to 17 years Est,3438039,CDM,983,RC,99394,HCPCS,Outpatient,,,291.19,145.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
99397- Periodic Comp Preventive Med 65+ years Est,3438042,CDM,983,RC,99397,HCPCS,Outpatient,,,341.72,170.86,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
"99397- Prev Visit, Est, 65 & Over",3438043,CDM,983,RC,99397,HCPCS,Outpatient,,,341.72,170.86,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
99411- Prev Med Counsel+Risk Factor Redj Grp Spx 30 Min,3438064,CDM,983,RC,99411,HCPCS,Outpatient,,,53.19,26.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
99412- Prev Med Counsel+Risk Factor Redj Grp Spx 60 Min,3438066,CDM,983,RC,99412,HCPCS,Outpatient,,,66.48,33.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
99417 - Prolonged outpatient E/M Service - ea addl 15 min,3640926,CDM,983,RC,99417,HCPCS,Outpatient,,,91,45.5,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
ONLINE E/M PHYS CULM 7 DAYS 21+MIN,3527890,CDM,960,RC,99423,HCPCS,Outpatient,,,123.18,61.59,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
99429- Unlisted Preventive Medicine Service,3438069,CDM,983,RC,99429,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
99439- Chrnc Care Mgmt Svc Ea Addl,3918991,CDM,982,RC,99439,HCPCS,Outpatient,,,121.26,60.63,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
99444- Online e/m by phys/qhp,3438077,CDM,983,RC,99444,HCPCS,Outpatient,,,119.67,59.84,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
99450- Basic life disability exam,3438088,CDM,983,RC,99450,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
99455- Work Related/Med Dblt Xm Treating Phys,3438090,CDM,983,RC,99455,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
99456- Work Related/Med Dblt Xm Oth/Thn Treating Phys,3438092,CDM,983,RC,99456,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
"99487- Complex chronic care management, 60 minutes",3431351,CDM,960,RC,99487,HCPCS,Outpatient,,,181.62,90.81,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
99489- Com chronic care mngt/add 30 min,3431072,CDM,510,RC,99489,HCPCS,Outpatient,,,176.33,88.17,,132.25,75,,,percent of total billed charges,75% of total billed charges,132.25,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,35.15,100,,,Fee Schedule,100% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.15,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.69,14,,,percent of total billed charges,14% of total billed charges,24.69,132.25,
99489- Complx chron care addl30 min,3438134,CDM,983,RC,99489,HCPCS,Outpatient,,,176.33,88.17,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
99490 Chronic Care Management,3438180,CDM,983,RC,99490,HCPCS,Outpatient,,,161.34,80.67,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
99495- Trans care mgmt 14 day disch,3438135,CDM,510,RC,99495,HCPCS,Outpatient,,,372.33,186.17,,279.25,75,,,percent of total billed charges,75% of total billed charges,279.25,75,,,percent of total billed charges,75% of total billed charges,113.62,100,,,Fee Schedule,100% of CMS OPPS Rate,99.55,100,,,Fee Schedule,100% of WV Medicaid Rate,187.47,165,,,Fee Schedule,165% of CMS OPPS Rate,117.76,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,326.38,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,447.6,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,560.66,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,99.55,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,113.62,100,,,Fee Schedule,100% of CMS OPPS Rate,117.76,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,52.13,14,,,percent of total billed charges,14% of total billed charges,52.13,560.66,
99496- Trans care mgmt 7 day disch,3438136,CDM,510,RC,99496,HCPCS,Outpatient,,,503.97,251.99,,377.98,75,,,percent of total billed charges,75% of total billed charges,377.98,75,,,percent of total billed charges,75% of total billed charges,113.62,100,,,Fee Schedule,100% of CMS OPPS Rate,134.69,100,,,Fee Schedule,100% of WV Medicaid Rate,187.47,165,,,Fee Schedule,165% of CMS OPPS Rate,117.76,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,326.38,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,447.6,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,560.66,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,134.69,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,113.62,100,,,Fee Schedule,100% of CMS OPPS Rate,117.76,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,70.56,14,,,percent of total billed charges,14% of total billed charges,70.56,560.66,
99500 Home visit prenatal,3430565,CDM,960,RC,99500,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
99606 Mtms by pharm est 15 min,3430567,CDM,960,RC,99606,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
0001A - ADM SARSCOV2 30MCG/0.3ML 1ST,3999148,CDM,771,RC,0001A,HCPCS,Outpatient,,,96.62,48.31,,72.47,75,,,percent of total billed charges,75% of total billed charges,72.47,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.53,14,,,percent of total billed charges,14% of total billed charges,13.53,72.47,
0002A - ADM SARSCOV2 30MCG/0.3ML 2ND,3997221,CDM,771,RC,0002A,HCPCS,Outpatient,,,96.62,48.31,,72.47,75,,,percent of total billed charges,75% of total billed charges,72.47,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.53,14,,,percent of total billed charges,14% of total billed charges,13.53,72.47,
0003A - ADM SARSCOV2 30MCG/0.3ML 3RD,3997222,CDM,771,RC,0003A,HCPCS,Outpatient,,,96.62,48.31,,72.47,75,,,percent of total billed charges,75% of total billed charges,72.47,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.53,14,,,percent of total billed charges,14% of total billed charges,13.53,72.47,
0004A - ADM SARSCOV2 30MCG/0.3ML BST,3999149,CDM,771,RC,0004A,HCPCS,Outpatient,,,96.62,48.31,,72.47,75,,,percent of total billed charges,75% of total billed charges,72.47,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.53,14,,,percent of total billed charges,14% of total billed charges,13.53,72.47,
0011A - ADM SARSCOV2 100MCG/0.5ML1ST,3997223,CDM,771,RC,0011A,HCPCS,Outpatient,,,96.62,48.31,,72.47,75,,,percent of total billed charges,75% of total billed charges,72.47,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.53,14,,,percent of total billed charges,14% of total billed charges,13.53,72.47,
0012A - ADM SARSCOV2 100MCG/0.5ML2ND,3997224,CDM,771,RC,0012A,HCPCS,Outpatient,,,96.62,48.31,,72.47,75,,,percent of total billed charges,75% of total billed charges,72.47,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.53,14,,,percent of total billed charges,14% of total billed charges,13.53,72.47,
0013A - ADM SARSCOV2 100MCG/0.5ML3RD,3997225,CDM,771,RC,0013A,HCPCS,Outpatient,,,96.62,48.31,,72.47,75,,,percent of total billed charges,75% of total billed charges,72.47,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.53,14,,,percent of total billed charges,14% of total billed charges,13.53,72.47,
0031A - ADM SARSCOV2 VAC AD26 .5ML,3999150,CDM,771,RC,0031A,HCPCS,Outpatient,,,96.62,48.31,,72.47,75,,,percent of total billed charges,75% of total billed charges,72.47,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.53,14,,,percent of total billed charges,14% of total billed charges,13.53,72.47,
0034A - ADM SARSCOV2 VAC AD26 .5ML B,3999151,CDM,771,RC,0034A,HCPCS,Outpatient,,,96.62,48.31,,72.47,75,,,percent of total billed charges,75% of total billed charges,72.47,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.53,14,,,percent of total billed charges,14% of total billed charges,13.53,72.47,
0041A - IMM ADMN SARSCOV2 5 MCG/0.5 ML 1ST DOSE,4037470,CDM,771,RC,0041A,HCPCS,Outpatient,,,96.62,48.31,,72.47,75,,,percent of total billed charges,75% of total billed charges,72.47,75,,,percent of total billed charges,75% of total billed charges,39.02,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,64.39,165,,,Fee Schedule,165% of CMS OPPS Rate,40.45,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,112.11,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,153.76,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,192.6,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,39.02,100,,,Fee Schedule,100% of CMS OPPS Rate,40.45,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,13.53,14,,,percent of total billed charges,14% of total billed charges,13.53,192.6,
ADM SARSCV2 30MCG TRS-SUCR 1,4227161,CDM,771,RC,0051A,HCPCS,Outpatient,,,80.03,40.02,,60.02,75,,,percent of total billed charges,75% of total billed charges,60.02,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.2,14,,,percent of total billed charges,14% of total billed charges,11.2,60.02,
ADM SARSCV2 30MCG TRS-SUCR 2,4227162,CDM,771,RC,0052A,HCPCS,Outpatient,,,80.03,40.02,,60.02,75,,,percent of total billed charges,75% of total billed charges,60.02,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.2,14,,,percent of total billed charges,14% of total billed charges,11.2,60.02,
ADM SARSCV2 30MCG TRS-SUCR 3,4227163,CDM,771,RC,0053A,HCPCS,Outpatient,,,80.03,40.02,,60.02,75,,,percent of total billed charges,75% of total billed charges,60.02,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.2,14,,,percent of total billed charges,14% of total billed charges,11.2,60.02,
0064A - ADM SARSCOV2 50MCG/0.25MLBST,3997226,CDM,771,RC,0064A,HCPCS,Outpatient,,,96.62,48.31,,72.47,75,,,percent of total billed charges,75% of total billed charges,72.47,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.53,14,,,percent of total billed charges,14% of total billed charges,13.53,72.47,
0071A - ADM SARSCV2 10MCG TRS-SUCR 1,3997227,CDM,771,RC,0071A,HCPCS,Outpatient,,,96.62,48.31,,72.47,75,,,percent of total billed charges,75% of total billed charges,72.47,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.53,14,,,percent of total billed charges,14% of total billed charges,13.53,72.47,
Admin PED Covid: First Dose: Pfizer PED 0071A,3867236,CDM,771,RC,0071A,HCPCS,Outpatient,,,96.62,48.31,,72.47,75,,,percent of total billed charges,75% of total billed charges,72.47,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.53,14,,,percent of total billed charges,14% of total billed charges,13.53,72.47,
0072A - ADM SARSCV2 10MCG TRS-SUCR 2,3997228,CDM,771,RC,0072A,HCPCS,Outpatient,,,96.62,48.31,,72.47,75,,,percent of total billed charges,75% of total billed charges,72.47,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.53,14,,,percent of total billed charges,14% of total billed charges,13.53,72.47,
Admin Ped Covid: Second Dose: Pfizer PED 0072A,3867235,CDM,771,RC,0072A,HCPCS,Outpatient,,,96.62,48.31,,72.47,75,,,percent of total billed charges,75% of total billed charges,72.47,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.53,14,,,percent of total billed charges,14% of total billed charges,13.53,72.47,
0073A - Adm Sarscv2 10 mcg Trs-Sucr 3,4169605,CDM,983,RC,0073A,HCPCS,Outpatient,,,94.98,47.49,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
Third Dose: Pfizer PED 0073A,4037366,CDM,771,RC,0073A,HCPCS,Outpatient,,,96.62,48.31,,72.47,75,,,percent of total billed charges,75% of total billed charges,72.47,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.53,14,,,percent of total billed charges,14% of total billed charges,13.53,72.47,
First Dose: Pfizer 6m-4y 0081A,4061289,CDM,771,RC,0081A,HCPCS,Outpatient,,,96.62,48.31,,72.47,75,,,percent of total billed charges,75% of total billed charges,72.47,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.53,14,,,percent of total billed charges,14% of total billed charges,13.53,72.47,
Second Dose: Pfizer 6m-4y 0082A,4061288,CDM,771,RC,0082A,HCPCS,Outpatient,,,96.62,48.31,,72.47,75,,,percent of total billed charges,75% of total billed charges,72.47,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.53,14,,,percent of total billed charges,14% of total billed charges,13.53,72.47,
Third Dose: Pfizer 6m-4y 0083A,4061287,CDM,771,RC,0083A,HCPCS,Outpatient,,,96.62,48.31,,72.47,75,,,percent of total billed charges,75% of total billed charges,72.47,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.53,14,,,percent of total billed charges,14% of total billed charges,13.53,72.47,
0124A - Adm SARSCV2 BVL 30mcg/.3ML Booster,4189301,CDM,983,RC,0124A,HCPCS,Outpatient,,,100.39,50.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
Bivalent Booster: Pfizer 0124A,4179748,CDM,771,RC,0124A,HCPCS,Outpatient,,,100.39,50.2,,75.29,75,,,percent of total billed charges,75% of total billed charges,75.29,75,,,percent of total billed charges,75% of total billed charges,39.02,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,64.39,165,,,Fee Schedule,165% of CMS OPPS Rate,40.45,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,112.11,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,153.76,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,192.6,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,39.02,100,,,Fee Schedule,100% of CMS OPPS Rate,40.45,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,14.05,14,,,percent of total billed charges,14% of total billed charges,14.05,192.6,
ADM SARSCV2 30MCG TRS-SUCR B,4227179,CDM,771,RC,0154A,HCPCS,Outpatient,,,80.03,40.02,,60.02,75,,,percent of total billed charges,75% of total billed charges,60.02,75,,,percent of total billed charges,75% of total billed charges,39.02,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,64.39,165,,,Fee Schedule,165% of CMS OPPS Rate,40.45,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,112.11,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,153.76,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,192.6,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,39.02,100,,,Fee Schedule,100% of CMS OPPS Rate,40.45,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,11.2,14,,,percent of total billed charges,14% of total billed charges,11.2,192.6,
ADM SARSCV2 BVL 10MCG/2ML Booster,4223275,CDM,983,RC,0154A,HCPCS,Outpatient,,,80.03,40.02,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
0296T CardioKey Application,3575069,CDM,960,RC,0296T,HCPCS,Outpatient,,,28.08,14.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
0298T CardioKey Interpretation,3575070,CDM,960,RC,0298T,HCPCS,Outpatient,,,64.91,32.46,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
0500F- Initial preventive physical exam (IPPE),3428311,CDM,983,RC,0500F,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
TCAT Rmv/Debulk ICAR Mas Perq,4223276,CDM,960,RC,0644T,HCPCS,Outpatient,,,212,106,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
3354F - CLIN SIGN DEP SYMP BY STAND DEP ASSESS TOOL,3999152,CDM,510,RC,3354F,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
541PEP Pre employment Physical,3438253,CDM,510,RC,541PEP,HCPCS,Outpatient,,,99.72,49.86,,74.79,75,,,percent of total billed charges,75% of total billed charges,74.79,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.96,14,,,percent of total billed charges,14% of total billed charges,13.96,74.79,
561OM DOT Physicial,3438252,CDM,510,RC,561OM,HCPCS,Outpatient,,,99.72,49.86,,74.79,75,,,percent of total billed charges,75% of total billed charges,74.79,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.96,14,,,percent of total billed charges,14% of total billed charges,13.96,74.79,
611C Drug Screen Collection,3435567,CDM,510,RC,611C,HCPCS,Outpatient,,,30.58,15.29,,22.94,75,,,percent of total billed charges,75% of total billed charges,22.94,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.28,14,,,percent of total billed charges,14% of total billed charges,4.28,22.94,
611D DOT Drug Screen,3435568,CDM,510,RC,611D,HCPCS,Outpatient,,,59.84,29.92,,44.88,75,,,percent of total billed charges,75% of total billed charges,44.88,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.38,14,,,percent of total billed charges,14% of total billed charges,8.38,44.88,
611HR Hair Specimen,3435569,CDM,510,RC,611HR,HCPCS,Outpatient,,,126.32,63.16,,94.74,75,,,percent of total billed charges,75% of total billed charges,94.74,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.68,14,,,percent of total billed charges,14% of total billed charges,17.68,94.74,
611N Non DOT Drug Screen,3435570,CDM,510,RC,611N,HCPCS,Outpatient,,,59.84,29.92,,44.88,75,,,percent of total billed charges,75% of total billed charges,44.88,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.38,14,,,percent of total billed charges,14% of total billed charges,8.38,44.88,
BLS MILEAGE,3527830,CDM,981,RC,A0380,HCPCS,Outpatient,,,8.78,4.39,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
ALS MILEAGE,3527832,CDM,981,RC,A0390,HCPCS,Outpatient,,,8.78,4.39,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
ALS-1 NON EMERGENCY,3527831,CDM,981,RC,A0426,HCPCS,Outpatient,,,263.42,131.71,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
BLS-NON EMERGENCY,3527829,CDM,981,RC,A0428,HCPCS,Outpatient,,,219.52,109.76,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
"A4561- Pessary rubber, any type",3431438,CDM,450,RC,A4561,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.92,102,,,Fee Schedule,102% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.53,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.53,19.92,
"A4562- Pessary, non rubber,any type",3431439,CDM,450,RC,A4562,HCPCS,Outpatient,,,343.71,171.86,,257.78,75,,,percent of total billed charges,75% of total billed charges,257.78,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,49.59,102,,,Fee Schedule,102% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.62,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.12,14,,,percent of total billed charges,14% of total billed charges,48.12,257.78,
A6197-KERRACEL AG 4X5IN,3436119,CDM,279,RC,A6197,HCPCS,Outpatient,,,35.12,17.56,,26.34,75,,,percent of total billed charges,75% of total billed charges,26.34,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,16.42,102,,,Fee Schedule,102% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.1,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.92,14,,,percent of total billed charges,14% of total billed charges,4.92,26.34,
A6235-DUODERM XTHIN 6X6IN,3436129,CDM,279,RC,A6235,HCPCS,Outpatient,,,15.05,7.53,,11.29,75,,,percent of total billed charges,75% of total billed charges,11.29,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,16.79,102,,,Fee Schedule,102% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.46,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.11,14,,,percent of total billed charges,14% of total billed charges,2.11,16.79,
A9500-NM Isotope Sesamibi Add-on,4263189,CDM,343,RC,A9500,HCPCS,Outpatient,,,506.78,253.39,,380.09,75,,,percent of total billed charges,75% of total billed charges,380.09,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,70.95,14,,,percent of total billed charges,14% of total billed charges,70.95,380.09,
"A9606- Radium RA-223 dichloride, therapeutic, per microcurie",3435846,CDM,450,RC,A9606,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,157.91,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,260.55,165,,,Fee Schedule,165% of CMS OPPS Rate,175.28,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,485.77,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,666.2,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,834.49,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,157.91,100,,,Fee Schedule,100% of CMS OPPS Rate,175.28,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,157.91,834.49,
DOTPE  Self-Pay DOT Exam,3438189,CDM,999,RC,DOTPE,HCPCS,Outpatient,,,120,60,,90,75,,,percent of total billed charges,75% of total billed charges,90,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.8,14,,,percent of total billed charges,14% of total billed charges,16.8,90,
Single Tip Cane,3428523,CDM,981,RC,E0100,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
E0114 - Crutch Underarm Pair No Wood,4189318,CDM,983,RC,E0114,HCPCS,Outpatient,,,151.96,75.98,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
Folding Walker W/Wheels,3428430,CDM,981,RC,E0149,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
Flexibility Evaluation,4199643,CDM,978,RC,FLEX,HCPCS,Outpatient,,,31.8,15.9,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
G0008 - Flu vaccine admin,3574864,CDM,960,RC,G0008,HCPCS,Outpatient,,,70.47,35.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
Medicare G0008,3444227,CDM,771,RC,G0008,HCPCS,Outpatient,,,70.47,35.24,,52.85,75,,,percent of total billed charges,75% of total billed charges,52.85,75,,,percent of total billed charges,75% of total billed charges,39.83,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,65.72,165,,,Fee Schedule,165% of CMS OPPS Rate,41.28,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,114.41,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,156.91,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,196.54,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,39.83,100,,,Fee Schedule,100% of CMS OPPS Rate,41.28,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,9.87,14,,,percent of total billed charges,14% of total billed charges,9.87,196.54,
ADMIN PNEUMOCOCCAL VACCINE,3435725,CDM,771,RC,G0009,HCPCS,Outpatient,,,239.98,119.99,,179.99,75,,,percent of total billed charges,75% of total billed charges,179.99,75,,,percent of total billed charges,75% of total billed charges,39.83,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,65.72,165,,,Fee Schedule,165% of CMS OPPS Rate,41.28,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,114.41,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,156.91,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,196.54,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,39.83,100,,,Fee Schedule,100% of CMS OPPS Rate,41.28,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,33.6,14,,,percent of total billed charges,14% of total billed charges,33.6,196.54,
G0009 Pneumococcal admin,3574862,CDM,960,RC,G0009,HCPCS,Outpatient,,,239.88,119.94,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
G0010 - Hep B admin,3574863,CDM,960,RC,G0010,HCPCS,Outpatient,,,70.47,35.24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
G0101- Cervical Or Vaginal Cancer Screening,3431440,CDM,510,RC,G0101,HCPCS,Outpatient,,,99.99,50,,74.99,75,,,percent of total billed charges,75% of total billed charges,74.99,75,,,percent of total billed charges,75% of total billed charges,71.29,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,117.66,165,,,Fee Schedule,165% of CMS OPPS Rate,73.9,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,204.82,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,280.89,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,351.86,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,71.29,100,,,Fee Schedule,100% of CMS OPPS Rate,73.9,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,14,14,,,percent of total billed charges,14% of total billed charges,14,351.86,
"G0179- Home health re-certification, physician",3435919,CDM,510,RC,G0179,HCPCS,Outpatient,,,101.88,50.94,,76.41,75,,,percent of total billed charges,75% of total billed charges,76.41,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.26,14,,,percent of total billed charges,14% of total billed charges,14.26,76.41,
"G0182- Hospice, care plan oversite, by physician, 30 min",3435921,CDM,510,RC,G0182,HCPCS,Outpatient,,,270.82,135.41,,203.12,75,,,percent of total billed charges,75% of total billed charges,203.12,75,,,percent of total billed charges,75% of total billed charges,86.66,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.91,14,,,percent of total billed charges,14% of total billed charges,37.91,203.12,
BREATHING RETRAINING,3435727,CDM,410,RC,G0237,HCPCS,Outpatient,,,23.74,11.87,,17.81,75,,,percent of total billed charges,75% of total billed charges,17.81,75,,,percent of total billed charges,75% of total billed charges,23.46,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,38.71,165,,,Fee Schedule,165% of CMS OPPS Rate,24.31,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,67.4,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,92.43,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,115.78,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,23.46,100,,,Fee Schedule,100% of CMS OPPS Rate,24.31,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,3.32,14,,,percent of total billed charges,14% of total billed charges,3.32,115.78,
Breathing Retraining Outpatient,634103,CDM,410,RC,G0237,HCPCS,Outpatient,,,23.74,11.87,,17.81,75,,,percent of total billed charges,75% of total billed charges,17.81,75,,,percent of total billed charges,75% of total billed charges,23.46,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,38.71,165,,,Fee Schedule,165% of CMS OPPS Rate,24.31,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,67.4,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,92.43,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,115.78,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,23.46,100,,,Fee Schedule,100% of CMS OPPS Rate,24.31,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,3.32,14,,,percent of total billed charges,14% of total billed charges,3.32,115.78,
Pulmonary Rehab Breathing Retraining,651868,CDM,410,RC,G0237,HCPCS,Outpatient,,,23.74,11.87,,17.81,75,,,percent of total billed charges,75% of total billed charges,17.81,75,,,percent of total billed charges,75% of total billed charges,23.46,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,38.71,165,,,Fee Schedule,165% of CMS OPPS Rate,24.31,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,67.4,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,92.43,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,115.78,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,23.46,100,,,Fee Schedule,100% of CMS OPPS Rate,24.31,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,3.32,14,,,percent of total billed charges,14% of total billed charges,3.32,115.78,
Therapeutic Procedure to Improve Respiratory Function; Per 1,4109132,CDM,410,RC,G0238,HCPCS,Outpatient,,,23.74,11.87,,17.81,75,,,percent of total billed charges,75% of total billed charges,17.81,75,,,percent of total billed charges,75% of total billed charges,23.46,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,38.71,165,,,Fee Schedule,165% of CMS OPPS Rate,24.31,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,67.4,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,92.43,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,115.78,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,23.46,100,,,Fee Schedule,100% of CMS OPPS Rate,24.31,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,3.32,14,,,percent of total billed charges,14% of total billed charges,3.32,115.78,
Home Management Training,634106,CDM,410,RC,G0239,HCPCS,Outpatient,,,30.32,15.16,,22.74,75,,,percent of total billed charges,75% of total billed charges,22.74,75,,,percent of total billed charges,75% of total billed charges,31.92,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,52.67,165,,,Fee Schedule,165% of CMS OPPS Rate,33.08,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,91.7,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,125.76,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,157.53,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,31.92,100,,,Fee Schedule,100% of CMS OPPS Rate,33.08,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4.24,14,,,percent of total billed charges,14% of total billed charges,4.24,157.53,
G0248- Demonstrate use home iINR monitor,3430574,CDM,450,RC,G0248,HCPCS,Outpatient,,,152.06,76.03,,114.05,75,,,percent of total billed charges,75% of total billed charges,114.05,75,,,percent of total billed charges,75% of total billed charges,113.62,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,187.47,165,,,Fee Schedule,165% of CMS OPPS Rate,117.76,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,326.38,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,447.6,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,560.66,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,113.62,100,,,Fee Schedule,100% of CMS OPPS Rate,117.76,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,21.29,14,,,percent of total billed charges,14% of total billed charges,21.29,560.66,
G0270 - MNT subs tx for change dx,4037466,CDM,983,RC,G0270,HCPCS,Outpatient,,,80.74,40.37,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
"G0277 HBOT, Full Body Chamber, 30 Minutes",3436143,CDM,761,RC,G0277,HCPCS,Outpatient,,,917.05,458.53,,687.79,75,,,percent of total billed charges,75% of total billed charges,687.79,75,,,percent of total billed charges,75% of total billed charges,117.58,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,194.01,165,,,Fee Schedule,165% of CMS OPPS Rate,121.86,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,337.74,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,463.19,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,580.2,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,117.58,100,,,Fee Schedule,100% of CMS OPPS Rate,121.86,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,128.39,14,,,percent of total billed charges,14% of total billed charges,117.58,687.79,
"G0279 - TOMOSYNTHESIS, MAMMO",3999153,CDM,983,RC,G0279,HCPCS,Outpatient,,,55.27,27.64,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
WHFMT MA Diagnostic TOMO,3610993,CDM,972,RC,G0279,HCPCS,Outpatient,,,132.28,66.14,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
Occult Blood Screening (FIT test),3334727,CDM,300,RC,G0328,HCPCS,Outpatient,,,107.14,53.57,,80.36,75,,,percent of total billed charges,75% of total billed charges,80.36,75,,,percent of total billed charges,75% of total billed charges,18.05,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,18.05,165,,,Fee Schedule,165% of CMS OPPS Rate,18.05,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,63.99,354.54,,,Fee Schedule,354.54% of CMS OPPS Fee Schedule Rate,77.38,428.7,,,Fee Schedule,428.7% of CMS OPPS Fee Schedule Rate,81.37,450.81,,,Fee Schedule,450.81% of CMS OPPS Fee Schedule Rate,,,,,Other,Not Separately reimbursable,18.05,100,,,Fee Schedule,100% of CMS OPPS Rate,18.05,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,15,14,,,percent of total billed charges,14% of total billed charges,15,81.37,
Occult Blood Screening (FIT test) X 3,3334916,CDM,300,RC,G0328,HCPCS,Outpatient,,,107.14,53.57,,80.36,75,,,percent of total billed charges,75% of total billed charges,80.36,75,,,percent of total billed charges,75% of total billed charges,18.05,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,18.05,165,,,Fee Schedule,165% of CMS OPPS Rate,18.05,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,63.99,354.54,,,Fee Schedule,354.54% of CMS OPPS Fee Schedule Rate,77.38,428.7,,,Fee Schedule,428.7% of CMS OPPS Fee Schedule Rate,81.37,450.81,,,Fee Schedule,450.81% of CMS OPPS Fee Schedule Rate,,,,,Other,Not Separately reimbursable,18.05,100,,,Fee Schedule,100% of CMS OPPS Rate,18.05,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,15,14,,,percent of total billed charges,14% of total billed charges,15,81.37,
G0372- Phys Srv Req For Pwr Mob Device,3435923,CDM,510,RC,G0372,HCPCS,Outpatient,,,23.06,11.53,,17.3,75,,,percent of total billed charges,75% of total billed charges,17.3,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.23,14,,,percent of total billed charges,14% of total billed charges,3.23,17.3,
G0399- Home Sleep Test 3,3430575,CDM,920,RC,G0399,HCPCS,Outpatient,,,1038.8,519.4,,779.1,75,,,percent of total billed charges,75% of total billed charges,779.1,75,,,percent of total billed charges,75% of total billed charges,136.72,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,225.58,165,,,Fee Schedule,165% of CMS OPPS Rate,141.69,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,392.72,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,538.59,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,674.64,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,136.72,100,,,Fee Schedule,100% of CMS OPPS Rate,141.69,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,145.43,14,,,percent of total billed charges,14% of total billed charges,136.72,779.1,
G0400 - Home Sleep Test/Type 4 Portable-Unattended,4347086,CDM,510,RC,G0400,HCPCS,Outpatient,,,1524.25,762.13,,1143.19,75,,,percent of total billed charges,75% of total billed charges,1143.19,75,,,percent of total billed charges,75% of total billed charges,263.29,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,434.44,165,,,Fee Schedule,165% of CMS OPPS Rate,272.88,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,756.29,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1037.2,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1299.2,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,263.29,100,,,Fee Schedule,100% of CMS OPPS Rate,272.88,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,213.4,14,,,percent of total billed charges,14% of total billed charges,213.4,1299.2,
G0402Initial Wellness Visit ''Welcome to Medicare'',3442036,CDM,983,RC,G0402,HCPCS,Outpatient,,,426.2,213.1,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
IPPE-Welcome to Medicare G0402,3428471,CDM,983,RC,G0402,HCPCS,Outpatient,,,426.2,213.1,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
G0403- Ekg For Init Preventive Exam,3428455,CDM,983,RC,G0403,HCPCS,Outpatient,,,36.01,18.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
G0404- EKG tracing for IPPE,3428456,CDM,983,RC,G0404,HCPCS,Outpatient,,,14.52,7.26,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
G0405- EKG interpret & report for IPPE,3428457,CDM,983,RC,G0405,HCPCS,Outpatient,,,21.49,10.75,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
G0429 - dermal filler injection,3572730,CDM,983,RC,G0429,HCPCS,Outpatient,,,9346.96,4673.48,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
G0438 AWV w/PPS initial visit,3428458,CDM,510,RC,G0438,HCPCS,Outpatient,,,426.2,213.1,,319.65,75,,,percent of total billed charges,75% of total billed charges,319.65,75,,,percent of total billed charges,75% of total billed charges,157.9,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,260.54,165,,,Fee Schedule,165% of CMS OPPS Rate,154.05,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,559.82,354.54,,,Fee Schedule,354.54% of CMS OPPS Fee Schedule Rate,676.92,428.7,,,Fee Schedule,428.7% of CMS OPPS Fee Schedule Rate,711.83,450.81,,,Fee Schedule,450.81% of CMS OPPS Fee Schedule Rate,,,,,Other,Not Separately reimbursable,157.9,100,,,Fee Schedule,100% of CMS OPPS Rate,154.05,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,59.67,14,,,percent of total billed charges,14% of total billed charges,59.67,711.83,
"G0438- Ppps, Initial Visit",3435669,CDM,510,RC,G0438,HCPCS,Outpatient,,,426.2,213.1,,319.65,75,,,percent of total billed charges,75% of total billed charges,319.65,75,,,percent of total billed charges,75% of total billed charges,157.9,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,260.54,165,,,Fee Schedule,165% of CMS OPPS Rate,154.05,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,559.82,354.54,,,Fee Schedule,354.54% of CMS OPPS Fee Schedule Rate,676.92,428.7,,,Fee Schedule,428.7% of CMS OPPS Fee Schedule Rate,711.83,450.81,,,Fee Schedule,450.81% of CMS OPPS Fee Schedule Rate,,,,,Other,Not Separately reimbursable,157.9,100,,,Fee Schedule,100% of CMS OPPS Rate,154.05,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,59.67,14,,,percent of total billed charges,14% of total billed charges,59.67,711.83,
G0439 AWV w/PPS subsequent visit,3428459,CDM,510,RC,G0439,HCPCS,Outpatient,,,330.95,165.48,,248.21,75,,,percent of total billed charges,75% of total billed charges,248.21,75,,,percent of total billed charges,75% of total billed charges,122.66,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,202.39,165,,,Fee Schedule,165% of CMS OPPS Rate,119.67,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,434.88,354.54,,,Fee Schedule,354.54% of CMS OPPS Fee Schedule Rate,525.84,428.7,,,Fee Schedule,428.7% of CMS OPPS Fee Schedule Rate,552.96,450.81,,,Fee Schedule,450.81% of CMS OPPS Fee Schedule Rate,,,,,Other,Not Separately reimbursable,122.66,100,,,Fee Schedule,100% of CMS OPPS Rate,119.67,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,46.33,14,,,percent of total billed charges,14% of total billed charges,46.33,552.96,
"G0439- Ppps, Subseq Visit",3435670,CDM,510,RC,G0439,HCPCS,Outpatient,,,330.95,165.48,,248.21,75,,,percent of total billed charges,75% of total billed charges,248.21,75,,,percent of total billed charges,75% of total billed charges,122.66,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,202.39,165,,,Fee Schedule,165% of CMS OPPS Rate,119.67,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,434.88,354.54,,,Fee Schedule,354.54% of CMS OPPS Fee Schedule Rate,525.84,428.7,,,Fee Schedule,428.7% of CMS OPPS Fee Schedule Rate,552.96,450.81,,,Fee Schedule,450.81% of CMS OPPS Fee Schedule Rate,,,,,Other,Not Separately reimbursable,122.66,100,,,Fee Schedule,100% of CMS OPPS Rate,119.67,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,46.33,14,,,percent of total billed charges,14% of total billed charges,46.33,552.96,
G0463 - EST PATIENT LVL 1,3717121,CDM,510,RC,G0463,HCPCS,Outpatient,,,238.27,119.14,,178.7,75,,,percent of total billed charges,75% of total billed charges,178.7,75,,,percent of total billed charges,75% of total billed charges,113.62,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,187.47,165,,,Fee Schedule,165% of CMS OPPS Rate,117.76,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,326.38,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,447.6,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,560.66,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,113.62,100,,,Fee Schedule,100% of CMS OPPS Rate,117.76,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,33.36,14,,,percent of total billed charges,14% of total billed charges,33.36,560.66,
G0463 OCC EYE CLINIC VISIT,3686903,CDM,510,RC,G0463,HCPCS,Outpatient,,,238.27,119.14,,178.7,75,,,percent of total billed charges,75% of total billed charges,178.7,75,,,percent of total billed charges,75% of total billed charges,113.62,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,187.47,165,,,Fee Schedule,165% of CMS OPPS Rate,117.76,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,326.38,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,447.6,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,560.66,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,113.62,100,,,Fee Schedule,100% of CMS OPPS Rate,117.76,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,33.36,14,,,percent of total billed charges,14% of total billed charges,33.36,560.66,
G0500 - MOD SEDAT ENDO SERVICE >5YRS,3999154,CDM,370,RC,G0500,HCPCS,Outpatient,,,133.78,66.89,,100.34,75,,,percent of total billed charges,75% of total billed charges,100.34,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.73,14,,,percent of total billed charges,14% of total billed charges,18.73,100.34,
G2212 - Prolonged OP E/M Service-beyond the maximum (ea addl 15 min),3623709,CDM,510,RC,G2212,HCPCS,Outpatient,,,99.72,49.86,,74.79,75,,,percent of total billed charges,75% of total billed charges,74.79,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.96,14,,,percent of total billed charges,14% of total billed charges,13.96,74.79,
G6002-GUIDANCE FOR RADIAJ TX DLVR,3400484,CDM,983,RC,G6002,HCPCS,Outpatient,,,125.07,62.54,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
G8431 Positive Depression Screen w/follow up plan documented,3438182,CDM,983,RC,G8431,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
G9299- No Eval Risk Venus thromboembolic Card risk Prior to procedure,3430584,CDM,960,RC,G9299,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
Intensive Outpatient Treatment,3438168,CDM,983,RC,H0015,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
H0019- BH Intensive Residential Treatment Services,3438158,CDM,960,RC,H0019,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
H0032- BH Individual Treatment Plan Update/Review,3438161,CDM,960,RC,H0032,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
H0035- Partial Hospitalization - Age 18 and Older,3438162,CDM,983,RC,H0035,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
H2010 -Comprehensive med svc 15 min,3430585,CDM,960,RC,H2010,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
AMB EPINEPHrine Charge:0.3 mg EPINEPHrine Inj,3444289,CDM,636,RC,J0171,HCPCS,Outpatient,,,40.39,20.2,,30.29,75,,,percent of total billed charges,75% of total billed charges,30.29,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.65,14,,,percent of total billed charges,14% of total billed charges,5.65,30.29,
AMB EPINEPHrine Charge:0.5 mg EPINEPHrine Inj,3444290,CDM,636,RC,J0171,HCPCS,Outpatient,,,40.39,20.2,,30.29,75,,,percent of total billed charges,75% of total billed charges,30.29,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.65,14,,,percent of total billed charges,14% of total billed charges,5.65,30.29,
AMB alprostadil Charge:10 mcg  alprostadil  Inj,3444240,CDM,636,RC,J0270,HCPCS,Outpatient,,,797.5,398.75,,598.13,75,,,percent of total billed charges,75% of total billed charges,598.13,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,111.65,14,,,percent of total billed charges,14% of total billed charges,111.65,598.13,
AMB alprostadil Charge:2.5 mcg  alprostadil  Inj,3444238,CDM,636,RC,J0270,HCPCS,Outpatient,,,797.5,398.75,,598.13,75,,,percent of total billed charges,75% of total billed charges,598.13,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,111.65,14,,,percent of total billed charges,14% of total billed charges,111.65,598.13,
AMB alprostadil Charge:5 mcg  alprostadil  Inj,3444239,CDM,636,RC,J0270,HCPCS,Outpatient,,,797.5,398.75,,598.13,75,,,percent of total billed charges,75% of total billed charges,598.13,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,111.65,14,,,percent of total billed charges,14% of total billed charges,111.65,598.13,
AMB amiodarone Charge:150 mg amiodarone Inj,3444242,CDM,636,RC,J0282,HCPCS,Outpatient,,,5.4,2.7,,4.05,75,,,percent of total billed charges,75% of total billed charges,4.05,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,4.05,4.05,
AMB atropine Charge:0.4 mg atropine Inj,3444243,CDM,636,RC,J0461,HCPCS,Outpatient,,,0.07,0.04,,0.05,75,,,percent of total billed charges,75% of total billed charges,0.05,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,0.05,0.05,
AMB benralizumab Charge:300 mg benralizumab Inj,3444247,CDM,636,RC,J0517,HCPCS,Outpatient,,,14447.38,7223.69,,10835.54,75,,,percent of total billed charges,75% of total billed charges,10835.54,75,,,percent of total billed charges,75% of total billed charges,170.56,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,281.42,165,,,Fee Schedule,165% of CMS OPPS Rate,189.32,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4697.06,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5794.01,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,5010.33,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,170.56,100,,,Fee Schedule,100% of CMS OPPS Rate,189.32,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,2022.63,14,,,percent of total billed charges,14% of total billed charges,170.56,10835.54,
AMB onabotulinumtoxinA Charge -> 100 unit Botox Inj,3616873,CDM,636,RC,J0585,HCPCS,Outpatient,,,3804,1902,,2853,75,,,percent of total billed charges,75% of total billed charges,2853,75,,,percent of total billed charges,75% of total billed charges,6.33,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,10.44,165,,,Fee Schedule,165% of CMS OPPS Rate,7.02,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,19.47,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,26.7,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,33.45,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,6.33,100,,,Fee Schedule,100% of CMS OPPS Rate,7.02,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,532.56,14,,,percent of total billed charges,14% of total billed charges,6.33,2853,
AMB onabotulinumtoxinA Charge -> 200 unit Botox Inj,3616872,CDM,636,RC,J0585,HCPCS,Outpatient,,,7608,3804,,5706,75,,,percent of total billed charges,75% of total billed charges,5706,75,,,percent of total billed charges,75% of total billed charges,6.33,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,10.44,165,,,Fee Schedule,165% of CMS OPPS Rate,7.02,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,19.47,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,3007.1,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,33.45,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,6.33,100,,,Fee Schedule,100% of CMS OPPS Rate,7.02,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1065.12,14,,,percent of total billed charges,14% of total billed charges,6.33,5706,
"J0585 - Injection, onabotulinumtoxinA, 1 unit",3430587,CDM,636,RC,J0585,HCPCS,Outpatient,,,16.8,8.4,,12.6,75,,,percent of total billed charges,75% of total billed charges,12.6,75,,,percent of total billed charges,75% of total billed charges,6.33,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,10.44,165,,,Fee Schedule,165% of CMS OPPS Rate,7.02,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,19.47,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,26.7,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,33.45,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,6.33,100,,,Fee Schedule,100% of CMS OPPS Rate,7.02,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,2.35,14,,,percent of total billed charges,14% of total billed charges,2.35,33.45,
J0585-OCC EYE BOTOX SUPPLY PER UNIT,3536987,CDM,636,RC,J0585,HCPCS,Outpatient,,,38,19,,28.5,75,,,percent of total billed charges,75% of total billed charges,28.5,75,,,percent of total billed charges,75% of total billed charges,6.33,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,10.44,165,,,Fee Schedule,165% of CMS OPPS Rate,7.02,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,19.47,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,26.7,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,33.45,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,6.33,100,,,Fee Schedule,100% of CMS OPPS Rate,7.02,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,5.32,14,,,percent of total billed charges,14% of total billed charges,5.32,33.45,
onabotulinumtoxinA,,,636,RC,J0585,HCPCS,Outpatient,,,1622.7,811.35,,1217.03,75,,,percent of total billed charges,75% of total billed charges,1217.03,75,,,percent of total billed charges,75% of total billed charges,6.33,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,10.44,165,,,Fee Schedule,165% of CMS OPPS Rate,7.02,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,19.47,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,26.7,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,33.45,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,6.33,100,,,Fee Schedule,100% of CMS OPPS Rate,7.02,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,227.18,14,,,percent of total billed charges,14% of total billed charges,6.33,1217.03,
J0587 - Botox - 100 units,3918949,CDM,636,RC,J0587,HCPCS,Outpatient,,,1393.28,696.64,,1044.96,75,,,percent of total billed charges,75% of total billed charges,1044.96,75,,,percent of total billed charges,75% of total billed charges,13.04,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,21.51,165,,,Fee Schedule,165% of CMS OPPS Rate,14.47,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,40.11,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,55.01,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,68.91,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,13.04,100,,,Fee Schedule,100% of CMS OPPS Rate,14.47,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,195.06,14,,,percent of total billed charges,14% of total billed charges,13.04,1044.96,
AMB incobotulinumtoxinA Charge:25unit Xeomin Inj,3444320,CDM,636,RC,J0588,HCPCS,Outpatient,,,5.63,2.82,,4.22,75,,,percent of total billed charges,75% of total billed charges,4.22,75,,,percent of total billed charges,75% of total billed charges,5.19,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,8.56,165,,,Fee Schedule,165% of CMS OPPS Rate,5.76,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,15.96,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,21.89,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,27.42,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,5.19,100,,,Fee Schedule,100% of CMS OPPS Rate,5.76,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,,14,,,Other,Not Separately reimbursable,4.22,27.42,
AMB incobotulinumtoxinA Charge:50unit Xeomin Inj,3444321,CDM,636,RC,J0588,HCPCS,Outpatient,,,5.63,2.82,,4.22,75,,,percent of total billed charges,75% of total billed charges,4.22,75,,,percent of total billed charges,75% of total billed charges,5.19,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,8.56,165,,,Fee Schedule,165% of CMS OPPS Rate,5.76,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,15.96,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,21.89,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,27.42,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,5.19,100,,,Fee Schedule,100% of CMS OPPS Rate,5.76,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,,14,,,Other,Not Separately reimbursable,4.22,27.42,
AMB canakinumab Charge:150 mg canakinumab Inj,3444252,CDM,636,RC,J0638,HCPCS,Outpatient,,,46234.04,23117.02,,34675.53,75,,,percent of total billed charges,75% of total billed charges,34675.53,75,,,percent of total billed charges,75% of total billed charges,5863.86,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,5873.78,165,,,Fee Schedule,165% of CMS OPPS Rate,5865.54,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,14868.44,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,18318.33,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,15753.97,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,5863.86,100,,,Fee Schedule,100% of CMS OPPS Rate,5865.54,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,6472.77,14,,,percent of total billed charges,14% of total billed charges,5863.86,34675.53,
AMB cefTRIAXone Charge:1000 mg cefTRIAXone Inj,3444253,CDM,636,RC,J0696,HCPCS,Outpatient,,,103.39,51.7,,77.54,75,,,percent of total billed charges,75% of total billed charges,77.54,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.47,14,,,percent of total billed charges,14% of total billed charges,14.47,77.54,
AMB cefTRIAXone Charge:250 mg cefTRIAXone Inj,3444255,CDM,636,RC,J0696,HCPCS,Outpatient,,,2.03,1.02,,1.52,75,,,percent of total billed charges,75% of total billed charges,1.52,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,1.52,1.52,
AMB cefTRIAXone Charge:500 mg cefTRIAXone Inj,3444254,CDM,636,RC,J0696,HCPCS,Outpatient,,,60.41,30.21,,45.31,75,,,percent of total billed charges,75% of total billed charges,45.31,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.46,14,,,percent of total billed charges,14% of total billed charges,8.46,45.31,
J0696 - Ceftriaxone - 250mg,3918950,CDM,636,RC,J0696,HCPCS,Outpatient,,,45.92,22.96,,34.44,75,,,percent of total billed charges,75% of total billed charges,34.44,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.43,14,,,percent of total billed charges,14% of total billed charges,6.43,34.44,
AMB betamethasone Charge:12 mg betamethasone Inj,3444251,CDM,636,RC,J0702,HCPCS,Outpatient,,,56.61,28.31,,42.46,75,,,percent of total billed charges,75% of total billed charges,42.46,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.93,14,,,percent of total billed charges,14% of total billed charges,7.93,42.46,
AMB betamethasone Charge:6 mg betamethasone Inj,3444249,CDM,636,RC,J0702,HCPCS,Outpatient,,,28.3,14.15,,21.23,75,,,percent of total billed charges,75% of total billed charges,21.23,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.96,14,,,percent of total billed charges,14% of total billed charges,3.96,21.23,
AMB betamethasone Charge:9 mg betamethasone Inj,3444250,CDM,636,RC,J0702,HCPCS,Outpatient,,,56.61,28.31,,42.46,75,,,percent of total billed charges,75% of total billed charges,42.46,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.93,14,,,percent of total billed charges,14% of total billed charges,7.93,42.46,
AMB certolizumab Charge:400 mg certolizumab Inj,3444256,CDM,636,RC,J0717,HCPCS,Outpatient,,,26004.02,13002.01,,19503.02,75,,,percent of total billed charges,75% of total billed charges,19503.02,75,,,percent of total billed charges,75% of total billed charges,3290.12,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,3290.52,165,,,Fee Schedule,165% of CMS OPPS Rate,3290.19,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8338.14,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,10269.4,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,8818.6,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,3290.12,100,,,Fee Schedule,100% of CMS OPPS Rate,3290.19,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,3640.56,14,,,percent of total billed charges,14% of total billed charges,3290.12,19503.02,
J0717 - Cimza - 1mg,3918953,CDM,636,RC,J0717,HCPCS,Outpatient,,,8.95,4.48,,6.71,75,,,percent of total billed charges,75% of total billed charges,6.71,75,,,percent of total billed charges,75% of total billed charges,4.9,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,8.08,165,,,Fee Schedule,165% of CMS OPPS Rate,5.43,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,15.07,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,20.67,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,25.89,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,4.9,100,,,Fee Schedule,100% of CMS OPPS Rate,5.43,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1.25,14,,,percent of total billed charges,14% of total billed charges,1.25,25.89,
"J0717 - Injection, certolizumab pegol, 1 mg",3918952,CDM,636,RC,J0717,HCPCS,Outpatient,,,8.95,4.48,,6.71,75,,,percent of total billed charges,75% of total billed charges,6.71,75,,,percent of total billed charges,75% of total billed charges,4.9,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,8.08,165,,,Fee Schedule,165% of CMS OPPS Rate,5.43,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,15.07,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,20.67,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,25.89,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,4.9,100,,,Fee Schedule,100% of CMS OPPS Rate,5.43,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1.25,14,,,percent of total billed charges,14% of total billed charges,1.25,25.89,
AMB collagenase clostridium Charge:0.58 mg Xiaflex Inj,3444259,CDM,636,RC,J0775,HCPCS,Outpatient,,,36596.35,18298.18,,27447.26,75,,,percent of total billed charges,75% of total billed charges,27447.26,75,,,percent of total billed charges,75% of total billed charges,4637.91,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,4643.41,165,,,Fee Schedule,165% of CMS OPPS Rate,4638.84,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,11757.94,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,14484.57,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,12450.92,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,4637.91,100,,,Fee Schedule,100% of CMS OPPS Rate,4638.84,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,5123.49,14,,,percent of total billed charges,14% of total billed charges,4637.91,27447.26,
10 mg prochlorperazine Inj,4241578,CDM,636,RC,J0780,HCPCS,Outpatient,,,49.95,24.98,,37.46,75,,,percent of total billed charges,75% of total billed charges,37.46,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.99,14,,,percent of total billed charges,14% of total billed charges,6.99,37.46,
5 mg prochlorperazine Inj,4241579,CDM,636,RC,J0780,HCPCS,Outpatient,,,49.95,24.98,,37.46,75,,,percent of total billed charges,75% of total billed charges,37.46,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.99,14,,,percent of total billed charges,14% of total billed charges,6.99,37.46,
AMB Denosumab Charge:120 mg denosumab Inj,3444270,CDM,636,RC,J0897,HCPCS,Outpatient,,,17264.75,8632.38,,12948.56,75,,,percent of total billed charges,75% of total billed charges,12948.56,75,,,percent of total billed charges,75% of total billed charges,24.22,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,39.96,165,,,Fee Schedule,165% of CMS OPPS Rate,26.88,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,5543.97,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,6829.18,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,5868.75,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,24.22,100,,,Fee Schedule,100% of CMS OPPS Rate,26.88,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,2417.07,14,,,percent of total billed charges,14% of total billed charges,24.22,12948.56,
AMB Denosumab Charge:60 mg denosumab Inj,3444269,CDM,636,RC,J0897,HCPCS,Outpatient,,,9385.85,4692.93,,7039.39,75,,,percent of total billed charges,75% of total billed charges,7039.39,75,,,percent of total billed charges,75% of total billed charges,24.22,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,39.96,165,,,Fee Schedule,165% of CMS OPPS Rate,26.88,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,3018.18,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,3718.46,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,3197.8,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,24.22,100,,,Fee Schedule,100% of CMS OPPS Rate,26.88,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1314.02,14,,,percent of total billed charges,14% of total billed charges,24.22,7039.39,
"J0897 - Injection, denosumab, 1 mg",3918954,CDM,636,RC,J0897,HCPCS,Outpatient,,,2979.56,1489.78,,2234.67,75,,,percent of total billed charges,75% of total billed charges,2234.67,75,,,percent of total billed charges,75% of total billed charges,24.22,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,39.96,165,,,Fee Schedule,165% of CMS OPPS Rate,26.88,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,74.5,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,102.18,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,127.99,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,24.22,100,,,Fee Schedule,100% of CMS OPPS Rate,26.88,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,417.14,14,,,percent of total billed charges,14% of total billed charges,24.22,2234.67,
J0897 - Prolia - 1mg,3918955,CDM,636,RC,J0897,HCPCS,Outpatient,,,2979.56,1489.78,,2234.67,75,,,percent of total billed charges,75% of total billed charges,2234.67,75,,,percent of total billed charges,75% of total billed charges,24.22,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,39.96,165,,,Fee Schedule,165% of CMS OPPS Rate,26.88,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,74.5,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,102.18,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,127.99,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,24.22,100,,,Fee Schedule,100% of CMS OPPS Rate,26.88,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,417.14,14,,,percent of total billed charges,14% of total billed charges,24.22,2234.67,
80mg DEPO-Medrol Inj,3444357,CDM,636,RC,J1010,HCPCS,Outpatient,,,44.06,22.03,,33.05,75,,,percent of total billed charges,75% of total billed charges,33.05,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.17,14,,,percent of total billed charges,14% of total billed charges,6.17,33.05,
AMB MethylPREDNISolone Charge:40 mg DEPO-Medrol Inj,3444356,CDM,636,RC,J1010,HCPCS,Outpatient,,,30.69,15.35,,23.02,75,,,percent of total billed charges,75% of total billed charges,23.02,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.3,14,,,percent of total billed charges,14% of total billed charges,4.3,23.02,
AMB MethylPREDNISolone Charge:40 mg DEPO-Medrol Inj,3711090,CDM,636,RC,J1010,HCPCS,Outpatient,,,15.35,7.68,,11.51,75,,,percent of total billed charges,75% of total billed charges,11.51,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.15,14,,,percent of total billed charges,14% of total billed charges,2.15,11.51,
"J1010-RHM DEPOMEDROL,40MG",3430593,CDM,636,RC,J1010,HCPCS,Outpatient,,,16.8,8.4,,12.6,75,,,percent of total billed charges,75% of total billed charges,12.6,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.35,14,,,percent of total billed charges,14% of total billed charges,2.35,12.6,
"J1030 - Injection, methylprednisolone acetate, 40 mg",3918956,CDM,636,RC,J1010,HCPCS,Outpatient,,,45.92,22.96,,34.44,75,,,percent of total billed charges,75% of total billed charges,34.44,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.43,14,,,percent of total billed charges,14% of total billed charges,6.43,34.44,
J1030 - RHM DepoMedrol - 40mg,3918957,CDM,636,RC,J1010,HCPCS,Outpatient,,,16.8,8.4,,12.6,75,,,percent of total billed charges,75% of total billed charges,12.6,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.35,14,,,percent of total billed charges,14% of total billed charges,2.35,12.6,
"J1040 - Methylprednisolone, 80 mg",3918958,CDM,636,RC,J1010,HCPCS,Outpatient,,,57.12,28.56,,42.84,75,,,percent of total billed charges,75% of total billed charges,42.84,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8,14,,,percent of total billed charges,14% of total billed charges,8,42.84,
AMB medroxyPROGESTERone Charge:150 mg DEPO-Provera Inj,3444350,CDM,636,RC,J1050,HCPCS,Outpatient,,,230.4,115.2,,172.8,75,,,percent of total billed charges,75% of total billed charges,172.8,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.26,14,,,percent of total billed charges,14% of total billed charges,32.26,172.8,
100 mg Depo-Testosterone Inj,3616862,CDM,636,RC,J1071,HCPCS,Outpatient,,,63,31.5,,47.25,75,,,percent of total billed charges,75% of total billed charges,47.25,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.82,14,,,percent of total billed charges,14% of total billed charges,8.82,47.25,
150 mg Depo-Testosterone Inj,4215708,CDM,636,RC,J1071,HCPCS,Outpatient,,,94.5,47.25,,70.88,75,,,percent of total billed charges,75% of total billed charges,70.88,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.23,14,,,percent of total billed charges,14% of total billed charges,13.23,70.88,
250 mg Depo-Testosterone Inj,4215715,CDM,636,RC,J1071,HCPCS,Outpatient,,,157.5,78.75,,118.13,75,,,percent of total billed charges,75% of total billed charges,118.13,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.05,14,,,percent of total billed charges,14% of total billed charges,22.05,118.13,
50 mg Depo-Testosterone Inj,3616863,CDM,636,RC,J1071,HCPCS,Outpatient,,,31.5,15.75,,23.63,75,,,percent of total billed charges,75% of total billed charges,23.63,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.41,14,,,percent of total billed charges,14% of total billed charges,4.41,23.63,
AMB Testosterone Charge:1000 mg Aveed Inj,3444413,CDM,636,RC,J1071,HCPCS,Outpatient,,,5607.36,2803.68,,4205.52,75,,,percent of total billed charges,75% of total billed charges,4205.52,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,785.03,14,,,percent of total billed charges,14% of total billed charges,785.03,4205.52,
AMB Testosterone Charge:200 mg Depo-Testosterone Inj,3444410,CDM,636,RC,J1071,HCPCS,Outpatient,,,126,63,,94.5,75,,,percent of total billed charges,75% of total billed charges,94.5,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.64,14,,,percent of total billed charges,14% of total billed charges,17.64,94.5,
AMB Testosterone Charge:300mg Depo-Testosterone Inj,3444411,CDM,636,RC,J1071,HCPCS,Outpatient,,,189,94.5,,141.75,75,,,percent of total billed charges,75% of total billed charges,141.75,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.46,14,,,percent of total billed charges,14% of total billed charges,26.46,141.75,
AMB Testosterone Charge:500mg Depo-Testosterone Inj,3444412,CDM,636,RC,J1071,HCPCS,Outpatient,,,315,157.5,,236.25,75,,,percent of total billed charges,75% of total billed charges,236.25,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.1,14,,,percent of total billed charges,14% of total billed charges,44.1,236.25,
AMB Testosterone Charge:750 mg Aveed Inj,3444414,CDM,636,RC,J1071,HCPCS,Outpatient,,,4205.52,2102.76,,3154.14,75,,,percent of total billed charges,75% of total billed charges,3154.14,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,588.77,14,,,percent of total billed charges,14% of total billed charges,588.77,3154.14,
J1071 - Testosterone - 1mg,3918959,CDM,636,RC,J1071,HCPCS,Outpatient,,,43.7,21.85,,32.78,75,,,percent of total billed charges,75% of total billed charges,32.78,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.12,14,,,percent of total billed charges,14% of total billed charges,6.12,32.78,
AMB dexamethasone Charge -> 8 mg dexamethasone Inj,3444272,CDM,636,RC,J1100,HCPCS,Outpatient,,,0.16,0.08,,0.12,75,,,percent of total billed charges,75% of total billed charges,0.12,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,0.12,0.12,
AMB dexamethasone Charge:4 mg dexamethasone Inj,3444271,CDM,636,RC,J1100,HCPCS,Outpatient,,,0.16,0.08,,0.12,75,,,percent of total billed charges,75% of total billed charges,0.12,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,0.12,0.12,
J1100 - Dexamethasone - 1mg,3918960,CDM,636,RC,J1100,HCPCS,Outpatient,,,1.48,0.74,,1.11,75,,,percent of total billed charges,75% of total billed charges,1.11,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,1.11,1.11,
J1200 - Benadryl - upto 50mg,3918961,CDM,636,RC,J1200,HCPCS,Outpatient,,,1.66,0.83,,1.25,75,,,percent of total billed charges,75% of total billed charges,1.25,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,1.25,1.25,
AMB dimethyl sulfoxide Charge:50 mL Rimso-50 Inj,3444275,CDM,636,RC,J1212,HCPCS,Outpatient,,,3971.35,1985.68,,2978.51,75,,,percent of total billed charges,75% of total billed charges,2978.51,75,,,percent of total billed charges,75% of total billed charges,681.74,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1124.85,165,,,Fee Schedule,165% of CMS OPPS Rate,756.73,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,2097.23,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2876.19,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,3602.72,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,681.74,100,,,Fee Schedule,100% of CMS OPPS Rate,756.73,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,555.99,14,,,percent of total billed charges,14% of total billed charges,555.99,3602.72,
284 mg inclisiran (Leqvio) Inj,4081125,CDM,636,RC,J1306,HCPCS,Outpatient,,,8775,4387.5,,6581.25,75,,,percent of total billed charges,75% of total billed charges,6581.25,75,,,percent of total billed charges,75% of total billed charges,12.02,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,19.82,165,,,Fee Schedule,165% of CMS OPPS Rate,13.34,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,2817.67,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,3470.85,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,2982.67,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,12.02,100,,,Fee Schedule,100% of CMS OPPS Rate,13.34,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1228.5,14,,,percent of total billed charges,14% of total billed charges,12.02,6581.25,
"J1306 - Injection, inclisiran, 1 mg",4209176,CDM,636,RC,J1306,HCPCS,Outpatient,,,38.45,19.23,,28.84,75,,,percent of total billed charges,75% of total billed charges,28.84,75,,,percent of total billed charges,75% of total billed charges,12.02,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,19.82,165,,,Fee Schedule,165% of CMS OPPS Rate,13.34,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,36.97,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,50.71,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,63.52,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,12.02,100,,,Fee Schedule,100% of CMS OPPS Rate,13.34,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,5.38,14,,,percent of total billed charges,14% of total billed charges,5.38,63.52,
AMB gentamicin Charge:80 mg gentamincin Inj,3444299,CDM,636,RC,J1580,HCPCS,Outpatient,,,13.5,6.75,,10.13,75,,,percent of total billed charges,75% of total billed charges,10.13,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.89,14,,,percent of total billed charges,14% of total billed charges,1.89,10.13,
AMB glucagon Charge:1 mg glucagon Inj,3444300,CDM,636,RC,J1610,HCPCS,Outpatient,,,223.87,111.94,,167.9,75,,,percent of total billed charges,75% of total billed charges,167.9,75,,,percent of total billed charges,75% of total billed charges,187.5,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,309.37,165,,,Fee Schedule,165% of CMS OPPS Rate,208.12,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,576.79,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,791.04,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,990.86,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,187.5,100,,,Fee Schedule,100% of CMS OPPS Rate,208.12,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,31.34,14,,,percent of total billed charges,14% of total billed charges,31.34,990.86,
"40,000 units heparin Inj",4207118,CDM,636,RC,J1644,HCPCS,Outpatient,,,13.5,6.75,,10.13,75,,,percent of total billed charges,75% of total billed charges,10.13,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.89,14,,,percent of total billed charges,14% of total billed charges,1.89,10.13,
"AMB heparin Charge -> 10,000 units heparin Inj",3626983,CDM,636,RC,J1644,HCPCS,Outpatient,,,15.78,7.89,,11.84,75,,,percent of total billed charges,75% of total billed charges,11.84,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.21,14,,,percent of total billed charges,14% of total billed charges,2.21,11.84,
AMB hydrocortisone  Charge:100 mg hydrocortisone Inj,3444317,CDM,636,RC,J1720,HCPCS,Outpatient,,,14.45,7.23,,10.84,75,,,percent of total billed charges,75% of total billed charges,10.84,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.02,14,,,percent of total billed charges,14% of total billed charges,2.02,10.84,
AMB HYDROXYprogesterone Charge:250 mg HYDROXYprogesterone Inj,3444318,CDM,636,RC,J1726,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.82,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,22.8,165,,,Fee Schedule,165% of CMS OPPS Rate,15.34,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,42.51,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,58.3,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,73.03,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,13.82,100,,,Fee Schedule,100% of CMS OPPS Rate,15.34,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,13.82,73.03,
AMB HYDROXYprogesterone Charge:275 mg HYDROXYprogesterone Inj,3444319,CDM,636,RC,J1726,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.82,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,22.8,165,,,Fee Schedule,165% of CMS OPPS Rate,15.34,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,42.51,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,58.3,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,73.03,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,13.82,100,,,Fee Schedule,100% of CMS OPPS Rate,15.34,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,13.82,73.03,
AMB ketorolac Charge:30 mg ketorolac Inj,3444330,CDM,636,RC,J1885,HCPCS,Outpatient,,,30.38,15.19,,22.79,75,,,percent of total billed charges,75% of total billed charges,22.79,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.25,14,,,percent of total billed charges,14% of total billed charges,4.25,22.79,
AMB ketorolac Charge;60 mg ketorolac Inj,3444331,CDM,636,RC,J1885,HCPCS,Outpatient,,,30.38,15.19,,22.79,75,,,percent of total billed charges,75% of total billed charges,22.79,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.25,14,,,percent of total billed charges,14% of total billed charges,4.25,22.79,
"J1885 - Injection, ketorolac tromethamine, per 15 mg",3918962,CDM,636,RC,J1885,HCPCS,Outpatient,,,11.46,5.73,,8.6,75,,,percent of total billed charges,75% of total billed charges,8.6,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.6,14,,,percent of total billed charges,14% of total billed charges,1.6,8.6,
J1885 - Ketorolac  15mg,3918963,CDM,636,RC,J1885,HCPCS,Outpatient,,,11.46,5.73,,8.6,75,,,percent of total billed charges,75% of total billed charges,8.6,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.6,14,,,percent of total billed charges,14% of total billed charges,1.6,8.6,
AMB furosemide Charge:20 mg furosemide Inj,3444297,CDM,636,RC,J1940,HCPCS,Outpatient,,,13.5,6.75,,10.13,75,,,percent of total billed charges,75% of total billed charges,10.13,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.89,14,,,percent of total billed charges,14% of total billed charges,1.89,10.13,
AMB furosemide Charge:40 mg furosemide Inj,3444298,CDM,636,RC,J1940,HCPCS,Outpatient,,,13.5,6.75,,10.13,75,,,percent of total billed charges,75% of total billed charges,10.13,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.89,14,,,percent of total billed charges,14% of total billed charges,1.89,10.13,
J1940 - LASIX-20 mg furosemide Inj,4178536,CDM,636,RC,J1940,HCPCS,Outpatient,,,33.6,16.8,,25.2,75,,,percent of total billed charges,75% of total billed charges,25.2,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.7,14,,,percent of total billed charges,14% of total billed charges,4.7,25.2,
J1940 - LASIX-40 mg furosemide Inj,4178537,CDM,636,RC,J1940,HCPCS,Outpatient,,,67.2,33.6,,50.4,75,,,percent of total billed charges,75% of total billed charges,50.4,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.41,14,,,percent of total billed charges,14% of total billed charges,9.41,50.4,
11.25 mg leuprolide IM Inj,3444334,CDM,636,RC,J1950,HCPCS,Outpatient,,,21407.75,10703.88,,16055.81,75,,,percent of total billed charges,75% of total billed charges,16055.81,75,,,percent of total billed charges,75% of total billed charges,1524.34,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,2515.16,165,,,Fee Schedule,165% of CMS OPPS Rate,1692.01,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,7448.97,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,9256.01,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,8264.17,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,1524.34,100,,,Fee Schedule,100% of CMS OPPS Rate,1692.01,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,2997.09,14,,,percent of total billed charges,14% of total billed charges,1524.34,16055.81,
3.75 mg leuprolide IM Inj,3444336,CDM,636,RC,J1950,HCPCS,Outpatient,,,9801.95,4900.98,,7351.46,75,,,percent of total billed charges,75% of total billed charges,7351.46,75,,,percent of total billed charges,75% of total billed charges,1524.34,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,2515.16,165,,,Fee Schedule,165% of CMS OPPS Rate,1692.01,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4689.32,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,6431.03,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,8055.52,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,1524.34,100,,,Fee Schedule,100% of CMS OPPS Rate,1692.01,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1372.27,14,,,percent of total billed charges,14% of total billed charges,1372.27,8055.52,
"J1950 - Injection, leuprolide acetate (for depot suspension)",4169302,CDM,636,RC,J1950,HCPCS,Outpatient,,,7718.65,3859.33,,5788.99,75,,,percent of total billed charges,75% of total billed charges,5788.99,75,,,percent of total billed charges,75% of total billed charges,1524.34,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,2515.16,165,,,Fee Schedule,165% of CMS OPPS Rate,1692.01,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4689.32,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,6431.03,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,8055.52,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,1524.34,100,,,Fee Schedule,100% of CMS OPPS Rate,1692.01,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1080.61,14,,,percent of total billed charges,14% of total billed charges,1080.61,8055.52,
AMB bupivacaine Charge -> 10 mL bupivacaine Inj,3626948,CDM,636,RC,J2001,HCPCS,Outpatient,,,13.5,6.75,,10.13,75,,,percent of total billed charges,75% of total billed charges,10.13,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.89,14,,,percent of total billed charges,14% of total billed charges,1.89,10.13,
AMB epinephrine-lidocaine Charge -> 10mL lidocaine w/epi Inj,3444292,CDM,636,RC,J2001,HCPCS,Outpatient,,,36.45,18.23,,27.34,75,,,percent of total billed charges,75% of total billed charges,27.34,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.1,14,,,percent of total billed charges,14% of total billed charges,5.1,27.34,
AMB epinephrine-lidocaine Charge -> 20 mL lidocaine w/epi Inj,3444293,CDM,636,RC,J2001,HCPCS,Outpatient,,,72.9,36.45,,54.68,75,,,percent of total billed charges,75% of total billed charges,54.68,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.21,14,,,percent of total billed charges,14% of total billed charges,10.21,54.68,
AMB epinephrine-lidocaine Charge -> 5mL lidocaine w/epi Inj,3444291,CDM,636,RC,J2001,HCPCS,Outpatient,,,18.23,9.12,,13.67,75,,,percent of total billed charges,75% of total billed charges,13.67,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.55,14,,,percent of total billed charges,14% of total billed charges,2.55,13.67,
AMB mepolizumab Charge:100 mg Nucala Inj,3444355,CDM,636,RC,J2182,HCPCS,Outpatient,,,32.21,16.11,,24.16,75,,,percent of total billed charges,75% of total billed charges,24.16,75,,,percent of total billed charges,75% of total billed charges,30.17,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,49.78,165,,,Fee Schedule,165% of CMS OPPS Rate,33.47,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,92.81,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,127.28,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,159.43,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,30.17,100,,,Fee Schedule,100% of CMS OPPS Rate,33.47,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4.51,14,,,percent of total billed charges,14% of total billed charges,4.51,159.43,
AMB nalbuphine Charge:10mg Nubain Inj,3444369,CDM,636,RC,J2300,HCPCS,Outpatient,,,25.76,12.88,,19.32,75,,,percent of total billed charges,75% of total billed charges,19.32,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.61,14,,,percent of total billed charges,14% of total billed charges,3.61,19.32,
AMB nalbuphine Charge:5 mg Nubain Inj,3444368,CDM,636,RC,J2300,HCPCS,Outpatient,,,12.88,6.44,,9.66,75,,,percent of total billed charges,75% of total billed charges,9.66,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.8,14,,,percent of total billed charges,14% of total billed charges,1.8,9.66,
AMB naloxone Charge:0.2 mg Narcan Inj,3444371,CDM,636,RC,J2310,HCPCS,Outpatient,,,13.84,6.92,,10.38,75,,,percent of total billed charges,75% of total billed charges,10.38,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.94,14,,,percent of total billed charges,14% of total billed charges,1.94,10.38,
AMB naloxone Charge:0.4 mg Narcan Inj,3444370,CDM,636,RC,J2310,HCPCS,Outpatient,,,13.84,6.92,,10.38,75,,,percent of total billed charges,75% of total billed charges,10.38,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.94,14,,,percent of total billed charges,14% of total billed charges,1.94,10.38,
210 mg tezepelumab Inj,4199400,CDM,636,RC,J2356,HCPCS,Outpatient,,,9766.4,4883.2,,7324.8,75,,,percent of total billed charges,75% of total billed charges,7324.8,75,,,percent of total billed charges,75% of total billed charges,18.57,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,30.65,165,,,Fee Schedule,165% of CMS OPPS Rate,20.62,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,3138.01,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,3865.73,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,3323.08,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,18.57,100,,,Fee Schedule,100% of CMS OPPS Rate,20.62,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1367.3,14,,,percent of total billed charges,14% of total billed charges,18.57,7324.8,
AMB omalizumab Charge:150 mg Xolair Inj,3444375,CDM,636,RC,J2357,HCPCS,Outpatient,,,41.61,20.81,,31.21,75,,,percent of total billed charges,75% of total billed charges,31.21,75,,,percent of total billed charges,75% of total billed charges,39.09,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,64.48,165,,,Fee Schedule,165% of CMS OPPS Rate,43.38,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,120.25,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,164.91,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,206.57,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,39.09,100,,,Fee Schedule,100% of CMS OPPS Rate,43.38,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,5.83,14,,,percent of total billed charges,14% of total billed charges,5.83,206.57,
AMB omalizumab Charge:300 mg Xolair Inj,3444376,CDM,636,RC,J2357,HCPCS,Outpatient,,,41.61,20.81,,31.21,75,,,percent of total billed charges,75% of total billed charges,31.21,75,,,percent of total billed charges,75% of total billed charges,39.09,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,64.48,165,,,Fee Schedule,165% of CMS OPPS Rate,43.38,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,120.25,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,164.91,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,206.57,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,39.09,100,,,Fee Schedule,100% of CMS OPPS Rate,43.38,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,5.83,14,,,percent of total billed charges,14% of total billed charges,5.83,206.57,
AMB orphenadrine Charge:60 mg orphenadrine Inj,3444381,CDM,636,RC,J2360,HCPCS,Outpatient,,,8.64,4.32,,6.48,75,,,percent of total billed charges,75% of total billed charges,6.48,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.21,14,,,percent of total billed charges,14% of total billed charges,1.21,6.48,
J2360 - Norflex - upto 60mg,3918964,CDM,636,RC,J2360,HCPCS,Outpatient,,,8.64,4.32,,6.48,75,,,percent of total billed charges,75% of total billed charges,6.48,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.21,14,,,percent of total billed charges,14% of total billed charges,1.21,6.48,
AMB ondansetron:4mg ondansetron INJ,3444380,CDM,636,RC,J2405,HCPCS,Outpatient,,,13.5,6.75,,10.13,75,,,percent of total billed charges,75% of total billed charges,10.13,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.89,14,,,percent of total billed charges,14% of total billed charges,1.89,10.13,
J2405 - Zofran - 1mg,3918965,CDM,636,RC,J2405,HCPCS,Outpatient,,,0.82,0.41,,0.62,75,,,percent of total billed charges,75% of total billed charges,0.62,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,0.62,0.62,
AMB promethazine Charge:12.5 mg Phenergan Inj,3444389,CDM,636,RC,J2550,HCPCS,Outpatient,,,13.5,6.75,,10.13,75,,,percent of total billed charges,75% of total billed charges,10.13,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.89,14,,,percent of total billed charges,14% of total billed charges,1.89,10.13,
AMB promethazine Charge:25 mg Phenergan Inj,3444390,CDM,636,RC,J2550,HCPCS,Outpatient,,,13.5,6.75,,10.13,75,,,percent of total billed charges,75% of total billed charges,10.13,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.89,14,,,percent of total billed charges,14% of total billed charges,1.89,10.13,
AMB promethazine Charge:50 mg Phenergan Inj,3444391,CDM,636,RC,J2550,HCPCS,Outpatient,,,13.5,6.75,,10.13,75,,,percent of total billed charges,75% of total billed charges,10.13,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.89,14,,,percent of total billed charges,14% of total billed charges,1.89,10.13,
J2550 - Phenergan - upto 50mg,3918966,CDM,636,RC,J2550,HCPCS,Outpatient,,,26.88,13.44,,20.16,75,,,percent of total billed charges,75% of total billed charges,20.16,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.76,14,,,percent of total billed charges,14% of total billed charges,3.76,20.16,
0.4 mg regadenoson Inj,4241444,CDM,636,RC,J2785,HCPCS,Outpatient,,,695.95,347.98,,521.96,75,,,percent of total billed charges,75% of total billed charges,521.96,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,97.43,14,,,percent of total billed charges,14% of total billed charges,97.43,521.96,
AMB RHo (D) immune globulin Charge:300 mcg RhoGAM Inj,3444392,CDM,636,RC,J2790,HCPCS,Outpatient,,,635,317.5,,476.25,75,,,percent of total billed charges,75% of total billed charges,476.25,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,88.9,14,,,percent of total billed charges,14% of total billed charges,88.9,476.25,
AMB RHo (D) immune globulin Charge:300 mcg RhoGAM Inj,3563024,CDM,636,RC,J2790,HCPCS,Outpatient,,,172.48,86.24,,129.36,75,,,percent of total billed charges,75% of total billed charges,129.36,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.15,14,,,percent of total billed charges,14% of total billed charges,24.15,129.36,
"J2790 - Injection, Rho D immune globulin, human, full dose,",3918967,CDM,636,RC,J2790,HCPCS,Outpatient,,,172.48,86.24,,129.36,75,,,percent of total billed charges,75% of total billed charges,129.36,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.15,14,,,percent of total billed charges,14% of total billed charges,24.15,129.36,
J2790 - Rhogam - 300mcg (1500 IU),3918968,CDM,636,RC,J2790,HCPCS,Outpatient,,,17.9,8.95,,13.43,75,,,percent of total billed charges,75% of total billed charges,13.43,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.51,14,,,percent of total billed charges,14% of total billed charges,2.51,13.43,
AMB RHo (D) immune globulin Charge -> 300 mcg Rhophylac Inj,4339403,CDM,636,RC,J2791,HCPCS,Outpatient,,,962.3,481.15,,721.73,75,,,percent of total billed charges,75% of total billed charges,721.73,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,134.72,14,,,percent of total billed charges,14% of total billed charges,134.72,721.73,
AMB ropivacaine Charge -> 10 mL ropivacaine Inj,3627011,CDM,636,RC,J2795,HCPCS,Outpatient,,,22.4,11.2,,16.8,75,,,percent of total billed charges,75% of total billed charges,16.8,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.14,14,,,percent of total billed charges,14% of total billed charges,3.14,16.8,
AMB ropivacaine Charge -> 5 mL ropivacaine Inj,3627010,CDM,636,RC,J2795,HCPCS,Outpatient,,,11.2,5.6,,8.4,75,,,percent of total billed charges,75% of total billed charges,8.4,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.57,14,,,percent of total billed charges,14% of total billed charges,1.57,8.4,
AMB MethylPREDNISolone Charge:125 mg SOLU-Medrol Inj,3444359,CDM,636,RC,J2919,HCPCS,Outpatient,,,27.47,13.74,,20.6,75,,,percent of total billed charges,75% of total billed charges,20.6,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.85,14,,,percent of total billed charges,14% of total billed charges,3.85,20.6,
AMB MethylPREDNISolone Charge:40 mg SOLU-Medrol Inj,3444358,CDM,636,RC,J2919,HCPCS,Outpatient,,,16.24,8.12,,12.18,75,,,percent of total billed charges,75% of total billed charges,12.18,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,14,,,percent of total billed charges,14% of total billed charges,2.27,12.18,
METHYLPREDNISOLONE INJ,3435737,CDM,636,RC,J2919,HCPCS,Outpatient,,,13.44,6.72,,10.08,75,,,percent of total billed charges,75% of total billed charges,10.08,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.88,14,,,percent of total billed charges,14% of total billed charges,1.88,10.08,
AMB romosozumab Charge -> 105 mg romosozumab Inj,3563077,CDM,636,RC,J3111,HCPCS,Outpatient,,,2763.06,1381.53,,2072.3,75,,,percent of total billed charges,75% of total billed charges,2072.3,75,,,percent of total billed charges,75% of total billed charges,10.35,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,17.07,165,,,Fee Schedule,165% of CMS OPPS Rate,11.48,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,31.83,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,43.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,54.69,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,10.35,100,,,Fee Schedule,100% of CMS OPPS Rate,11.48,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,386.83,14,,,percent of total billed charges,14% of total billed charges,10.35,2072.3,
AMB romosozumab Charge -> 210 mg romosozumab Inj,3563076,CDM,636,RC,J3111,HCPCS,Outpatient,,,5525.87,2762.94,,4144.4,75,,,percent of total billed charges,75% of total billed charges,4144.4,75,,,percent of total billed charges,75% of total billed charges,10.35,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,17.07,165,,,Fee Schedule,165% of CMS OPPS Rate,11.48,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,31.83,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,43.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,54.69,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,10.35,100,,,Fee Schedule,100% of CMS OPPS Rate,11.48,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,773.62,14,,,percent of total billed charges,14% of total billed charges,10.35,4144.4,
J3111 - Evenity - 1mg,3918971,CDM,636,RC,J3111,HCPCS,Outpatient,,,4584.63,2292.32,,3438.47,75,,,percent of total billed charges,75% of total billed charges,3438.47,75,,,percent of total billed charges,75% of total billed charges,10.35,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,17.07,165,,,Fee Schedule,165% of CMS OPPS Rate,11.48,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,31.83,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,43.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,54.69,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,10.35,100,,,Fee Schedule,100% of CMS OPPS Rate,11.48,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,641.85,14,,,percent of total billed charges,14% of total billed charges,10.35,3438.47,
162 mg tocilizumab Inj,3877034,CDM,636,RC,J3262,HCPCS,Outpatient,,,2336.68,1168.34,,1752.51,75,,,percent of total billed charges,75% of total billed charges,1752.51,75,,,percent of total billed charges,75% of total billed charges,6.19,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,10.21,165,,,Fee Schedule,165% of CMS OPPS Rate,6.87,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,19.04,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,26.11,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,32.71,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,6.19,100,,,Fee Schedule,100% of CMS OPPS Rate,6.87,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,327.14,14,,,percent of total billed charges,14% of total billed charges,6.19,1752.51,
10 mg Kenalog Inj,4305698,CDM,636,RC,J3301,HCPCS,Outpatient,,,14.51,7.26,,10.88,75,,,percent of total billed charges,75% of total billed charges,10.88,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.03,14,,,percent of total billed charges,14% of total billed charges,2.03,10.88,
AMB triamcinolone Charge:40 mg Kenalog Inj,3444415,CDM,636,RC,J3301,HCPCS,Outpatient,,,22.95,11.48,,17.21,75,,,percent of total billed charges,75% of total billed charges,17.21,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.21,14,,,percent of total billed charges,14% of total billed charges,3.21,17.21,
"J3301 - Injection, triamcinolone acetonide, not otherwise sp",3918972,CDM,636,RC,J3301,HCPCS,Outpatient,,,7.46,3.73,,5.6,75,,,percent of total billed charges,75% of total billed charges,5.6,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.04,14,,,percent of total billed charges,14% of total billed charges,1.04,5.6,
J3301 - Kenalog 10 MG,3918973,CDM,636,RC,J3301,HCPCS,Outpatient,,,7.46,3.73,,5.6,75,,,percent of total billed charges,75% of total billed charges,5.6,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.04,14,,,percent of total billed charges,14% of total billed charges,1.04,5.6,
AMB triptorelin Charge:3.75 mg Trelstar,3444416,CDM,636,RC,J3315,HCPCS,Outpatient,,,4879.45,2439.73,,3659.59,75,,,percent of total billed charges,75% of total billed charges,3659.59,75,,,percent of total billed charges,75% of total billed charges,401.75,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,662.88,165,,,Fee Schedule,165% of CMS OPPS Rate,445.94,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1235.9,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1694.94,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,2123.08,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,401.75,100,,,Fee Schedule,100% of CMS OPPS Rate,445.94,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,683.12,14,,,percent of total billed charges,14% of total billed charges,401.75,3659.59,
AMB ustekinumab Charge:45 mg Stelera Inj,3444419,CDM,636,RC,J3358,HCPCS,Outpatient,,,13.29,6.65,,9.97,75,,,percent of total billed charges,75% of total billed charges,9.97,75,,,percent of total billed charges,75% of total billed charges,12.62,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,20.82,165,,,Fee Schedule,165% of CMS OPPS Rate,14,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,38.82,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,53.24,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,66.69,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,12.62,100,,,Fee Schedule,100% of CMS OPPS Rate,14,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1.86,14,,,percent of total billed charges,14% of total billed charges,1.86,66.69,
AMB cyanocobalamin Charge:1000mcg cyanocobalamin Inj,3444262,CDM,636,RC,J3420,HCPCS,Outpatient,,,18.66,9.33,,14,75,,,percent of total billed charges,75% of total billed charges,14,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.61,14,,,percent of total billed charges,14% of total billed charges,2.61,14,
AMB cyanocobalamin Charge:500mcg cyanocobalamin Inj,3444263,CDM,636,RC,J3420,HCPCS,Outpatient,,,18.65,9.33,,13.99,75,,,percent of total billed charges,75% of total billed charges,13.99,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.61,14,,,percent of total billed charges,14% of total billed charges,2.61,13.99,
J3420 - B12 - upto 1000 mcg,3918974,CDM,636,RC,J3420,HCPCS,Outpatient,,,30.24,15.12,,22.68,75,,,percent of total billed charges,75% of total billed charges,22.68,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.23,14,,,percent of total billed charges,14% of total billed charges,4.23,22.68,
J3420-MSA VITAMIN B-12 INJ,3430597,CDM,636,RC,J3420,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
AMB hyaluronidase Charge:200 unit hyaluronidase Inj,3444316,CDM,636,RC,J3470,HCPCS,Outpatient,,,183.46,91.73,,137.6,75,,,percent of total billed charges,75% of total billed charges,137.6,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.68,14,,,percent of total billed charges,14% of total billed charges,25.68,137.6,
AMB potassium chloride Charge -> 20 mEq KCl Inj,3626977,CDM,636,RC,J3480,HCPCS,Outpatient,,,10.08,5.04,,7.56,75,,,percent of total billed charges,75% of total billed charges,7.56,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,14,,,percent of total billed charges,14% of total billed charges,1.41,7.56,
AMB bupivacaine Charge -> 15 mL bupivacaine Inj,3626949,CDM,636,RC,J3490,HCPCS,Outpatient,,,13.5,6.75,,10.13,75,,,percent of total billed charges,75% of total billed charges,10.13,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.89,14,,,percent of total billed charges,14% of total billed charges,1.89,10.13,
AMB bupivacaine Charge -> 20 mL bupivacaine Inj,3626950,CDM,636,RC,J3490,HCPCS,Outpatient,,,13.5,6.75,,10.13,75,,,percent of total billed charges,75% of total billed charges,10.13,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.89,14,,,percent of total billed charges,14% of total billed charges,1.89,10.13,
AMB dupilumab Charge:200 mg duplimab Inj,3444286,CDM,636,RC,J3590,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
AMB dupilumab Charge:300 mg duplimab Inj,3444288,CDM,636,RC,J3590,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
AMB dupilumab Charge:400 mg duplimab Inj,3444285,CDM,636,RC,J3590,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
AMB dupilumab Charge:600 mg duplimab Inj,3444287,CDM,636,RC,J3590,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
J3590 Axiofill 250mg + Q4186 Epifix 14mm,4205140,CDM,636,RC,J3590,HCPCS,Outpatient,,,6036,3018,,4527,75,,,percent of total billed charges,75% of total billed charges,4527,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,845.04,14,,,percent of total billed charges,14% of total billed charges,845.04,4527,
J3590 Axiofill 500mg + Q4186 Epifix 14mm,4205141,CDM,636,RC,J3590,HCPCS,Outpatient,,,8861,4430.5,,6645.75,75,,,percent of total billed charges,75% of total billed charges,6645.75,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1240.54,14,,,percent of total billed charges,14% of total billed charges,1240.54,6645.75,
AMB sodium chloride Charge -> 40 mL Sodium Chloride Inj,3626966,CDM,636,RC,J7030,HCPCS,Outpatient,,,15.66,7.83,,11.75,75,,,percent of total billed charges,75% of total billed charges,11.75,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.19,14,,,percent of total billed charges,14% of total billed charges,2.19,11.75,
AMB sodium chloride Charge -> 5 mL Sodium Chloride Inj,3626965,CDM,636,RC,J7030,HCPCS,Outpatient,,,13.5,6.75,,10.13,75,,,percent of total billed charges,75% of total billed charges,10.13,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.89,14,,,percent of total billed charges,14% of total billed charges,1.89,10.13,
AMB sodium chloride Charge -> 60 mL Sodium Chloride Inj,3626967,CDM,636,RC,J7030,HCPCS,Outpatient,,,23.48,11.74,,17.61,75,,,percent of total billed charges,75% of total billed charges,17.61,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.29,14,,,percent of total billed charges,14% of total billed charges,3.29,17.61,
AMB sodium chloride Charge:2 mL Sodium Chloride Inj,3444400,CDM,636,RC,J7030,HCPCS,Outpatient,,,13.5,6.75,,10.13,75,,,percent of total billed charges,75% of total billed charges,10.13,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.89,14,,,percent of total billed charges,14% of total billed charges,1.89,10.13,
AMB Levonorgestrel Charge:19.5 mg Kyleena Implant,3444338,CDM,636,RC,J7296,HCPCS,Outpatient,,,2832.95,1416.48,,2124.71,75,,,percent of total billed charges,75% of total billed charges,2124.71,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,396.61,14,,,percent of total billed charges,14% of total billed charges,396.61,2124.71,
J7296 - Kyleena  (Levonorgestrel-releasing intrauterine cont,3918975,CDM,636,RC,J7296,HCPCS,Outpatient,,,2135.84,1067.92,,1601.88,75,,,percent of total billed charges,75% of total billed charges,1601.88,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,299.02,14,,,percent of total billed charges,14% of total billed charges,299.02,1601.88,
AMB Levonorgestrel Charge:52 mg Liletta Implant,3444339,CDM,636,RC,J7297,HCPCS,Outpatient,,,2281.77,1140.89,,1711.33,75,,,percent of total billed charges,75% of total billed charges,1711.33,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,319.45,14,,,percent of total billed charges,14% of total billed charges,319.45,1711.33,
Levonorgestrel 52 mg Liletta Implant,4171307,CDM,636,RC,J7297,HCPCS,Outpatient,,,2135.84,1067.92,,1601.88,75,,,percent of total billed charges,75% of total billed charges,1601.88,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,299.02,14,,,percent of total billed charges,14% of total billed charges,299.02,1601.88,
AMB Levonorgestrel Charge:52 mg Mirena Implant,3444340,CDM,636,RC,J7298,HCPCS,Outpatient,,,2832.95,1416.48,,2124.71,75,,,percent of total billed charges,75% of total billed charges,2124.71,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,396.61,14,,,percent of total billed charges,14% of total billed charges,396.61,2124.71,
J7298 - Levonorgestrel-releasing intrauterine contraceptive,3918976,CDM,636,RC,J7298,HCPCS,Outpatient,,,2135.84,1067.92,,1601.88,75,,,percent of total billed charges,75% of total billed charges,1601.88,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,299.02,14,,,percent of total billed charges,14% of total billed charges,299.02,1601.88,
AMB copper IUD Charge:Paragard Implant,3444260,CDM,636,RC,J7300,HCPCS,Outpatient,,,2182.95,1091.48,,1637.21,75,,,percent of total billed charges,75% of total billed charges,1637.21,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,305.61,14,,,percent of total billed charges,14% of total billed charges,305.61,1637.21,
J7300 - Intrauterine copper contraceptive,3918977,CDM,636,RC,J7300,HCPCS,Outpatient,,,1827.84,913.92,,1370.88,75,,,percent of total billed charges,75% of total billed charges,1370.88,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,255.9,14,,,percent of total billed charges,14% of total billed charges,255.9,1370.88,
AMB Levonorgestrel Charge:17.5 mg Skyla Implant,3444341,CDM,636,RC,J7301,HCPCS,Outpatient,,,2358.9,1179.45,,1769.18,75,,,percent of total billed charges,75% of total billed charges,1769.18,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,330.25,14,,,percent of total billed charges,14% of total billed charges,330.25,1769.18,
Levonorgestrel 13.5 mg Skyla Implant,4171308,CDM,636,RC,J7301,HCPCS,Outpatient,,,1778.56,889.28,,1333.92,75,,,percent of total billed charges,75% of total billed charges,1333.92,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,249,14,,,percent of total billed charges,14% of total billed charges,249,1333.92,
AMB Nexplanon 68mg Charge:68 mg Nexplanon Implant,3444372,CDM,636,RC,J7307,HCPCS,Outpatient,,,2949.71,1474.86,,2212.28,75,,,percent of total billed charges,75% of total billed charges,2212.28,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,412.96,14,,,percent of total billed charges,14% of total billed charges,412.96,2212.28,
"J7307 - Etonogestrel (contraceptive) implant system, includi",3918978,CDM,636,RC,J7307,HCPCS,Outpatient,,,2094.4,1047.2,,1570.8,75,,,percent of total billed charges,75% of total billed charges,1570.8,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,293.22,14,,,percent of total billed charges,14% of total billed charges,293.22,1570.8,
AMB sodium hyaluronate Charge:20 mg Durolane Inj,3444401,CDM,636,RC,J7318,HCPCS,Outpatient,,,2040.64,1020.32,,1530.48,75,,,percent of total billed charges,75% of total billed charges,1530.48,75,,,percent of total billed charges,75% of total billed charges,6.27,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,10.34,165,,,Fee Schedule,165% of CMS OPPS Rate,6.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,19.28,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,26.45,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,33.13,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,6.27,100,,,Fee Schedule,100% of CMS OPPS Rate,6.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,285.69,14,,,percent of total billed charges,14% of total billed charges,6.27,1530.48,
J7318 - Durolane - 1mg,3918979,CDM,636,RC,J7318,HCPCS,Outpatient,,,102.03,51.02,,76.52,75,,,percent of total billed charges,75% of total billed charges,76.52,75,,,percent of total billed charges,75% of total billed charges,6.27,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,10.34,165,,,Fee Schedule,165% of CMS OPPS Rate,6.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,19.28,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,26.45,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,33.13,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,6.27,100,,,Fee Schedule,100% of CMS OPPS Rate,6.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,14.28,14,,,percent of total billed charges,14% of total billed charges,6.27,76.52,
AMB sodium hyaluronate Charge:25 mg Supartz Inj,3444403,CDM,636,RC,J7321,HCPCS,Outpatient,,,808.48,404.24,,606.36,75,,,percent of total billed charges,75% of total billed charges,606.36,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,113.19,14,,,percent of total billed charges,14% of total billed charges,113.19,606.36,
AMB sodium hyaluronate Charge:20 mg Euflexxa Inj,3444402,CDM,636,RC,J7323,HCPCS,Outpatient,,,2049.6,1024.8,,1537.2,75,,,percent of total billed charges,75% of total billed charges,1537.2,75,,,percent of total billed charges,75% of total billed charges,123.14,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,203.18,165,,,Fee Schedule,165% of CMS OPPS Rate,136.68,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,378.81,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,519.51,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,650.74,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,123.14,100,,,Fee Schedule,100% of CMS OPPS Rate,136.68,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,286.94,14,,,percent of total billed charges,14% of total billed charges,123.14,1537.2,
AMB sodium hyaluronate Charge:30 mg Orthovisc Inj,3444404,CDM,636,RC,J7324,HCPCS,Outpatient,,,600.32,300.16,,450.24,75,,,percent of total billed charges,75% of total billed charges,450.24,75,,,percent of total billed charges,75% of total billed charges,136.26,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,224.82,165,,,Fee Schedule,165% of CMS OPPS Rate,151.24,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,419.17,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,574.86,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,720.07,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,136.26,100,,,Fee Schedule,100% of CMS OPPS Rate,151.24,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,84.04,14,,,percent of total billed charges,14% of total billed charges,84.04,720.07,
AMB Synvisc Charge:16 mg Synvisc Inj,3444405,CDM,636,RC,J7325,HCPCS,Outpatient,,,12.32,6.16,,9.24,75,,,percent of total billed charges,75% of total billed charges,9.24,75,,,percent of total billed charges,75% of total billed charges,8.77,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,14.47,165,,,Fee Schedule,165% of CMS OPPS Rate,9.73,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,26.97,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,36.99,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,46.34,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,8.77,100,,,Fee Schedule,100% of CMS OPPS Rate,9.73,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1.72,14,,,percent of total billed charges,14% of total billed charges,1.72,46.34,
AMB Synvisc Charge:48 mg Synvisc Inj,3444406,CDM,636,RC,J7325,HCPCS,Outpatient,,,12.32,6.16,,9.24,75,,,percent of total billed charges,75% of total billed charges,9.24,75,,,percent of total billed charges,75% of total billed charges,8.77,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,14.47,165,,,Fee Schedule,165% of CMS OPPS Rate,9.73,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,26.97,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,36.99,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,46.34,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,8.77,100,,,Fee Schedule,100% of CMS OPPS Rate,9.73,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1.72,14,,,percent of total billed charges,14% of total billed charges,1.72,46.34,
AMB levalbuterol Charge:levalbuterol Neb Soln,3444337,CDM,636,RC,J7611,HCPCS,Outpatient,,,13.5,6.75,,10.13,75,,,percent of total billed charges,75% of total billed charges,10.13,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.88,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.88,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,1.89,14,,,percent of total billed charges,14% of total billed charges,1.89,10.13,
ALBUTEROL IPRATROP NON-COMP,3435726,CDM,250,RC,J7620,HCPCS,Outpatient,,,8.4,4.2,,6.3,75,,,percent of total billed charges,75% of total billed charges,6.3,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.18,14,,,percent of total billed charges,14% of total billed charges,1.18,6.3,
AMB albuterol Charge:albuterol Neb Soln,3444236,CDM,636,RC,J7620,HCPCS,Outpatient,,,13.5,6.75,,10.13,75,,,percent of total billed charges,75% of total billed charges,10.13,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.89,14,,,percent of total billed charges,14% of total billed charges,1.89,10.13,
AMB DuoNeb Charge:DuoNeb Neb Soln,3444284,CDM,636,RC,J7620,HCPCS,Outpatient,,,25.2,12.6,,18.9,75,,,percent of total billed charges,75% of total billed charges,18.9,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.53,14,,,percent of total billed charges,14% of total billed charges,3.53,18.9,
AMB ipratropium Charge:ipratropium Neb Soln,3444327,CDM,636,RC,J7645,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
IPRATROPIUM BROMIDE COMP,3435736,CDM,636,RC,J7645,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
16.7 mg BCG Inj,4017340,CDM,636,RC,J9030,HCPCS,Outpatient,,,314.76,157.38,,236.07,75,,,percent of total billed charges,75% of total billed charges,236.07,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.07,14,,,percent of total billed charges,14% of total billed charges,44.07,236.07,
25 mg BCG Inj,4017341,CDM,636,RC,J9030,HCPCS,Outpatient,,,471.2,235.6,,353.4,75,,,percent of total billed charges,75% of total billed charges,353.4,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,65.97,14,,,percent of total billed charges,14% of total billed charges,65.97,353.4,
AMB BCG Charge:50 mg BCG Inj,3444246,CDM,636,RC,J9030,HCPCS,Outpatient,,,942.4,471.2,,706.8,75,,,percent of total billed charges,75% of total billed charges,706.8,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,131.94,14,,,percent of total billed charges,14% of total billed charges,131.94,706.8,
AMB degarelix Charge:120 mg degarelix Inj,3444266,CDM,636,RC,J9155,HCPCS,Outpatient,,,4572.55,2286.28,,3429.41,75,,,percent of total billed charges,75% of total billed charges,3429.41,75,,,percent of total billed charges,75% of total billed charges,4.13,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,6.81,165,,,Fee Schedule,165% of CMS OPPS Rate,4.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,12.7,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,17.42,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,21.82,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,4.13,100,,,Fee Schedule,100% of CMS OPPS Rate,4.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,640.16,14,,,percent of total billed charges,14% of total billed charges,4.13,3429.41,
AMB degarelix Charge:240 mg degarelix Inj,3444265,CDM,636,RC,J9155,HCPCS,Outpatient,,,9145.1,4572.55,,6858.83,75,,,percent of total billed charges,75% of total billed charges,6858.83,75,,,percent of total billed charges,75% of total billed charges,4.13,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,6.81,165,,,Fee Schedule,165% of CMS OPPS Rate,4.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,2933.28,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,3612.81,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,3102.91,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,4.13,100,,,Fee Schedule,100% of CMS OPPS Rate,4.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1280.31,14,,,percent of total billed charges,14% of total billed charges,4.13,6858.83,
AMB degarelix Charge:80 mg degarelix Inj,3444267,CDM,636,RC,J9155,HCPCS,Outpatient,,,3048.37,1524.19,,2286.28,75,,,percent of total billed charges,75% of total billed charges,2286.28,75,,,percent of total billed charges,75% of total billed charges,4.13,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,6.81,165,,,Fee Schedule,165% of CMS OPPS Rate,4.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,12.7,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,17.42,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,21.82,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,4.13,100,,,Fee Schedule,100% of CMS OPPS Rate,4.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,426.77,14,,,percent of total billed charges,14% of total billed charges,4.13,2286.28,
2000 mg gemcitabine Inj,4267412,CDM,636,RC,J9201,HCPCS,Outpatient,,,244.62,122.31,,183.47,75,,,percent of total billed charges,75% of total billed charges,183.47,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.25,14,,,percent of total billed charges,14% of total billed charges,34.25,183.47,
AMB interferon alfa-2b Charge:1 MUnit Intron A Inj,3444326,CDM,636,RC,J9214,HCPCS,Outpatient,,,12817.8,6408.9,,9613.35,75,,,percent of total billed charges,75% of total billed charges,9613.35,75,,,percent of total billed charges,75% of total billed charges,32.57,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,53.74,165,,,Fee Schedule,165% of CMS OPPS Rate,36.15,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4121.6,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5077.85,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,4366.75,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,32.57,100,,,Fee Schedule,100% of CMS OPPS Rate,36.15,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1794.49,14,,,percent of total billed charges,14% of total billed charges,32.57,9613.35,
22.5 mg leuprolide IM Inj,5801840,CDM,636,RC,J9217,HCPCS,Outpatient,,,35041.55,17520.78,,26281.16,75,,,percent of total billed charges,75% of total billed charges,26281.16,75,,,percent of total billed charges,75% of total billed charges,4453.59,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,4467.13,165,,,Fee Schedule,165% of CMS OPPS Rate,4455.88,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,11297.56,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,13922.89,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,11989.2,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,4453.59,100,,,Fee Schedule,100% of CMS OPPS Rate,4455.88,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4905.82,14,,,percent of total billed charges,14% of total billed charges,4453.59,26281.16,
22.5 mg leuprolide SubCu Inj,3867205,CDM,636,RC,J9217,HCPCS,Outpatient,,,8130.4,4065.2,,6097.8,75,,,percent of total billed charges,75% of total billed charges,6097.8,75,,,percent of total billed charges,75% of total billed charges,166.69,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,275.02,165,,,Fee Schedule,165% of CMS OPPS Rate,185.02,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,512.78,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,3297.92,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,880.88,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,166.69,100,,,Fee Schedule,100% of CMS OPPS Rate,185.02,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1138.26,14,,,percent of total billed charges,14% of total billed charges,166.69,6097.8,
30 mg leuprolide IM Inj,3444333,CDM,636,RC,J9217,HCPCS,Outpatient,,,46722.2,23361.1,,35041.65,75,,,percent of total billed charges,75% of total billed charges,35041.65,75,,,percent of total billed charges,75% of total billed charges,5931.19,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,5944.73,165,,,Fee Schedule,165% of CMS OPPS Rate,5933.48,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,15042.09,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,18534.6,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,15948.94,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,5931.19,100,,,Fee Schedule,100% of CMS OPPS Rate,5933.48,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,6541.11,14,,,percent of total billed charges,14% of total billed charges,5931.19,35041.65,
30 mg leuprolide SubCu Inj,3867204,CDM,636,RC,J9217,HCPCS,Outpatient,,,10840.55,5420.28,,8130.41,75,,,percent of total billed charges,75% of total billed charges,8130.41,75,,,percent of total billed charges,75% of total billed charges,166.69,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,275.02,165,,,Fee Schedule,165% of CMS OPPS Rate,185.02,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,3539.31,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,4367.93,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,3785.06,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,166.69,100,,,Fee Schedule,100% of CMS OPPS Rate,185.02,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1517.68,14,,,percent of total billed charges,14% of total billed charges,166.69,8130.41,
45 mg leuprolide SubCu Inj,3867203,CDM,636,RC,J9217,HCPCS,Outpatient,,,16260.8,8130.4,,12195.6,75,,,percent of total billed charges,75% of total billed charges,12195.6,75,,,percent of total billed charges,75% of total billed charges,166.69,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,275.02,165,,,Fee Schedule,165% of CMS OPPS Rate,185.02,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,5276.91,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,6507.94,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,5622.52,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,166.69,100,,,Fee Schedule,100% of CMS OPPS Rate,185.02,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,2276.51,14,,,percent of total billed charges,14% of total billed charges,166.69,12195.6,
7.5 mg leuprolide IM Inj,3444335,CDM,636,RC,J9217,HCPCS,Outpatient,,,11680.55,5840.28,,8760.41,75,,,percent of total billed charges,75% of total billed charges,8760.41,75,,,percent of total billed charges,75% of total billed charges,166.69,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,275.02,165,,,Fee Schedule,165% of CMS OPPS Rate,185.02,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,3808.59,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,4699.58,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,4069.82,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,166.69,100,,,Fee Schedule,100% of CMS OPPS Rate,185.02,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1635.28,14,,,percent of total billed charges,14% of total billed charges,166.69,8760.41,
7.5 mg leuprolide SubCu Inj,3867202,CDM,636,RC,J9217,HCPCS,Outpatient,,,2710.15,1355.08,,2032.61,75,,,percent of total billed charges,75% of total billed charges,2032.61,75,,,percent of total billed charges,75% of total billed charges,166.69,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,275.02,165,,,Fee Schedule,165% of CMS OPPS Rate,185.02,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,512.78,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,703.24,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,880.88,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,166.69,100,,,Fee Schedule,100% of CMS OPPS Rate,185.02,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,379.42,14,,,percent of total billed charges,14% of total billed charges,166.69,2032.61,
J9217 - Eligard 7.5 MG,3918980,CDM,636,RC,J9217,HCPCS,Outpatient,,,102.03,51.02,,76.52,75,,,percent of total billed charges,75% of total billed charges,76.52,75,,,percent of total billed charges,75% of total billed charges,166.69,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,275.02,165,,,Fee Schedule,165% of CMS OPPS Rate,185.02,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,512.78,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,703.24,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,880.88,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,166.69,100,,,Fee Schedule,100% of CMS OPPS Rate,185.02,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,14.28,14,,,percent of total billed charges,14% of total billed charges,14.28,880.88,
AMB mitoMYcin Charge:20mg mitoMYcin Instillation,3444363,CDM,636,RC,J9280,HCPCS,Outpatient,,,3539.1,1769.55,,2654.33,75,,,percent of total billed charges,75% of total billed charges,2654.33,75,,,percent of total billed charges,75% of total billed charges,95.61,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,157.75,165,,,Fee Schedule,165% of CMS OPPS Rate,106.12,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,294.12,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,403.36,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,505.26,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,95.61,100,,,Fee Schedule,100% of CMS OPPS Rate,106.12,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,495.47,14,,,percent of total billed charges,14% of total billed charges,95.61,2654.33,
AMB mitoMYcin Charge:40mg mitoMYcin Instillation,3617068,CDM,636,RC,J9280,HCPCS,Outpatient,,,7078.2,3539.1,,5308.65,75,,,percent of total billed charges,75% of total billed charges,5308.65,75,,,percent of total billed charges,75% of total billed charges,95.61,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,157.75,165,,,Fee Schedule,165% of CMS OPPS Rate,106.12,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,294.12,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,403.36,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,505.26,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,95.61,100,,,Fee Schedule,100% of CMS OPPS Rate,106.12,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,990.95,14,,,percent of total billed charges,14% of total billed charges,95.61,5308.65,
Cervical Collar Flex/Foam,3428407,CDM,981,RC,L0120,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
Cerv Collar Semirig 2 pc,3428406,CDM,981,RC,L0172,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
Cerv Clr Semirg 2pc W/Ext,3428405,CDM,981,RC,L0174,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
Rib Belt,3428516,CDM,981,RC,L0220,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
"Lumbar Orthosis, Flexible",3428484,CDM,981,RC,L0625,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
"KO, Elas w/Condyl Pad & Jnts",3428477,CDM,981,RC,L1820,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
KO Adj Joint Rigid,3428475,CDM,981,RC,L1832,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
KO Rgd w/o Jnt Prefab,3428476,CDM,981,RC,L1836,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
AFO Ankle Gauntlet,3428381,CDM,981,RC,L1902,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
AFO Mltigmnts Support,3428382,CDM,981,RC,L1906,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
AFO Adjustble,3428380,CDM,981,RC,L1930,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
Ankl Cntrl Stirp Rigid,3428384,CDM,981,RC,L1932,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
AFO Plastic Rehab,3428383,CDM,981,RC,L1951,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
L3260 Ambulatory Surgical Boot Ea,3436153,CDM,279,RC,L3260,HCPCS,Outpatient,,,12.86,6.43,,9.65,75,,,percent of total billed charges,75% of total billed charges,9.65,75,,,percent of total billed charges,75% of total billed charges,4.12,32,,,percent of total billed charges,32% of total billed charges,85.92,102,,,Fee Schedule,102% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,84.24,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.8,14,,,percent of total billed charges,14% of total billed charges,1.8,85.92,
Surgical Boot/Shoe Ea,3428526,CDM,981,RC,L3260,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
Shoulder Orthsis Figure 8,3428522,CDM,981,RC,L3650,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
Shoulder Orthsis Clavicle,3428521,CDM,981,RC,L3670,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
SO Single Shoulder Prefab,3428525,CDM,981,RC,L3678,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
Thmb Spica/Wrist Fx Brace,3428529,CDM,981,RC,L3809,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
WHO Wrist Extension,3428541,CDM,981,RC,L3908,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
Humeral Fracture Brace,3428464,CDM,981,RC,L3980,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
Radius/Ulna Fx Brace,3428513,CDM,981,RC,L3982,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
Ulnar Gutter Splint,3428536,CDM,981,RC,L3982,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
Musculoskeletal Screening,4199644,CDM,978,RC,MS,HCPCS,Outpatient,,,75,37.5,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
"Q0091- Screening Pap Smear,Specimen Prep",3431441,CDM,510,RC,Q0091,HCPCS,Outpatient,,,106.37,53.19,,79.78,75,,,percent of total billed charges,75% of total billed charges,79.78,75,,,percent of total billed charges,75% of total billed charges,23.46,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,38.71,165,,,Fee Schedule,165% of CMS OPPS Rate,24.31,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,67.4,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,92.43,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,115.78,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,23.46,100,,,Fee Schedule,100% of CMS OPPS Rate,24.31,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,14.89,14,,,percent of total billed charges,14% of total billed charges,14.89,115.78,
Q0111 Wet mounts w preparations,3428512,CDM,510,RC,Q0111,HCPCS,Outpatient,,,15.48,7.74,,11.61,75,,,percent of total billed charges,75% of total billed charges,11.61,75,,,percent of total billed charges,75% of total billed charges,17.3,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,17.3,100,,,Fee Schedule,100% of CMS OPPS Rate,15.92,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,61.37,354.54,,,Fee Schedule,354.54% of CMS OPPS Fee Schedule Rate,74.2,428.7,,,Fee Schedule,428.7% of CMS OPPS Fee Schedule Rate,78.03,450.81,,,Fee Schedule,450.81% of CMS OPPS Fee Schedule Rate,,,,,Other,Not Separately reimbursable,17.3,100,,,Fee Schedule,100% of CMS OPPS Rate,15.92,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,2.17,14,,,percent of total billed charges,14% of total billed charges,2.17,78.03,
AMB ondansetron:4 mg ondansetron Tab,3444379,CDM,636,RC,Q0162,HCPCS,Outpatient,,,50.15,25.08,,37.61,75,,,percent of total billed charges,75% of total billed charges,37.61,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.02,14,,,percent of total billed charges,14% of total billed charges,7.02,37.61,
"Q4106 Dermagraft (38), Per sq cm",3783110,CDM,278,RC,Q4106,HCPCS,Outpatient,,,65.79,32.9,,49.34,75,,,percent of total billed charges,75% of total billed charges,49.34,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.21,14,,,percent of total billed charges,14% of total billed charges,9.21,49.34,
Q4121 Theraskin 1.75x1.75cm (3) per sq cm,4351234,CDM,278,RC,Q4121,HCPCS,Outpatient,,,3538,1769,,2653.5,75,,,percent of total billed charges,75% of total billed charges,2653.5,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,495.32,14,,,percent of total billed charges,14% of total billed charges,495.32,2653.5,
Q4121 Theraskin 2.5x2.5cm (6) per sq cm,4351235,CDM,278,RC,Q4121,HCPCS,Outpatient,,,1972,986,,1479,75,,,percent of total billed charges,75% of total billed charges,1479,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,276.08,14,,,percent of total billed charges,14% of total billed charges,276.08,1479,
Q4121 Theraskin 2.5x5.1cm (13) per sq cm,4351236,CDM,278,RC,Q4121,HCPCS,Outpatient,,,928,464,,696,75,,,percent of total billed charges,75% of total billed charges,696,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,129.92,14,,,percent of total billed charges,14% of total billed charges,129.92,696,
Q4121 Theraskin 4x6.5cm (26) per sq cm,4351237,CDM,278,RC,Q4121,HCPCS,Outpatient,,,525,262.5,,393.75,75,,,percent of total billed charges,75% of total billed charges,393.75,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,73.5,14,,,percent of total billed charges,14% of total billed charges,73.5,393.75,
"Q4121 Theraskin 5.1cm x 7.6cm (39), Per sq cm",3984938,CDM,278,RC,Q4121,HCPCS,Outpatient,,,400,200,,300,75,,,percent of total billed charges,75% of total billed charges,300,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56,14,,,percent of total billed charges,14% of total billed charges,56,300,
Q4121 Theraskin 7.6x15.24cm (116) per sq cm,4351238,CDM,278,RC,Q4121,HCPCS,Outpatient,,,349,174.5,,261.75,75,,,percent of total billed charges,75% of total billed charges,261.75,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.86,14,,,percent of total billed charges,14% of total billed charges,48.86,261.75,
"Q4158 Kerecis Omega3 1.75cm x 1.75cm (4), Per sq cm",3984950,CDM,278,RC,Q4158,HCPCS,Outpatient,,,1591,795.5,,1193.25,75,,,percent of total billed charges,75% of total billed charges,1193.25,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,222.74,14,,,percent of total billed charges,14% of total billed charges,222.74,1193.25,
"Q4158 Kerecis Omega3 3cm x 3.5cm (11), Per sq cm",3984956,CDM,278,RC,Q4158,HCPCS,Outpatient,,,796,398,,597,75,,,percent of total billed charges,75% of total billed charges,597,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,111.44,14,,,percent of total billed charges,14% of total billed charges,111.44,597,
"Q4158 Kerecis Omega3 3cm x 7cm (21), Per sq cm",3984962,CDM,278,RC,Q4158,HCPCS,Outpatient,,,666,333,,499.5,75,,,percent of total billed charges,75% of total billed charges,499.5,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.24,14,,,percent of total billed charges,14% of total billed charges,93.24,499.5,
"Q4158 Kerecis Omega3 5cm x 7cm (35), Per sq cm",3984968,CDM,278,RC,Q4158,HCPCS,Outpatient,,,492,246,,369,75,,,percent of total billed charges,75% of total billed charges,369,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68.88,14,,,percent of total billed charges,14% of total billed charges,68.88,369,
"Q4158 Kerecis Omega3 7cm x 10cm (70), Per sq cm",3991161,CDM,278,RC,Q4158,HCPCS,Outpatient,,,574,287,,430.5,75,,,percent of total billed charges,75% of total billed charges,430.5,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,80.36,14,,,percent of total billed charges,14% of total billed charges,80.36,430.5,
"Q4158 Kerecis Omega3 7cm x 7cm (49), Per sq cm",3984974,CDM,278,RC,Q4158,HCPCS,Outpatient,,,401,200.5,,300.75,75,,,percent of total billed charges,75% of total billed charges,300.75,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.14,14,,,percent of total billed charges,14% of total billed charges,56.14,300.75,
"Q4158 Kerecis Omega3 Micro 19cm2 (19), Per sq cm",3984992,CDM,278,RC,Q4158,HCPCS,Outpatient,,,662,331,,496.5,75,,,percent of total billed charges,75% of total billed charges,496.5,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,92.68,14,,,percent of total billed charges,14% of total billed charges,92.68,496.5,
"Q4158 Kerecis Omega3 Micro 4cm2 (4), Per sq cm",3984976,CDM,278,RC,Q4158,HCPCS,Outpatient,,,1591,795.5,,1193.25,75,,,percent of total billed charges,75% of total billed charges,1193.25,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,222.74,14,,,percent of total billed charges,14% of total billed charges,222.74,1193.25,
"Q4158 Kerecis Omega3 Micro 8cm2 (8), Per sq cm",3984986,CDM,278,RC,Q4158,HCPCS,Outpatient,,,939,469.5,,704.25,75,,,percent of total billed charges,75% of total billed charges,704.25,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,131.46,14,,,percent of total billed charges,14% of total billed charges,131.46,704.25,
"Q4159 Affinity fresh amniotic 2.5x2.5cm (7), Per sq cm",4223263,CDM,278,RC,Q4159,HCPCS,Outpatient,,,2567,1283.5,,1925.25,75,,,percent of total billed charges,75% of total billed charges,1925.25,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,359.38,14,,,percent of total billed charges,14% of total billed charges,359.38,1925.25,
Q4160 Nushield 1.6cm disc (3) per sq cm,4351239,CDM,278,RC,Q4160,HCPCS,Outpatient,,,1578,789,,1183.5,75,,,percent of total billed charges,75% of total billed charges,1183.5,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,220.92,14,,,percent of total billed charges,14% of total billed charges,220.92,1183.5,
Q4160 Nushield 2x3cm (6) per sq cm,4351240,CDM,278,RC,Q4160,HCPCS,Outpatient,,,1588,794,,1191,75,,,percent of total billed charges,75% of total billed charges,1191,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,222.32,14,,,percent of total billed charges,14% of total billed charges,222.32,1191,
Q4160 Nushield 2x4cm (8) per sq cm,4351241,CDM,278,RC,Q4160,HCPCS,Outpatient,,,1423,711.5,,1067.25,75,,,percent of total billed charges,75% of total billed charges,1067.25,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,199.22,14,,,percent of total billed charges,14% of total billed charges,199.22,1067.25,
Q4160 Nushield 3x4cm (12 ) per sq cm,4351242,CDM,278,RC,Q4160,HCPCS,Outpatient,,,1373,686.5,,1029.75,75,,,percent of total billed charges,75% of total billed charges,1029.75,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,192.22,14,,,percent of total billed charges,14% of total billed charges,192.22,1029.75,
"Q4186 Epifix 14mm (2), Per sq cm",3984998,CDM,278,RC,Q4186,HCPCS,Outpatient,,,299.5,149.75,,224.63,75,,,percent of total billed charges,75% of total billed charges,224.63,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.93,14,,,percent of total billed charges,14% of total billed charges,41.93,224.63,
"Q4186 Epifix 14mm (2), Per sq cm",4205142,CDM,278,RC,Q4186,HCPCS,Outpatient,,,1023.68,511.84,,767.76,75,,,percent of total billed charges,75% of total billed charges,767.76,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,143.32,14,,,percent of total billed charges,14% of total billed charges,143.32,767.76,
"Q4186 Epifix 18mm (3), Per sq cm",3732918,CDM,278,RC,Q4186,HCPCS,Outpatient,,,457,228.5,,342.75,75,,,percent of total billed charges,75% of total billed charges,342.75,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,63.98,14,,,percent of total billed charges,14% of total billed charges,63.98,342.75,
"Q4186 Epifix 2cm x 2cm (4), Per sq cm",3732917,CDM,278,RC,Q4186,HCPCS,Outpatient,,,492.75,246.38,,369.56,75,,,percent of total billed charges,75% of total billed charges,369.56,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68.99,14,,,percent of total billed charges,14% of total billed charges,68.99,369.56,
"Q4186 Epifix 2cm x 3cm (6), Per sq cm",3985004,CDM,278,RC,Q4186,HCPCS,Outpatient,,,381.5,190.75,,286.13,75,,,percent of total billed charges,75% of total billed charges,286.13,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.41,14,,,percent of total billed charges,14% of total billed charges,53.41,286.13,
"Q4186 Epifix 2cm x 4cm (8), Per sq cm",3732919,CDM,278,RC,Q4186,HCPCS,Outpatient,,,321.25,160.63,,240.94,75,,,percent of total billed charges,75% of total billed charges,240.94,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.98,14,,,percent of total billed charges,14% of total billed charges,44.98,240.94,
"Q4186 Epifix 3cm x 4cm (12), Per sq cm",3985010,CDM,278,RC,Q4186,HCPCS,Outpatient,,,381.5,190.75,,286.13,75,,,percent of total billed charges,75% of total billed charges,286.13,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.41,14,,,percent of total billed charges,14% of total billed charges,53.41,286.13,
"Q4186 Epifix 4cm x 4cm (16), Per sq cm",3985016,CDM,278,RC,Q4186,HCPCS,Outpatient,,,374.44,187.22,,280.83,75,,,percent of total billed charges,75% of total billed charges,280.83,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.42,14,,,percent of total billed charges,14% of total billed charges,52.42,280.83,
"Q4186 Epifix 5cm x 6cm (30), Per sq cm",3985022,CDM,278,RC,Q4186,HCPCS,Outpatient,,,379.7,189.85,,284.78,75,,,percent of total billed charges,75% of total billed charges,284.78,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.16,14,,,percent of total billed charges,14% of total billed charges,53.16,284.78,
"Q4186 Epifix 7cm x 7cm (49), Per sq cm",3985028,CDM,278,RC,Q4186,HCPCS,Outpatient,,,379.41,189.71,,284.56,75,,,percent of total billed charges,75% of total billed charges,284.56,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.12,14,,,percent of total billed charges,14% of total billed charges,53.12,284.56,
"Q4186 Epifix Mesh 2cm x 3cm (4), Per sq cm",3985034,CDM,278,RC,Q4186,HCPCS,Outpatient,,,572.25,286.13,,429.19,75,,,percent of total billed charges,75% of total billed charges,429.19,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,80.12,14,,,percent of total billed charges,14% of total billed charges,80.12,429.19,
"Q4186 Epifix Mesh 3.5cm x 3.5cm (8), Per sq cm",3985040,CDM,278,RC,Q4186,HCPCS,Outpatient,,,298.63,149.32,,223.97,75,,,percent of total billed charges,75% of total billed charges,223.97,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.81,14,,,percent of total billed charges,14% of total billed charges,41.81,223.97,
"Q4186 Epifix Mesh 4cm x 4.5cm (11), Per sq cm",3732920,CDM,278,RC,Q4186,HCPCS,Outpatient,,,235.36,117.68,,176.52,75,,,percent of total billed charges,75% of total billed charges,176.52,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.95,14,,,percent of total billed charges,14% of total billed charges,32.95,176.52,
Q4196 Nushield 4x4cm (16) per sq cm,4351243,CDM,278,RC,Q4196,HCPCS,Outpatient,,,1067,533.5,,800.25,75,,,percent of total billed charges,75% of total billed charges,800.25,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,149.38,14,,,percent of total billed charges,14% of total billed charges,149.38,800.25,
Q4196 Nushield 4x6cm (24) per sq cm,4351244,CDM,278,RC,Q4196,HCPCS,Outpatient,,,936,468,,702,75,,,percent of total billed charges,75% of total billed charges,702,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,131.04,14,,,percent of total billed charges,14% of total billed charges,131.04,702,
Q4196 puraply am 1.6 disc (3) per sq cm,4351245,CDM,278,RC,Q4196,HCPCS,Outpatient,,,1797,898.5,,1347.75,75,,,percent of total billed charges,75% of total billed charges,1347.75,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,251.58,14,,,percent of total billed charges,14% of total billed charges,251.58,1347.75,
Q4196 puraply am 2x2cm (4) per sq cm,4351246,CDM,278,RC,Q4196,HCPCS,Outpatient,,,2246,1123,,1684.5,75,,,percent of total billed charges,75% of total billed charges,1684.5,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,314.44,14,,,percent of total billed charges,14% of total billed charges,314.44,1684.5,
Q4196 puraply am 2x4cm (8) per sq cm,4351247,CDM,278,RC,Q4196,HCPCS,Outpatient,,,1348,674,,1011,75,,,percent of total billed charges,75% of total billed charges,1011,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,188.72,14,,,percent of total billed charges,14% of total billed charges,188.72,1011,
"Q4196 Puraply AM 3x4 (12), per sq cm",4281267,CDM,278,RC,Q4196,HCPCS,Outpatient,,,1318,659,,988.5,75,,,percent of total billed charges,75% of total billed charges,988.5,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,184.52,14,,,percent of total billed charges,14% of total billed charges,184.52,988.5,
"Q4196 PuraplyAM 4x4cm  (16), per sq cm",4231174,CDM,278,RC,Q4196,HCPCS,Outpatient,,,216,108,,162,75,,,percent of total billed charges,75% of total billed charges,162,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.24,14,,,percent of total billed charges,14% of total billed charges,30.24,162,
"Q4196 PuraplyAMXT 4.91cm x 4.91cm (25), Per sq cm",3985046,CDM,278,RC,Q4196,HCPCS,Outpatient,,,272,136,,204,75,,,percent of total billed charges,75% of total billed charges,204,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.08,14,,,percent of total billed charges,14% of total billed charges,38.08,204,
"CL Definity Contrast , per mL",3632862,CDM,636,RC,Q9957,HCPCS,Outpatient,,,241.92,120.96,,181.44,75,,,percent of total billed charges,75% of total billed charges,181.44,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.87,14,,,percent of total billed charges,14% of total billed charges,33.87,181.44,
"Definity Contrast , per mL",867985,CDM,636,RC,Q9957,HCPCS,Outpatient,,,241.92,120.96,,181.44,75,,,percent of total billed charges,75% of total billed charges,181.44,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.87,14,,,percent of total billed charges,14% of total billed charges,33.87,181.44,
ROTC,4199642,CDM,978,RC,ROTC,HCPCS,Outpatient,,,111.3,55.65,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,14,,,Other,Not Separately reimbursable,,,
150 mg testosterone Pellet,4041269,CDM,250,RC,S0189,HCPCS,Outpatient,,,376.32,188.16,,282.24,75,,,percent of total billed charges,75% of total billed charges,282.24,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.68,14,,,percent of total billed charges,14% of total billed charges,52.68,282.24,
300 mg testosterone Pellet,4041270,CDM,250,RC,S0189,HCPCS,Outpatient,,,752.64,376.32,,564.48,75,,,percent of total billed charges,75% of total billed charges,564.48,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,105.37,14,,,percent of total billed charges,14% of total billed charges,105.37,564.48,
75 mg testosterone Pellet,4041268,CDM,250,RC,S0189,HCPCS,Outpatient,,,168.75,84.38,,126.56,75,,,percent of total billed charges,75% of total billed charges,126.56,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.63,14,,,percent of total billed charges,14% of total billed charges,23.63,126.56,
S0610 Annual gynecological examina,3428517,CDM,920,RC,S0610,HCPCS,Outpatient,,,327.11,163.56,,245.33,75,,,percent of total billed charges,75% of total billed charges,245.33,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.8,14,,,percent of total billed charges,14% of total billed charges,45.8,245.33,
S0612 Annual gynecological examina,3428518,CDM,510,RC,S0612,HCPCS,Outpatient,,,361.67,180.84,,271.25,75,,,percent of total billed charges,75% of total billed charges,271.25,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50.63,14,,,percent of total billed charges,14% of total billed charges,50.63,271.25,
S2900- Surgical techniques requiring use of robotic surgical system (list separately in addition to,3566799,CDM,510,RC,S2900,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
S8185 Flutter device,3621406,CDM,510,RC,S8185,HCPCS,Outpatient,,,132.97,66.49,,99.73,75,,,percent of total billed charges,75% of total billed charges,99.73,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.62,14,,,percent of total billed charges,14% of total billed charges,18.62,99.73,
"S9455- Diabetic Management Program,Group Session",3435930,CDM,510,RC,S9455,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
S9484- BH Crisis Assessment & Intervention,3438171,CDM,960,RC,S9484,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
"S9981- Medical Rec Copying Fee,Admin",3435931,CDM,510,RC,S9981,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
"T2022- Case Management, Monthly",3438178,CDM,983,RC,T2022,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
T2023- Targeted Case Management Contact,3438179,CDM,983,RC,T2023,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
"V2799- Vision item or service, miscellaneous",3435630,CDM,510,RC,V2799,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
"10005 - Fine needle aspiration biopsy, including ultrasound",3572795,CDM,510,RC,10005,HCPCS,Outpatient,,,153.17,76.59,,114.88,75,,,percent of total billed charges,75% of total billed charges,114.88,75,,,percent of total billed charges,75% of total billed charges,610.13,100,,,Fee Schedule,100% of CMS OPPS Rate,254,102,,,Fee Schedule,102% of WV Medicaid Rate,1006.72,165,,,Fee Schedule,165% of CMS OPPS Rate,632.35,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1752.53,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2403.46,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,3010.58,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,249.02,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,610.13,100,,,Fee Schedule,100% of CMS OPPS Rate,632.35,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,21.44,14,,,percent of total billed charges,14% of total billed charges,21.44,3010.58,
SCSN US Exam,4345737,CDM,402,RC,10005,HCPCS,Outpatient,,,3244.85,1622.43,,2433.64,75,,,percent of total billed charges,75% of total billed charges,2433.64,75,,,percent of total billed charges,75% of total billed charges,610.13,100,,,Fee Schedule,100% of CMS OPPS Rate,254,102,,,Fee Schedule,102% of WV Medicaid Rate,1006.72,165,,,Fee Schedule,165% of CMS OPPS Rate,632.35,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1752.53,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2403.46,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,3010.58,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,249.02,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,610.13,100,,,Fee Schedule,100% of CMS OPPS Rate,632.35,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,454.28,14,,,percent of total billed charges,14% of total billed charges,249.02,3010.58,
SCSN US Exam,4345739,CDM,402,RC,10005,HCPCS,Outpatient,,,3244.85,1622.43,,2433.64,75,,,percent of total billed charges,75% of total billed charges,2433.64,75,,,percent of total billed charges,75% of total billed charges,610.13,100,,,Fee Schedule,100% of CMS OPPS Rate,254,102,,,Fee Schedule,102% of WV Medicaid Rate,1006.72,165,,,Fee Schedule,165% of CMS OPPS Rate,632.35,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1752.53,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2403.46,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,3010.58,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,249.02,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,610.13,100,,,Fee Schedule,100% of CMS OPPS Rate,632.35,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,454.28,14,,,percent of total billed charges,14% of total billed charges,249.02,3010.58,
10006-MSA FNA BIOPSY W/ ULTSND GD ADD LES,3428647,CDM,361,RC,10006,HCPCS,Outpatient,,,1402.79,701.4,,1052.09,75,,,percent of total billed charges,75% of total billed charges,1052.09,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,196.39,14,,,percent of total billed charges,14% of total billed charges,196.39,1052.09,
10007-MSA FNA BIOPSY W/ FLUORO GD 1ST LES,3428648,CDM,361,RC,10007,HCPCS,Outpatient,,,3552.91,1776.46,,2664.68,75,,,percent of total billed charges,75% of total billed charges,2664.68,75,,,percent of total billed charges,75% of total billed charges,610.13,100,,,Fee Schedule,100% of CMS OPPS Rate,191.36,102,,,Fee Schedule,102% of WV Medicaid Rate,1006.72,165,,,Fee Schedule,165% of CMS OPPS Rate,632.35,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1752.53,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2403.46,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,3010.58,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,187.61,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,610.13,100,,,Fee Schedule,100% of CMS OPPS Rate,632.35,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,497.41,14,,,percent of total billed charges,14% of total billed charges,187.61,3010.58,
10008-MSA FNA BIOPSY W/ FLUORO GD ADD LES,3428649,CDM,361,RC,10008,HCPCS,Outpatient,,,418,209,,313.5,75,,,percent of total billed charges,75% of total billed charges,313.5,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,58.52,14,,,percent of total billed charges,14% of total billed charges,58.52,313.5,
10021- Fine needle asp w/o image guide,3431472,CDM,761,RC,10021,HCPCS,Outpatient,,,2013.58,1006.79,,1510.19,75,,,percent of total billed charges,75% of total billed charges,1510.19,75,,,percent of total billed charges,75% of total billed charges,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,51.05,102,,,Fee Schedule,102% of WV Medicaid Rate,578.72,165,,,Fee Schedule,165% of CMS OPPS Rate,363.51,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1007.47,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1381.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1730.67,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,50.05,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,363.51,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,281.9,14,,,percent of total billed charges,14% of total billed charges,50.05,1730.67,
"10035 Placement of soft tissue localization device(s) (eg, clip, metallic pellet, wire/needle, radio",3621199,CDM,510,RC,10035,HCPCS,Outpatient,,,702.75,351.38,,527.06,75,,,percent of total billed charges,75% of total billed charges,527.06,75,,,percent of total billed charges,75% of total billed charges,610.13,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1006.72,165,,,Fee Schedule,165% of CMS OPPS Rate,632.35,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1752.53,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2403.46,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,3010.58,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,610.13,100,,,Fee Schedule,100% of CMS OPPS Rate,632.35,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,98.39,14,,,percent of total billed charges,14% of total billed charges,98.39,3010.58,
10040- Acne surgery,3431474,CDM,761,RC,10040,HCPCS,Outpatient,,,885.98,442.99,,664.49,75,,,percent of total billed charges,75% of total billed charges,664.49,75,,,percent of total billed charges,75% of total billed charges,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,280.12,165,,,Fee Schedule,165% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,487.65,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,668.78,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,837.71,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,124.04,14,,,percent of total billed charges,14% of total billed charges,124.04,837.71,
10060- Abscess/simple/single/I  & D,3431475,CDM,761,RC,10060,HCPCS,Outpatient,,,1010.98,505.49,,758.24,75,,,percent of total billed charges,75% of total billed charges,758.24,75,,,percent of total billed charges,75% of total billed charges,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,64.15,102,,,Fee Schedule,102% of WV Medicaid Rate,280.12,165,,,Fee Schedule,165% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,487.65,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,668.77,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,837.71,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,62.89,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,141.54,14,,,percent of total billed charges,14% of total billed charges,62.89,837.71,
10060 Incision & Drainage Abscess Simple/Single,3436008,CDM,761,RC,10060,HCPCS,Outpatient,,,1010.98,505.49,,758.24,75,,,percent of total billed charges,75% of total billed charges,758.24,75,,,percent of total billed charges,75% of total billed charges,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,64.15,102,,,Fee Schedule,102% of WV Medicaid Rate,280.12,165,,,Fee Schedule,165% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,487.65,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,668.77,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,837.71,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,62.89,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,141.54,14,,,percent of total billed charges,14% of total billed charges,62.89,837.71,
"10061- I&D ,Abscess, Complex or S",3428656,CDM,761,RC,10061,HCPCS,Outpatient,,,2013.58,1006.79,,1510.19,75,,,percent of total billed charges,75% of total billed charges,1510.19,75,,,percent of total billed charges,75% of total billed charges,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,96.91,102,,,Fee Schedule,102% of WV Medicaid Rate,578.72,165,,,Fee Schedule,165% of CMS OPPS Rate,363.51,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1007.47,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1381.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1730.67,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,95.01,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,363.51,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,281.9,14,,,percent of total billed charges,14% of total billed charges,95.01,1730.67,
10061 Incision & Drainage Abscess Complicated/Multiple,3436009,CDM,761,RC,10061,HCPCS,Outpatient,,,2013.58,1006.79,,1510.19,75,,,percent of total billed charges,75% of total billed charges,1510.19,75,,,percent of total billed charges,75% of total billed charges,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,96.91,102,,,Fee Schedule,102% of WV Medicaid Rate,578.72,165,,,Fee Schedule,165% of CMS OPPS Rate,363.51,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1007.47,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1381.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1730.67,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,95.01,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,363.51,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,281.9,14,,,percent of total billed charges,14% of total billed charges,95.01,1730.67,
"10061- Incision and Drainage, Complex",3428467,CDM,510,RC,10061,HCPCS,Outpatient,,,2013.58,1006.79,,1510.19,75,,,percent of total billed charges,75% of total billed charges,1510.19,75,,,percent of total billed charges,75% of total billed charges,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,96.91,102,,,Fee Schedule,102% of WV Medicaid Rate,578.72,165,,,Fee Schedule,165% of CMS OPPS Rate,363.51,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1007.47,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1381.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1730.67,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,95.01,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,363.51,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,281.9,14,,,percent of total billed charges,14% of total billed charges,95.01,1730.67,
"10080- Incision and Drainage( IND) Pilonidal Cyst, Simple",3428657,CDM,510,RC,10080,HCPCS,Outpatient,,,3552.91,1776.46,,2664.68,75,,,percent of total billed charges,75% of total billed charges,2664.68,75,,,percent of total billed charges,75% of total billed charges,610.13,100,,,Fee Schedule,100% of CMS OPPS Rate,171.71,102,,,Fee Schedule,102% of WV Medicaid Rate,1006.72,165,,,Fee Schedule,165% of CMS OPPS Rate,632.35,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1752.53,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2403.46,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,3010.58,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,168.34,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,610.13,100,,,Fee Schedule,100% of CMS OPPS Rate,632.35,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,497.41,14,,,percent of total billed charges,14% of total billed charges,168.34,3010.58,
10081- I & D/pilonidal cyst/complicated,3431476,CDM,761,RC,10081,HCPCS,Outpatient,,,3552.91,1776.46,,2664.68,75,,,percent of total billed charges,75% of total billed charges,2664.68,75,,,percent of total billed charges,75% of total billed charges,610.13,100,,,Fee Schedule,100% of CMS OPPS Rate,206.38,102,,,Fee Schedule,102% of WV Medicaid Rate,1006.72,165,,,Fee Schedule,165% of CMS OPPS Rate,632.35,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1752.53,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2403.46,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,3010.58,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,202.33,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,610.13,100,,,Fee Schedule,100% of CMS OPPS Rate,632.35,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,497.41,14,,,percent of total billed charges,14% of total billed charges,202.33,3010.58,
10120- Incision/rmv FB/SQ tis/simple,3431477,CDM,761,RC,10120,HCPCS,Outpatient,,,2013.58,1006.79,,1510.19,75,,,percent of total billed charges,75% of total billed charges,1510.19,75,,,percent of total billed charges,75% of total billed charges,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,85.17,102,,,Fee Schedule,102% of WV Medicaid Rate,578.72,165,,,Fee Schedule,165% of CMS OPPS Rate,363.51,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1007.47,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1381.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1730.67,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,83.5,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,363.51,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,281.9,14,,,percent of total billed charges,14% of total billed charges,83.5,1730.67,
10121- Incision/rmv FB/SQ tis/complicat,3431478,CDM,761,RC,10121,HCPCS,Outpatient,,,8187.18,4093.59,,6140.39,75,,,percent of total billed charges,75% of total billed charges,6140.39,75,,,percent of total billed charges,75% of total billed charges,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,479.67,102,,,Fee Schedule,102% of WV Medicaid Rate,2326.19,165,,,Fee Schedule,165% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4049.52,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5553.61,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6956.46,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,470.26,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1146.21,14,,,percent of total billed charges,14% of total billed charges,470.26,6956.46,
"10140- Incision and Drainage of hematoma, seroma or fluid collection",4346598,CDM,510,RC,10140,HCPCS,Outpatient,,,8187.18,4093.59,,6140.39,75,,,percent of total billed charges,75% of total billed charges,6140.39,75,,,percent of total billed charges,75% of total billed charges,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,89.55,102,,,Fee Schedule,102% of WV Medicaid Rate,2326.19,165,,,Fee Schedule,165% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4049.52,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5553.61,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6956.46,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,87.79,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1146.21,14,,,percent of total billed charges,14% of total billed charges,87.79,6956.46,
10160- Punc asp/abscess/hema/bulla/cyst,3428658,CDM,761,RC,10160,HCPCS,Outpatient,,,2013.58,1006.79,,1510.19,75,,,percent of total billed charges,75% of total billed charges,1510.19,75,,,percent of total billed charges,75% of total billed charges,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,66.88,102,,,Fee Schedule,102% of WV Medicaid Rate,578.72,165,,,Fee Schedule,165% of CMS OPPS Rate,363.51,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1007.47,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1381.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1730.67,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,65.57,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,363.51,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,281.9,14,,,percent of total billed charges,14% of total billed charges,65.57,1730.67,
10180 Incision & Drainage Complex PO Wound Infection,3436011,CDM,761,RC,10180,HCPCS,Outpatient,,,14348.96,7174.48,,10761.72,75,,,percent of total billed charges,75% of total billed charges,10761.72,75,,,percent of total billed charges,75% of total billed charges,2428.67,100,,,Fee Schedule,100% of CMS OPPS Rate,803.83,102,,,Fee Schedule,102% of WV Medicaid Rate,4007.32,165,,,Fee Schedule,165% of CMS OPPS Rate,2517.11,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,6976.06,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,9567.11,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,11983.78,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,788.07,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2428.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2517.11,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,2008.85,14,,,percent of total billed charges,14% of total billed charges,788.07,11983.78,
"10180- Incision and Drainage, Compex post-op wound infection",4346593,CDM,510,RC,10180,HCPCS,Outpatient,,,14348.96,7174.48,,10761.72,75,,,percent of total billed charges,75% of total billed charges,10761.72,75,,,percent of total billed charges,75% of total billed charges,2428.67,100,,,Fee Schedule,100% of CMS OPPS Rate,803.83,102,,,Fee Schedule,102% of WV Medicaid Rate,4007.32,165,,,Fee Schedule,165% of CMS OPPS Rate,2517.11,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,6976.06,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,9567.11,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,11983.78,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,788.07,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2428.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2517.11,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,2008.85,14,,,percent of total billed charges,14% of total billed charges,788.07,11983.78,
10180- Postop wound infection/complex/I&D,3431479,CDM,761,RC,10180,HCPCS,Outpatient,,,14348.96,7174.48,,10761.72,75,,,percent of total billed charges,75% of total billed charges,10761.72,75,,,percent of total billed charges,75% of total billed charges,2428.67,100,,,Fee Schedule,100% of CMS OPPS Rate,803.83,102,,,Fee Schedule,102% of WV Medicaid Rate,4007.32,165,,,Fee Schedule,165% of CMS OPPS Rate,2517.11,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,6976.06,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,9567.11,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,11983.78,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,788.07,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2428.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2517.11,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,2008.85,14,,,percent of total billed charges,14% of total billed charges,788.07,11983.78,
11000- Debrid ecz/inf skin up tp 10% body,3428659,CDM,510,RC,11000,HCPCS,Outpatient,,,3171.52,1585.76,,2378.64,75,,,percent of total billed charges,75% of total billed charges,2378.64,75,,,percent of total billed charges,75% of total billed charges,546.17,100,,,Fee Schedule,100% of CMS OPPS Rate,29.48,102,,,Fee Schedule,102% of WV Medicaid Rate,901.2,165,,,Fee Schedule,165% of CMS OPPS Rate,566.07,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1568.84,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2151.55,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,2695.04,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,28.9,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,546.17,100,,,Fee Schedule,100% of CMS OPPS Rate,566.07,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,444.01,14,,,percent of total billed charges,14% of total billed charges,28.9,2695.04,
11001 - DBRDMT EXTNSVE ECZEMA/INFECT SKN EA 10% BDY SURF,4037472,CDM,510,RC,11001,HCPCS,Outpatient,,,1780.8,890.4,,1335.6,75,,,percent of total billed charges,75% of total billed charges,1335.6,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,249.31,14,,,percent of total billed charges,14% of total billed charges,249.31,1335.6,
11011- Debride/rmv FB/open fx/skin/sq/mus,3431484,CDM,510,RC,11011,HCPCS,Outpatient,,,6552.91,3276.46,,4914.68,75,,,percent of total billed charges,75% of total billed charges,4914.68,75,,,percent of total billed charges,75% of total billed charges,610.13,100,,,Fee Schedule,100% of CMS OPPS Rate,254,102,,,Fee Schedule,102% of WV Medicaid Rate,1006.72,165,,,Fee Schedule,165% of CMS OPPS Rate,632.35,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1752.53,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2403.46,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,3010.58,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,249.02,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,610.13,100,,,Fee Schedule,100% of CMS OPPS Rate,632.35,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,917.41,14,,,percent of total billed charges,14% of total billed charges,249.02,4914.68,
11042 Debridement Subcutaneous Tissue 20 Sq Cm/<,3436013,CDM,761,RC,11042,HCPCS,Outpatient,,,2013.58,1006.79,,1510.19,75,,,percent of total billed charges,75% of total billed charges,1510.19,75,,,percent of total billed charges,75% of total billed charges,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,141.09,102,,,Fee Schedule,102% of WV Medicaid Rate,578.72,165,,,Fee Schedule,165% of CMS OPPS Rate,363.51,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1007.47,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1381.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1730.67,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,138.32,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,363.51,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,281.9,14,,,percent of total billed charges,14% of total billed charges,138.32,1730.67,
11042-DEB SUBQ Tissue 20 SQ CM/<,3574980,CDM,510,RC,11042,HCPCS,Outpatient,,,2013.58,1006.79,,1510.19,75,,,percent of total billed charges,75% of total billed charges,1510.19,75,,,percent of total billed charges,75% of total billed charges,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,141.09,102,,,Fee Schedule,102% of WV Medicaid Rate,578.72,165,,,Fee Schedule,165% of CMS OPPS Rate,363.51,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1007.47,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1381.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1730.67,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,138.32,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,363.51,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,281.9,14,,,percent of total billed charges,14% of total billed charges,138.32,1730.67,
11043 Deb Musc Fascia 20 Sq Cm less than,3572727,CDM,510,RC,11043,HCPCS,Outpatient,,,3171.52,1585.76,,2378.64,75,,,percent of total billed charges,75% of total billed charges,2378.64,75,,,percent of total billed charges,75% of total billed charges,546.17,100,,,Fee Schedule,100% of CMS OPPS Rate,213.77,102,,,Fee Schedule,102% of WV Medicaid Rate,901.2,165,,,Fee Schedule,165% of CMS OPPS Rate,566.07,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1568.84,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2151.55,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,2695.04,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,209.58,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,546.17,100,,,Fee Schedule,100% of CMS OPPS Rate,566.07,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,444.01,14,,,percent of total billed charges,14% of total billed charges,209.58,2695.04,
11043 Debridement Muscle & Fascia 20 Sq Cm/<,3436016,CDM,761,RC,11043,HCPCS,Outpatient,,,3171.52,1585.76,,2378.64,75,,,percent of total billed charges,75% of total billed charges,2378.64,75,,,percent of total billed charges,75% of total billed charges,546.17,100,,,Fee Schedule,100% of CMS OPPS Rate,213.77,102,,,Fee Schedule,102% of WV Medicaid Rate,901.2,165,,,Fee Schedule,165% of CMS OPPS Rate,566.07,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1568.84,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2151.55,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,2695.04,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,209.58,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,546.17,100,,,Fee Schedule,100% of CMS OPPS Rate,566.07,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,444.01,14,,,percent of total billed charges,14% of total billed charges,209.58,2695.04,
11044 Debridement Bone Muscle & Fascia 20 Sq Cm/<,3436020,CDM,761,RC,11044,HCPCS,Outpatient,,,8187.18,4093.59,,6140.39,75,,,percent of total billed charges,75% of total billed charges,6140.39,75,,,percent of total billed charges,75% of total billed charges,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,479.67,102,,,Fee Schedule,102% of WV Medicaid Rate,2326.19,165,,,Fee Schedule,165% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4049.52,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5553.61,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6956.46,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,470.26,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1146.21,14,,,percent of total billed charges,14% of total billed charges,470.26,6956.46,
"11044 Debridement, bone (includes epidermis, dermis, subcutaneous tissue, muscle and/or fascia, if p",3621458,CDM,510,RC,11044,HCPCS,Outpatient,,,8187.18,4093.59,,6140.39,75,,,percent of total billed charges,75% of total billed charges,6140.39,75,,,percent of total billed charges,75% of total billed charges,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,479.67,102,,,Fee Schedule,102% of WV Medicaid Rate,2326.19,165,,,Fee Schedule,165% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4049.52,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5553.61,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6956.46,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,470.26,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1146.21,14,,,percent of total billed charges,14% of total billed charges,470.26,6956.46,
11045 Dbrdmt Subcutaneous Tissue Ea Addl 20 Sq Cm,3436023,CDM,761,RC,11045,HCPCS,Outpatient,,,649.09,324.55,,486.82,75,,,percent of total billed charges,75% of total billed charges,486.82,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,90.87,14,,,percent of total billed charges,14% of total billed charges,90.87,486.82,
11045 Debride subq tiss ea add 20sq cm,3570187,CDM,510,RC,11045,HCPCS,Outpatient,,,649.09,324.55,,486.82,75,,,percent of total billed charges,75% of total billed charges,486.82,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,90.87,14,,,percent of total billed charges,14% of total billed charges,90.87,486.82,
11046 Deb Mus Fasica Add On,3550404,CDM,510,RC,11046,HCPCS,Outpatient,,,753.31,376.66,,564.98,75,,,percent of total billed charges,75% of total billed charges,564.98,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,105.46,14,,,percent of total billed charges,14% of total billed charges,105.46,564.98,
11046 Debridement Muscle & Fascia Ea Addl 20 Sq Cm,3436025,CDM,761,RC,11046,HCPCS,Outpatient,,,753.31,376.66,,564.98,75,,,percent of total billed charges,75% of total billed charges,564.98,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,105.46,14,,,percent of total billed charges,14% of total billed charges,105.46,564.98,
11047 Debridement Bone Each Additional 20 Sq Cm,3436026,CDM,761,RC,11047,HCPCS,Outpatient,,,2532.54,1266.27,,1899.41,75,,,percent of total billed charges,75% of total billed charges,1899.41,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,354.56,14,,,percent of total billed charges,14% of total billed charges,354.56,1899.41,
11047- Debridement/bone/ea add 20 sq cm,3431488,CDM,761,RC,11047,HCPCS,Outpatient,,,2532.54,1266.27,,1899.41,75,,,percent of total billed charges,75% of total billed charges,1899.41,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,354.56,14,,,percent of total billed charges,14% of total billed charges,354.56,1899.41,
11055- Trim hyperkeratotic lesion/sng,3431489,CDM,761,RC,11055,HCPCS,Outpatient,,,1010.98,505.49,,758.24,75,,,percent of total billed charges,75% of total billed charges,758.24,75,,,percent of total billed charges,75% of total billed charges,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,280.12,165,,,Fee Schedule,165% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,487.65,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,668.78,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,837.71,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,141.54,14,,,percent of total billed charges,14% of total billed charges,141.54,837.71,
11056- Trim hyperkeratotic lesion/2-4,3431490,CDM,761,RC,11056,HCPCS,Outpatient,,,1010.98,505.49,,758.24,75,,,percent of total billed charges,75% of total billed charges,758.24,75,,,percent of total billed charges,75% of total billed charges,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,280.12,165,,,Fee Schedule,165% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,487.65,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,668.78,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,837.71,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,141.54,14,,,percent of total billed charges,14% of total billed charges,141.54,837.71,
11057- Trim hyperkeratotic lesion/>4,3431491,CDM,761,RC,11057,HCPCS,Outpatient,,,1010.98,505.49,,758.24,75,,,percent of total billed charges,75% of total billed charges,758.24,75,,,percent of total billed charges,75% of total billed charges,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,54.87,102,,,Fee Schedule,102% of WV Medicaid Rate,280.12,165,,,Fee Schedule,165% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,487.65,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,668.77,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,837.71,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,53.79,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,141.54,14,,,percent of total billed charges,14% of total billed charges,53.79,837.71,
11102 Shave Biopsy,3428674,CDM,761,RC,11102,HCPCS,Outpatient,,,1010.98,505.49,,758.24,75,,,percent of total billed charges,75% of total billed charges,758.24,75,,,percent of total billed charges,75% of total billed charges,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,63.33,102,,,Fee Schedule,102% of WV Medicaid Rate,280.12,165,,,Fee Schedule,165% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,487.65,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,668.77,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,837.71,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,62.09,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,141.54,14,,,percent of total billed charges,14% of total billed charges,62.09,837.71,
11103 Additional Shave Biopsy,3428675,CDM,761,RC,11103,HCPCS,Outpatient,,,126.24,63.12,,94.68,75,,,percent of total billed charges,75% of total billed charges,94.68,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.67,14,,,percent of total billed charges,14% of total billed charges,17.67,94.68,
11104 Punch Biopsy with Suture,3428676,CDM,761,RC,11104,HCPCS,Outpatient,,,2013.58,1006.79,,1510.19,75,,,percent of total billed charges,75% of total billed charges,1510.19,75,,,percent of total billed charges,75% of total billed charges,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,78.36,102,,,Fee Schedule,102% of WV Medicaid Rate,578.72,165,,,Fee Schedule,165% of CMS OPPS Rate,363.51,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1007.47,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1381.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1730.67,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,76.82,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,363.51,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,281.9,14,,,percent of total billed charges,14% of total billed charges,76.82,1730.67,
11105 Add'l Punch Biospy with suture,3428677,CDM,761,RC,11105,HCPCS,Outpatient,,,429.95,214.98,,322.46,75,,,percent of total billed charges,75% of total billed charges,322.46,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.19,14,,,percent of total billed charges,14% of total billed charges,60.19,322.46,
11106 Wedge Biopsy with Suture,3428678,CDM,761,RC,11106,HCPCS,Outpatient,,,3171.52,1585.76,,2378.64,75,,,percent of total billed charges,75% of total billed charges,2378.64,75,,,percent of total billed charges,75% of total billed charges,546.17,100,,,Fee Schedule,100% of CMS OPPS Rate,97.45,102,,,Fee Schedule,102% of WV Medicaid Rate,901.2,165,,,Fee Schedule,165% of CMS OPPS Rate,566.07,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1568.84,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2151.55,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,2695.04,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,95.54,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,546.17,100,,,Fee Schedule,100% of CMS OPPS Rate,566.07,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,444.01,14,,,percent of total billed charges,14% of total billed charges,95.54,2695.04,
11107 Add'l Wedge Biopsy with suture,3428679,CDM,761,RC,11107,HCPCS,Outpatient,,,175.38,87.69,,131.54,75,,,percent of total billed charges,75% of total billed charges,131.54,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.55,14,,,percent of total billed charges,14% of total billed charges,24.55,131.54,
11200- Remove skin tags </= 15,3431493,CDM,761,RC,11200,HCPCS,Outpatient,,,1010.98,505.49,,758.24,75,,,percent of total billed charges,75% of total billed charges,758.24,75,,,percent of total billed charges,75% of total billed charges,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,280.12,165,,,Fee Schedule,165% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,487.65,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,668.78,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,837.71,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,141.54,14,,,percent of total billed charges,14% of total billed charges,141.54,837.71,
11201- Remove skin tags/ea add 10 lesions,3431494,CDM,761,RC,11201,HCPCS,Outpatient,,,47.68,23.84,,35.76,75,,,percent of total billed charges,75% of total billed charges,35.76,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.68,14,,,percent of total billed charges,14% of total billed charges,6.68,35.76,
"11300- Shave Skin Lesion,0.5Cm Or Less",3431495,CDM,761,RC,11300,HCPCS,Outpatient,,,2013.58,1006.79,,1510.19,75,,,percent of total billed charges,75% of total billed charges,1510.19,75,,,percent of total billed charges,75% of total billed charges,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,578.73,165,,,Fee Schedule,165% of CMS OPPS Rate,363.52,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1007.47,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1381.67,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1730.68,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,363.52,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,281.9,14,,,percent of total billed charges,14% of total billed charges,281.9,1730.68,
"11301- Shave Skin Lesion,0.6-1.0Cm",3431496,CDM,761,RC,11301,HCPCS,Outpatient,,,1010.98,505.49,,758.24,75,,,percent of total billed charges,75% of total billed charges,758.24,75,,,percent of total billed charges,75% of total billed charges,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,280.12,165,,,Fee Schedule,165% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,487.65,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,668.78,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,837.71,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,141.54,14,,,percent of total billed charges,14% of total billed charges,141.54,837.71,
"11302- Shave Skin Lesion,1.1-2.0Cm",3431497,CDM,761,RC,11302,HCPCS,Outpatient,,,1010.98,505.49,,758.24,75,,,percent of total billed charges,75% of total billed charges,758.24,75,,,percent of total billed charges,75% of total billed charges,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,280.12,165,,,Fee Schedule,165% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,487.65,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,668.78,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,837.71,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,141.54,14,,,percent of total billed charges,14% of total billed charges,141.54,837.71,
11303- Shave epi/derm sng lesion/trunk/arm/leg/>2.0cm,3431498,CDM,761,RC,11303,HCPCS,Outpatient,,,2013.58,1006.79,,1510.19,75,,,percent of total billed charges,75% of total billed charges,1510.19,75,,,percent of total billed charges,75% of total billed charges,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,578.73,165,,,Fee Schedule,165% of CMS OPPS Rate,363.52,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1007.47,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1381.67,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1730.68,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,363.52,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,281.9,14,,,percent of total billed charges,14% of total billed charges,281.9,1730.68,
"11305- Shave Skin Lesion, .5Cm Or Less",3431499,CDM,761,RC,11305,HCPCS,Outpatient,,,1010.98,505.49,,758.24,75,,,percent of total billed charges,75% of total billed charges,758.24,75,,,percent of total billed charges,75% of total billed charges,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,280.12,165,,,Fee Schedule,165% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,487.65,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,668.78,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,837.71,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,141.54,14,,,percent of total billed charges,14% of total billed charges,141.54,837.71,
"11306- Shave Skin Lesion,0.6-1.0 Cm",3431500,CDM,761,RC,11306,HCPCS,Outpatient,,,1010.98,505.49,,758.24,75,,,percent of total billed charges,75% of total billed charges,758.24,75,,,percent of total billed charges,75% of total billed charges,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,280.12,165,,,Fee Schedule,165% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,487.65,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,668.78,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,837.71,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,141.54,14,,,percent of total billed charges,14% of total billed charges,141.54,837.71,
"11307- Shave Skin Lesion,1.1-2.0 Cm",3431501,CDM,761,RC,11307,HCPCS,Outpatient,,,1010.98,505.49,,758.24,75,,,percent of total billed charges,75% of total billed charges,758.24,75,,,percent of total billed charges,75% of total billed charges,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,73.31,102,,,Fee Schedule,102% of WV Medicaid Rate,280.12,165,,,Fee Schedule,165% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,487.65,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,668.77,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,837.71,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,71.87,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,141.54,14,,,percent of total billed charges,14% of total billed charges,71.87,837.71,
11308- Shave epi/derm sng lesion/scalp/neck/hnd/ft/genit/>2.0cm,3431502,CDM,761,RC,11308,HCPCS,Outpatient,,,2013.58,1006.79,,1510.19,75,,,percent of total billed charges,75% of total billed charges,1510.19,75,,,percent of total billed charges,75% of total billed charges,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,578.73,165,,,Fee Schedule,165% of CMS OPPS Rate,363.52,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1007.47,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1381.67,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1730.68,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,363.52,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,281.9,14,,,percent of total billed charges,14% of total billed charges,281.9,1730.68,
11310- Shave epi/derm sng lesion/face/ear/lid/nose/lip/0.5cm or <,3431503,CDM,761,RC,11310,HCPCS,Outpatient,,,1010.98,505.49,,758.24,75,,,percent of total billed charges,75% of total billed charges,758.24,75,,,percent of total billed charges,75% of total billed charges,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,70.98,102,,,Fee Schedule,102% of WV Medicaid Rate,280.12,165,,,Fee Schedule,165% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,487.65,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,668.77,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,837.71,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,69.59,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,141.54,14,,,percent of total billed charges,14% of total billed charges,69.59,837.71,
11311- Shave epi/derm sng lesion/face/ear/lid/nose/lip/0.6-1.0cm,3431504,CDM,761,RC,11311,HCPCS,Outpatient,,,1010.98,505.49,,758.24,75,,,percent of total billed charges,75% of total billed charges,758.24,75,,,percent of total billed charges,75% of total billed charges,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,73.31,102,,,Fee Schedule,102% of WV Medicaid Rate,280.12,165,,,Fee Schedule,165% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,487.65,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,668.77,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,837.71,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,71.87,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,141.54,14,,,percent of total billed charges,14% of total billed charges,71.87,837.71,
11312- Shave epi/derm sng lesion/face/ear/lid/nose/lip/1.1-2.0cm,3431505,CDM,761,RC,11312,HCPCS,Outpatient,,,2013.58,1006.79,,1510.19,75,,,percent of total billed charges,75% of total billed charges,1510.19,75,,,percent of total billed charges,75% of total billed charges,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,88.18,102,,,Fee Schedule,102% of WV Medicaid Rate,578.72,165,,,Fee Schedule,165% of CMS OPPS Rate,363.51,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1007.47,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1381.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1730.67,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,86.45,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,363.51,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,281.9,14,,,percent of total billed charges,14% of total billed charges,86.45,1730.67,
11313- Shave epi/derm sng lesion/face/ear/lid/nose/lip/>2.0cm,3431506,CDM,761,RC,11313,HCPCS,Outpatient,,,2013.58,1006.79,,1510.19,75,,,percent of total billed charges,75% of total billed charges,1510.19,75,,,percent of total billed charges,75% of total billed charges,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,97.19,102,,,Fee Schedule,102% of WV Medicaid Rate,578.72,165,,,Fee Schedule,165% of CMS OPPS Rate,363.51,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1007.47,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1381.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1730.67,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,95.28,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,363.51,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,281.9,14,,,percent of total billed charges,14% of total billed charges,95.28,1730.67,
11400- Exc Tr-Ext Benign+Marg 0.5 < Cm,3431507,CDM,761,RC,11400,HCPCS,Outpatient,,,3552.91,1776.46,,2664.68,75,,,percent of total billed charges,75% of total billed charges,2664.68,75,,,percent of total billed charges,75% of total billed charges,610.13,100,,,Fee Schedule,100% of CMS OPPS Rate,76.7,102,,,Fee Schedule,102% of WV Medicaid Rate,1006.72,165,,,Fee Schedule,165% of CMS OPPS Rate,632.35,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1752.53,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2403.46,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,3010.58,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,75.2,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,610.13,100,,,Fee Schedule,100% of CMS OPPS Rate,632.35,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,497.41,14,,,percent of total billed charges,14% of total billed charges,75.2,3010.58,
11401- Exc tr-ext benign+marg 0.6-1 cm,3431508,CDM,761,RC,11401,HCPCS,Outpatient,,,2013.58,1006.79,,1510.19,75,,,percent of total billed charges,75% of total billed charges,1510.19,75,,,percent of total billed charges,75% of total billed charges,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,87.9,102,,,Fee Schedule,102% of WV Medicaid Rate,578.72,165,,,Fee Schedule,165% of CMS OPPS Rate,363.51,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1007.47,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1381.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1730.67,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,86.18,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,363.51,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,281.9,14,,,percent of total billed charges,14% of total billed charges,86.18,1730.67,
11402- Exc tr-ext benign+marg 1.1-2 cm,3431509,CDM,761,RC,11402,HCPCS,Outpatient,,,3552.91,1776.46,,2664.68,75,,,percent of total billed charges,75% of total billed charges,2664.68,75,,,percent of total billed charges,75% of total billed charges,610.13,100,,,Fee Schedule,100% of CMS OPPS Rate,95.28,102,,,Fee Schedule,102% of WV Medicaid Rate,1006.72,165,,,Fee Schedule,165% of CMS OPPS Rate,632.35,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1752.53,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2403.46,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,3010.58,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,93.41,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,610.13,100,,,Fee Schedule,100% of CMS OPPS Rate,632.35,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,497.41,14,,,percent of total billed charges,14% of total billed charges,93.41,3010.58,
11403- Exc tr-ext bengin+marg 2.1-3cm,3431510,CDM,761,RC,11403,HCPCS,Outpatient,,,3552.91,1776.46,,2664.68,75,,,percent of total billed charges,75% of total billed charges,2664.68,75,,,percent of total billed charges,75% of total billed charges,610.13,100,,,Fee Schedule,100% of CMS OPPS Rate,103.73,102,,,Fee Schedule,102% of WV Medicaid Rate,1006.72,165,,,Fee Schedule,165% of CMS OPPS Rate,632.35,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1752.53,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2403.46,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,3010.58,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,101.7,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,610.13,100,,,Fee Schedule,100% of CMS OPPS Rate,632.35,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,497.41,14,,,percent of total billed charges,14% of total billed charges,101.7,3010.58,
11404- Exc tr-ext benign+marg 3.1-4 cm,3431511,CDM,761,RC,11404,HCPCS,Outpatient,,,8187.18,4093.59,,6140.39,75,,,percent of total billed charges,75% of total billed charges,6140.39,75,,,percent of total billed charges,75% of total billed charges,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,479.67,102,,,Fee Schedule,102% of WV Medicaid Rate,2326.19,165,,,Fee Schedule,165% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4049.52,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5553.61,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6956.46,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,470.26,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1146.21,14,,,percent of total billed charges,14% of total billed charges,470.26,6956.46,
11406- Exc tr-ext bengin+marg >4.0 cm,3431512,CDM,761,RC,11406,HCPCS,Outpatient,,,8187.18,4093.59,,6140.39,75,,,percent of total billed charges,75% of total billed charges,6140.39,75,,,percent of total billed charges,75% of total billed charges,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,479.67,102,,,Fee Schedule,102% of WV Medicaid Rate,2326.19,165,,,Fee Schedule,165% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4049.52,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5553.61,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6956.46,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,470.26,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1146.21,14,,,percent of total billed charges,14% of total billed charges,470.26,6956.46,
11420- Exc h-f-nk-sp benign+marg 0.5/<,3431513,CDM,761,RC,11420,HCPCS,Outpatient,,,8187.18,4093.59,,6140.39,75,,,percent of total billed charges,75% of total billed charges,6140.39,75,,,percent of total billed charges,75% of total billed charges,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,73.15,102,,,Fee Schedule,102% of WV Medicaid Rate,2326.19,165,,,Fee Schedule,165% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4049.52,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5553.61,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6956.46,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,71.72,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1146.21,14,,,percent of total billed charges,14% of total billed charges,71.72,6956.46,
Clinic Excision Benign Lesion 0.5- 11420,4351219,CDM,761,RC,11420,HCPCS,Outpatient,,,8187.18,4093.59,,6140.39,75,,,percent of total billed charges,75% of total billed charges,6140.39,75,,,percent of total billed charges,75% of total billed charges,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,73.15,102,,,Fee Schedule,102% of WV Medicaid Rate,2326.19,165,,,Fee Schedule,165% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4049.52,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5553.61,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6956.46,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,71.72,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1146.21,14,,,percent of total billed charges,14% of total billed charges,71.72,6956.46,
11421- Exc h-f-nk-sp benign+marg 0.6-1,3431514,CDM,761,RC,11421,HCPCS,Outpatient,,,3552.91,1776.46,,2664.68,75,,,percent of total billed charges,75% of total billed charges,2664.68,75,,,percent of total billed charges,75% of total billed charges,610.13,100,,,Fee Schedule,100% of CMS OPPS Rate,85.45,102,,,Fee Schedule,102% of WV Medicaid Rate,1006.72,165,,,Fee Schedule,165% of CMS OPPS Rate,632.35,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1752.53,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2403.46,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,3010.58,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,83.77,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,610.13,100,,,Fee Schedule,100% of CMS OPPS Rate,632.35,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,497.41,14,,,percent of total billed charges,14% of total billed charges,83.77,3010.58,
Clinic Excision Benign Lesion 0.6-1.0-  11421,4351220,CDM,761,RC,11421,HCPCS,Outpatient,,,3552.91,1776.46,,2664.68,75,,,percent of total billed charges,75% of total billed charges,2664.68,75,,,percent of total billed charges,75% of total billed charges,610.13,100,,,Fee Schedule,100% of CMS OPPS Rate,85.45,102,,,Fee Schedule,102% of WV Medicaid Rate,1006.72,165,,,Fee Schedule,165% of CMS OPPS Rate,632.35,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1752.53,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2403.46,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,3010.58,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,83.77,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,610.13,100,,,Fee Schedule,100% of CMS OPPS Rate,632.35,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,497.41,14,,,percent of total billed charges,14% of total billed charges,83.77,3010.58,
11422- Exc h-f-nk-sp benign1.1-2,3431515,CDM,761,RC,11422,HCPCS,Outpatient,,,8187.18,4093.59,,6140.39,75,,,percent of total billed charges,75% of total billed charges,6140.39,75,,,percent of total billed charges,75% of total billed charges,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,94.45,102,,,Fee Schedule,102% of WV Medicaid Rate,2326.19,165,,,Fee Schedule,165% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4049.52,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5553.61,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6956.46,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,92.6,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1146.21,14,,,percent of total billed charges,14% of total billed charges,92.6,6956.46,
Clinic Excision Benign Lesion 1.1-2.0 - 11422,4351221,CDM,761,RC,11422,HCPCS,Outpatient,,,8187.18,4093.59,,6140.39,75,,,percent of total billed charges,75% of total billed charges,6140.39,75,,,percent of total billed charges,75% of total billed charges,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,94.45,102,,,Fee Schedule,102% of WV Medicaid Rate,2326.19,165,,,Fee Schedule,165% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4049.52,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5553.61,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6956.46,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,92.6,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1146.21,14,,,percent of total billed charges,14% of total billed charges,92.6,6956.46,
11423- Exc h-f-nk-sp benign+marg 2.1-3,3431516,CDM,761,RC,11423,HCPCS,Outpatient,,,8187.18,4093.59,,6140.39,75,,,percent of total billed charges,75% of total billed charges,6140.39,75,,,percent of total billed charges,75% of total billed charges,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,102.92,102,,,Fee Schedule,102% of WV Medicaid Rate,2326.19,165,,,Fee Schedule,165% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4049.52,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5553.61,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6956.46,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,100.9,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1146.21,14,,,percent of total billed charges,14% of total billed charges,100.9,6956.46,
Clinic Excision Benign Lesion 2.1-3.0 - 11423,4351222,CDM,761,RC,11423,HCPCS,Outpatient,,,8187.18,4093.59,,6140.39,75,,,percent of total billed charges,75% of total billed charges,6140.39,75,,,percent of total billed charges,75% of total billed charges,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,102.92,102,,,Fee Schedule,102% of WV Medicaid Rate,2326.19,165,,,Fee Schedule,165% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4049.52,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5553.61,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6956.46,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,100.9,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1146.21,14,,,percent of total billed charges,14% of total billed charges,100.9,6956.46,
11424- Exc benign les/see area/3.1-4.0cm,3431517,CDM,761,RC,11424,HCPCS,Outpatient,,,8187.18,4093.59,,6140.39,75,,,percent of total billed charges,75% of total billed charges,6140.39,75,,,percent of total billed charges,75% of total billed charges,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,479.67,102,,,Fee Schedule,102% of WV Medicaid Rate,2326.19,165,,,Fee Schedule,165% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4049.52,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5553.61,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6956.46,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,470.26,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1146.21,14,,,percent of total billed charges,14% of total billed charges,470.26,6956.46,
Clinic Excision Benign Lesion 3.1-4.0 - 11424,4351223,CDM,761,RC,11424,HCPCS,Outpatient,,,8187.18,4093.59,,6140.39,75,,,percent of total billed charges,75% of total billed charges,6140.39,75,,,percent of total billed charges,75% of total billed charges,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,479.67,102,,,Fee Schedule,102% of WV Medicaid Rate,2326.19,165,,,Fee Schedule,165% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4049.52,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5553.61,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6956.46,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,470.26,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1146.21,14,,,percent of total billed charges,14% of total billed charges,470.26,6956.46,
11426- Exc h-f-nk-sp benign+marg >4 cm,3431518,CDM,761,RC,11426,HCPCS,Outpatient,,,14348.96,7174.48,,10761.72,75,,,percent of total billed charges,75% of total billed charges,10761.72,75,,,percent of total billed charges,75% of total billed charges,2428.67,100,,,Fee Schedule,100% of CMS OPPS Rate,803.83,102,,,Fee Schedule,102% of WV Medicaid Rate,4007.32,165,,,Fee Schedule,165% of CMS OPPS Rate,2517.11,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,6976.06,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,9567.11,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,11983.78,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,788.07,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2428.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2517.11,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,2008.85,14,,,percent of total billed charges,14% of total billed charges,788.07,11983.78,
Clinic Excision Benign Lesion over 4.0 - 11426,4351224,CDM,761,RC,11426,HCPCS,Outpatient,,,14348.96,7174.48,,10761.72,75,,,percent of total billed charges,75% of total billed charges,10761.72,75,,,percent of total billed charges,75% of total billed charges,2428.67,100,,,Fee Schedule,100% of CMS OPPS Rate,803.83,102,,,Fee Schedule,102% of WV Medicaid Rate,4007.32,165,,,Fee Schedule,165% of CMS OPPS Rate,2517.11,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,6976.06,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,9567.11,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,11983.78,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,788.07,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2428.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2517.11,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,2008.85,14,,,percent of total billed charges,14% of total billed charges,788.07,11983.78,
11440- Exc face-mm benign+marg 0.5 cm/<,3431519,CDM,761,RC,11440,HCPCS,Outpatient,,,3552.91,1776.46,,2664.68,75,,,percent of total billed charges,75% of total billed charges,2664.68,75,,,percent of total billed charges,75% of total billed charges,610.13,100,,,Fee Schedule,100% of CMS OPPS Rate,85.17,102,,,Fee Schedule,102% of WV Medicaid Rate,1006.72,165,,,Fee Schedule,165% of CMS OPPS Rate,632.35,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1752.53,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2403.46,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,3010.58,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,83.5,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,610.13,100,,,Fee Schedule,100% of CMS OPPS Rate,632.35,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,497.41,14,,,percent of total billed charges,14% of total billed charges,83.5,3010.58,
11441- Exc face-mm benign+marg 0.6-1 cm,3431520,CDM,761,RC,11441,HCPCS,Outpatient,,,3552.91,1776.46,,2664.68,75,,,percent of total billed charges,75% of total billed charges,2664.68,75,,,percent of total billed charges,75% of total billed charges,610.13,100,,,Fee Schedule,100% of CMS OPPS Rate,94.72,102,,,Fee Schedule,102% of WV Medicaid Rate,1006.72,165,,,Fee Schedule,165% of CMS OPPS Rate,632.35,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1752.53,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2403.46,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,3010.58,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,92.86,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,610.13,100,,,Fee Schedule,100% of CMS OPPS Rate,632.35,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,497.41,14,,,percent of total billed charges,14% of total billed charges,92.86,3010.58,
11442- Exc face-mm benign+marg 1.1-2 cm,3431521,CDM,761,RC,11442,HCPCS,Outpatient,,,3552.91,1776.46,,2664.68,75,,,percent of total billed charges,75% of total billed charges,2664.68,75,,,percent of total billed charges,75% of total billed charges,610.13,100,,,Fee Schedule,100% of CMS OPPS Rate,102.37,102,,,Fee Schedule,102% of WV Medicaid Rate,1006.72,165,,,Fee Schedule,165% of CMS OPPS Rate,632.35,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1752.53,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2403.46,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,3010.58,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,100.36,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,610.13,100,,,Fee Schedule,100% of CMS OPPS Rate,632.35,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,497.41,14,,,percent of total billed charges,14% of total billed charges,100.36,3010.58,
11443- Exc face-mm benign+marg 2.1-3 cm,3431522,CDM,761,RC,11443,HCPCS,Outpatient,,,8187.18,4093.59,,6140.39,75,,,percent of total billed charges,75% of total billed charges,6140.39,75,,,percent of total billed charges,75% of total billed charges,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,112.74,102,,,Fee Schedule,102% of WV Medicaid Rate,2326.19,165,,,Fee Schedule,165% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4049.52,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5553.61,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6956.46,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,110.53,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1146.21,14,,,percent of total billed charges,14% of total billed charges,110.53,6956.46,
11444- Exc/benign les/see area/3.1-4.0cm,3431523,CDM,761,RC,11444,HCPCS,Outpatient,,,8187.18,4093.59,,6140.39,75,,,percent of total billed charges,75% of total billed charges,6140.39,75,,,percent of total billed charges,75% of total billed charges,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,479.67,102,,,Fee Schedule,102% of WV Medicaid Rate,2326.19,165,,,Fee Schedule,165% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4049.52,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5553.61,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6956.46,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,470.26,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1146.21,14,,,percent of total billed charges,14% of total billed charges,470.26,6956.46,
11446- Exc benign lesion/see area/>4.0cm,3431524,CDM,761,RC,11446,HCPCS,Outpatient,,,14348.96,7174.48,,10761.72,75,,,percent of total billed charges,75% of total billed charges,10761.72,75,,,percent of total billed charges,75% of total billed charges,2428.67,100,,,Fee Schedule,100% of CMS OPPS Rate,803.83,102,,,Fee Schedule,102% of WV Medicaid Rate,4007.32,165,,,Fee Schedule,165% of CMS OPPS Rate,2517.11,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,6976.06,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,9567.11,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,11983.78,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,788.07,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2428.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2517.11,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,2008.85,14,,,percent of total billed charges,14% of total billed charges,788.07,11983.78,
11450- Exc/hidradenitis/axilla/smp/im rpr,3431525,CDM,761,RC,11450,HCPCS,Outpatient,,,14348.96,7174.48,,10761.72,75,,,percent of total billed charges,75% of total billed charges,10761.72,75,,,percent of total billed charges,75% of total billed charges,2428.67,100,,,Fee Schedule,100% of CMS OPPS Rate,803.83,102,,,Fee Schedule,102% of WV Medicaid Rate,4007.32,165,,,Fee Schedule,165% of CMS OPPS Rate,2517.11,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,6976.06,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,9567.11,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,11983.78,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,788.07,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2428.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2517.11,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,2008.85,14,,,percent of total billed charges,14% of total billed charges,788.07,11983.78,
11451- Exc/hidradenitis/axilla/comp rpr,3431526,CDM,761,RC,11451,HCPCS,Outpatient,,,14348.96,7174.48,,10761.72,75,,,percent of total billed charges,75% of total billed charges,10761.72,75,,,percent of total billed charges,75% of total billed charges,2428.67,100,,,Fee Schedule,100% of CMS OPPS Rate,803.83,102,,,Fee Schedule,102% of WV Medicaid Rate,4007.32,165,,,Fee Schedule,165% of CMS OPPS Rate,2517.11,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,6976.06,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,9567.11,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,11983.78,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,788.07,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2428.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2517.11,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,2008.85,14,,,percent of total billed charges,14% of total billed charges,788.07,11983.78,
11462- Exc/hidradenitis/ingun/smp/imt rpr,3431527,CDM,761,RC,11462,HCPCS,Outpatient,,,14348.96,7174.48,,10761.72,75,,,percent of total billed charges,75% of total billed charges,10761.72,75,,,percent of total billed charges,75% of total billed charges,2428.67,100,,,Fee Schedule,100% of CMS OPPS Rate,803.83,102,,,Fee Schedule,102% of WV Medicaid Rate,4007.32,165,,,Fee Schedule,165% of CMS OPPS Rate,2517.11,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,6976.06,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,9567.11,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,11983.78,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,788.07,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2428.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2517.11,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,2008.85,14,,,percent of total billed charges,14% of total billed charges,788.07,11983.78,
11463- Exc/hidradenitis/inguinal/comp rpr,3431528,CDM,761,RC,11463,HCPCS,Outpatient,,,14348.96,7174.48,,10761.72,75,,,percent of total billed charges,75% of total billed charges,10761.72,75,,,percent of total billed charges,75% of total billed charges,2428.67,100,,,Fee Schedule,100% of CMS OPPS Rate,803.83,102,,,Fee Schedule,102% of WV Medicaid Rate,4007.32,165,,,Fee Schedule,165% of CMS OPPS Rate,2517.11,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,6976.06,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,9567.11,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,11983.78,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,788.07,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2428.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2517.11,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,2008.85,14,,,percent of total billed charges,14% of total billed charges,788.07,11983.78,
11470- Exc hidradenit/perianal/neal/sp/in,3431529,CDM,761,RC,11470,HCPCS,Outpatient,,,14348.96,7174.48,,10761.72,75,,,percent of total billed charges,75% of total billed charges,10761.72,75,,,percent of total billed charges,75% of total billed charges,2428.67,100,,,Fee Schedule,100% of CMS OPPS Rate,803.83,102,,,Fee Schedule,102% of WV Medicaid Rate,4007.32,165,,,Fee Schedule,165% of CMS OPPS Rate,2517.11,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,6976.06,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,9567.11,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,11983.78,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,788.07,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2428.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2517.11,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,2008.85,14,,,percent of total billed charges,14% of total billed charges,788.07,11983.78,
11471- Exc hidradenitis/perianal/neal/com,3431530,CDM,761,RC,11471,HCPCS,Outpatient,,,14348.96,7174.48,,10761.72,75,,,percent of total billed charges,75% of total billed charges,10761.72,75,,,percent of total billed charges,75% of total billed charges,2428.67,100,,,Fee Schedule,100% of CMS OPPS Rate,803.83,102,,,Fee Schedule,102% of WV Medicaid Rate,4007.32,165,,,Fee Schedule,165% of CMS OPPS Rate,2517.11,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,6976.06,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,9567.11,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,11983.78,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,788.07,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2428.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2517.11,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,2008.85,14,,,percent of total billed charges,14% of total billed charges,788.07,11983.78,
11600- Exc/malig/trunk/arms/legs <0.5cm,3431531,CDM,761,RC,11600,HCPCS,Outpatient,,,3552.91,1776.46,,2664.68,75,,,percent of total billed charges,75% of total billed charges,2664.68,75,,,percent of total billed charges,75% of total billed charges,610.13,100,,,Fee Schedule,100% of CMS OPPS Rate,111.11,102,,,Fee Schedule,102% of WV Medicaid Rate,1006.72,165,,,Fee Schedule,165% of CMS OPPS Rate,632.35,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1752.53,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2403.46,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,3010.58,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,108.93,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,610.13,100,,,Fee Schedule,100% of CMS OPPS Rate,632.35,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,497.41,14,,,percent of total billed charges,14% of total billed charges,108.93,3010.58,
11601- Exc malig/trunk/arm/leg 0.6-1.0cm,3431532,CDM,761,RC,11601,HCPCS,Outpatient,,,3552.91,1776.46,,2664.68,75,,,percent of total billed charges,75% of total billed charges,2664.68,75,,,percent of total billed charges,75% of total billed charges,610.13,100,,,Fee Schedule,100% of CMS OPPS Rate,122.57,102,,,Fee Schedule,102% of WV Medicaid Rate,1006.72,165,,,Fee Schedule,165% of CMS OPPS Rate,632.35,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1752.53,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2403.46,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,3010.58,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,120.17,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,610.13,100,,,Fee Schedule,100% of CMS OPPS Rate,632.35,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,497.41,14,,,percent of total billed charges,14% of total billed charges,120.17,3010.58,
11602- Exc tr-ext mal+marg 1.1-2 cm,3431533,CDM,761,RC,11602,HCPCS,Outpatient,,,2013.58,1006.79,,1510.19,75,,,percent of total billed charges,75% of total billed charges,1510.19,75,,,percent of total billed charges,75% of total billed charges,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,129.4,102,,,Fee Schedule,102% of WV Medicaid Rate,578.72,165,,,Fee Schedule,165% of CMS OPPS Rate,363.51,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1007.47,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1381.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1730.67,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,126.86,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,363.51,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,281.9,14,,,percent of total billed charges,14% of total billed charges,126.86,1730.67,
11603- Exc tr-ext mal+marg 2.1-3 cm,3431534,CDM,761,RC,11603,HCPCS,Outpatient,,,3552.91,1776.46,,2664.68,75,,,percent of total billed charges,75% of total billed charges,2664.68,75,,,percent of total billed charges,75% of total billed charges,610.13,100,,,Fee Schedule,100% of CMS OPPS Rate,139.5,102,,,Fee Schedule,102% of WV Medicaid Rate,1006.72,165,,,Fee Schedule,165% of CMS OPPS Rate,632.35,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1752.53,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2403.46,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,3010.58,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,136.76,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,610.13,100,,,Fee Schedule,100% of CMS OPPS Rate,632.35,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,497.41,14,,,percent of total billed charges,14% of total billed charges,136.76,3010.58,
11604- Exc tr-ext mal+marg 3.1-4 cm,3431535,CDM,761,RC,11604,HCPCS,Outpatient,,,3552.91,1776.46,,2664.68,75,,,percent of total billed charges,75% of total billed charges,2664.68,75,,,percent of total billed charges,75% of total billed charges,610.13,100,,,Fee Schedule,100% of CMS OPPS Rate,254,102,,,Fee Schedule,102% of WV Medicaid Rate,1006.72,165,,,Fee Schedule,165% of CMS OPPS Rate,632.35,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1752.53,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2403.46,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,3010.58,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,249.02,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,610.13,100,,,Fee Schedule,100% of CMS OPPS Rate,632.35,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,497.41,14,,,percent of total billed charges,14% of total billed charges,249.02,3010.58,
11606- Exc tr-ext mal+marg >4 cm,3431536,CDM,761,RC,11606,HCPCS,Outpatient,,,8187.18,4093.59,,6140.39,75,,,percent of total billed charges,75% of total billed charges,6140.39,75,,,percent of total billed charges,75% of total billed charges,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,479.67,102,,,Fee Schedule,102% of WV Medicaid Rate,2326.19,165,,,Fee Schedule,165% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4049.52,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5553.61,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6956.46,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,470.26,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1146.21,14,,,percent of total billed charges,14% of total billed charges,470.26,6956.46,
11620- Exc/malig/see area/0.5cm or less,3431537,CDM,761,RC,11620,HCPCS,Outpatient,,,8187.18,4093.59,,6140.39,75,,,percent of total billed charges,75% of total billed charges,6140.39,75,,,percent of total billed charges,75% of total billed charges,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,111.37,102,,,Fee Schedule,102% of WV Medicaid Rate,2326.19,165,,,Fee Schedule,165% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4049.52,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5553.61,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6956.46,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,109.19,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1146.21,14,,,percent of total billed charges,14% of total billed charges,109.19,6956.46,
11621- Exc H-F-Nk-Sp Mlg+Marg 0.6-1.0 Cm,3431538,CDM,761,RC,11621,HCPCS,Outpatient,,,3552.91,1776.46,,2664.68,75,,,percent of total billed charges,75% of total billed charges,2664.68,75,,,percent of total billed charges,75% of total billed charges,610.13,100,,,Fee Schedule,100% of CMS OPPS Rate,122.85,102,,,Fee Schedule,102% of WV Medicaid Rate,1006.72,165,,,Fee Schedule,165% of CMS OPPS Rate,632.35,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1752.53,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2403.46,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,3010.58,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,120.44,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,610.13,100,,,Fee Schedule,100% of CMS OPPS Rate,632.35,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,497.41,14,,,percent of total billed charges,14% of total billed charges,120.44,3010.58,
11622- Exc s/n/h/f/g mal+mrg 1.1-2,3431539,CDM,761,RC,11622,HCPCS,Outpatient,,,3552.91,1776.46,,2664.68,75,,,percent of total billed charges,75% of total billed charges,2664.68,75,,,percent of total billed charges,75% of total billed charges,610.13,100,,,Fee Schedule,100% of CMS OPPS Rate,131.58,102,,,Fee Schedule,102% of WV Medicaid Rate,1006.72,165,,,Fee Schedule,165% of CMS OPPS Rate,632.35,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1752.53,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2403.46,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,3010.58,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,129,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,610.13,100,,,Fee Schedule,100% of CMS OPPS Rate,632.35,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,497.41,14,,,percent of total billed charges,14% of total billed charges,129,3010.58,
11623- Exc H-F-Nk-Sp Mlg+Marg 2.1-3 Cm,3431540,CDM,761,RC,11623,HCPCS,Outpatient,,,8187.18,4093.59,,6140.39,75,,,percent of total billed charges,75% of total billed charges,6140.39,75,,,percent of total billed charges,75% of total billed charges,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,144.41,102,,,Fee Schedule,102% of WV Medicaid Rate,2326.19,165,,,Fee Schedule,165% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4049.52,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5553.61,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6956.46,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,141.58,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1146.21,14,,,percent of total billed charges,14% of total billed charges,141.58,6956.46,
11624- Exc s/n/h/f/g mal+mrg 3.1-4,3431541,CDM,761,RC,11624,HCPCS,Outpatient,,,8187.18,4093.59,,6140.39,75,,,percent of total billed charges,75% of total billed charges,6140.39,75,,,percent of total billed charges,75% of total billed charges,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,479.67,102,,,Fee Schedule,102% of WV Medicaid Rate,2326.19,165,,,Fee Schedule,165% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4049.52,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5553.61,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6956.46,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,470.26,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1146.21,14,,,percent of total billed charges,14% of total billed charges,470.26,6956.46,
11626- Exc s/n/h/f/g mal+mrg >4 cm,3431542,CDM,761,RC,11626,HCPCS,Outpatient,,,14348.96,7174.48,,10761.72,75,,,percent of total billed charges,75% of total billed charges,10761.72,75,,,percent of total billed charges,75% of total billed charges,2428.67,100,,,Fee Schedule,100% of CMS OPPS Rate,803.83,102,,,Fee Schedule,102% of WV Medicaid Rate,4007.32,165,,,Fee Schedule,165% of CMS OPPS Rate,2517.11,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,6976.06,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,9567.11,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,11983.78,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,788.07,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2428.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2517.11,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,2008.85,14,,,percent of total billed charges,14% of total billed charges,788.07,11983.78,
11640- Exc/malg/fac/ear/lid/nos/lip<0.5cm,3431543,CDM,761,RC,11640,HCPCS,Outpatient,,,3552.91,1776.46,,2664.68,75,,,percent of total billed charges,75% of total billed charges,2664.68,75,,,percent of total billed charges,75% of total billed charges,610.13,100,,,Fee Schedule,100% of CMS OPPS Rate,114.38,102,,,Fee Schedule,102% of WV Medicaid Rate,1006.72,165,,,Fee Schedule,165% of CMS OPPS Rate,632.35,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1752.53,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2403.46,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,3010.58,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,112.14,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,610.13,100,,,Fee Schedule,100% of CMS OPPS Rate,632.35,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,497.41,14,,,percent of total billed charges,14% of total billed charges,112.14,3010.58,
11641- Exc f/e/e/n/l mal+mrg 0.6-1,3431544,CDM,761,RC,11641,HCPCS,Outpatient,,,3552.91,1776.46,,2664.68,75,,,percent of total billed charges,75% of total billed charges,2664.68,75,,,percent of total billed charges,75% of total billed charges,610.13,100,,,Fee Schedule,100% of CMS OPPS Rate,126.11,102,,,Fee Schedule,102% of WV Medicaid Rate,1006.72,165,,,Fee Schedule,165% of CMS OPPS Rate,632.35,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1752.53,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2403.46,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,3010.58,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,123.64,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,610.13,100,,,Fee Schedule,100% of CMS OPPS Rate,632.35,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,497.41,14,,,percent of total billed charges,14% of total billed charges,123.64,3010.58,
11642- Exc Face-Mm Malig+Marg 1.1-2,3431545,CDM,761,RC,11642,HCPCS,Outpatient,,,3552.91,1776.46,,2664.68,75,,,percent of total billed charges,75% of total billed charges,2664.68,75,,,percent of total billed charges,75% of total billed charges,610.13,100,,,Fee Schedule,100% of CMS OPPS Rate,137.04,102,,,Fee Schedule,102% of WV Medicaid Rate,1006.72,165,,,Fee Schedule,165% of CMS OPPS Rate,632.35,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1752.53,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2403.46,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,3010.58,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,134.35,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,610.13,100,,,Fee Schedule,100% of CMS OPPS Rate,632.35,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,497.41,14,,,percent of total billed charges,14% of total billed charges,134.35,3010.58,
11643- Exc f/e/e/n/l mal+mrg 2.1-3,3431546,CDM,761,RC,11643,HCPCS,Outpatient,,,8187.18,4093.59,,6140.39,75,,,percent of total billed charges,75% of total billed charges,6140.39,75,,,percent of total billed charges,75% of total billed charges,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,150.14,102,,,Fee Schedule,102% of WV Medicaid Rate,2326.19,165,,,Fee Schedule,165% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4049.52,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5553.61,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6956.46,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,147.2,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1146.21,14,,,percent of total billed charges,14% of total billed charges,147.2,6956.46,
11644- Exc Face-Mm Malig+Marg 3.1-4.0,3431547,CDM,761,RC,11644,HCPCS,Outpatient,,,8187.18,4093.59,,6140.39,75,,,percent of total billed charges,75% of total billed charges,6140.39,75,,,percent of total billed charges,75% of total billed charges,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,479.67,102,,,Fee Schedule,102% of WV Medicaid Rate,2326.19,165,,,Fee Schedule,165% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4049.52,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5553.61,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6956.46,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,470.26,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1146.21,14,,,percent of total billed charges,14% of total billed charges,470.26,6956.46,
11646- Exc/malig/fac/ear/lid/nose/lip>4cm,3431548,CDM,761,RC,11646,HCPCS,Outpatient,,,14348.96,7174.48,,10761.72,75,,,percent of total billed charges,75% of total billed charges,10761.72,75,,,percent of total billed charges,75% of total billed charges,2428.67,100,,,Fee Schedule,100% of CMS OPPS Rate,803.83,102,,,Fee Schedule,102% of WV Medicaid Rate,4007.32,165,,,Fee Schedule,165% of CMS OPPS Rate,2517.11,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,6976.06,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,9567.11,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,11983.78,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,788.07,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2428.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2517.11,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,2008.85,14,,,percent of total billed charges,14% of total billed charges,788.07,11983.78,
11721 - DEB NAIL 6 OR MORE Profee,3435765,CDM,510,RC,11721,HCPCS,Outpatient,,,308.88,154.44,,231.66,75,,,percent of total billed charges,75% of total billed charges,231.66,75,,,percent of total billed charges,75% of total billed charges,54.04,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,89.16,165,,,Fee Schedule,165% of CMS OPPS Rate,56,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,155.22,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,212.87,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,266.65,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,54.04,100,,,Fee Schedule,100% of CMS OPPS Rate,56,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,43.24,14,,,percent of total billed charges,14% of total billed charges,43.24,266.65,
11721- Debride/nails/any method/6 or more,3431551,CDM,761,RC,11721,HCPCS,Outpatient,,,308.88,154.44,,231.66,75,,,percent of total billed charges,75% of total billed charges,231.66,75,,,percent of total billed charges,75% of total billed charges,54.04,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,89.16,165,,,Fee Schedule,165% of CMS OPPS Rate,56,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,155.22,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,212.87,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,266.65,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,54.04,100,,,Fee Schedule,100% of CMS OPPS Rate,56,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,43.24,14,,,percent of total billed charges,14% of total billed charges,43.24,266.65,
11721 Debridement Nail Any Method 6/>,3549202,CDM,761,RC,11721,HCPCS,Outpatient,,,308.88,154.44,,231.66,75,,,percent of total billed charges,75% of total billed charges,231.66,75,,,percent of total billed charges,75% of total billed charges,54.04,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,89.16,165,,,Fee Schedule,165% of CMS OPPS Rate,56,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,155.22,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,212.87,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,266.65,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,54.04,100,,,Fee Schedule,100% of CMS OPPS Rate,56,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,43.24,14,,,percent of total billed charges,14% of total billed charges,43.24,266.65,
11730 - Nail avulsion; single,4023138,CDM,761,RC,11730,HCPCS,Outpatient,,,1010.98,505.49,,758.24,75,,,percent of total billed charges,75% of total billed charges,758.24,75,,,percent of total billed charges,75% of total billed charges,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,280.12,165,,,Fee Schedule,165% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,487.65,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,668.78,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,837.71,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,141.54,14,,,percent of total billed charges,14% of total billed charges,141.54,837.71,
11730- Avulsion/nail plate/simple/single,3431552,CDM,761,RC,11730,HCPCS,Outpatient,,,1010.98,505.49,,758.24,75,,,percent of total billed charges,75% of total billed charges,758.24,75,,,percent of total billed charges,75% of total billed charges,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,280.12,165,,,Fee Schedule,165% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,487.65,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,668.78,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,837.71,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,141.54,14,,,percent of total billed charges,14% of total billed charges,141.54,837.71,
11732 - Nail avulsion; each additional,4023139,CDM,761,RC,11732,HCPCS,Outpatient,,,395.34,197.67,,296.51,75,,,percent of total billed charges,75% of total billed charges,296.51,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55.35,14,,,percent of total billed charges,14% of total billed charges,55.35,296.51,
11732- Avulsion/nail plate/simple/ea add,3431553,CDM,761,RC,11732,HCPCS,Outpatient,,,395.34,197.67,,296.51,75,,,percent of total billed charges,75% of total billed charges,296.51,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55.35,14,,,percent of total billed charges,14% of total billed charges,55.35,296.51,
11750- Excise/nail/matrix/perm removal,3431555,CDM,761,RC,11750,HCPCS,Outpatient,,,141.35,70.68,,106.01,75,,,percent of total billed charges,75% of total billed charges,106.01,75,,,percent of total billed charges,75% of total billed charges,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,83.53,102,,,Fee Schedule,102% of WV Medicaid Rate,578.72,165,,,Fee Schedule,165% of CMS OPPS Rate,363.51,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1007.47,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1381.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1730.67,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,81.89,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,363.51,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,19.79,14,,,percent of total billed charges,14% of total billed charges,19.79,1730.67,
11900- Intralesional injection/</=7,3431563,CDM,761,RC,11900,HCPCS,Outpatient,,,1010.98,505.49,,758.24,75,,,percent of total billed charges,75% of total billed charges,758.24,75,,,percent of total billed charges,75% of total billed charges,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,280.12,165,,,Fee Schedule,165% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,487.65,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,668.78,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,837.71,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,141.54,14,,,percent of total billed charges,14% of total billed charges,141.54,837.71,
11901- Inj/intralesional/> 7 lesions,3431564,CDM,761,RC,11901,HCPCS,Outpatient,,,1010.98,505.49,,758.24,75,,,percent of total billed charges,75% of total billed charges,758.24,75,,,percent of total billed charges,75% of total billed charges,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,280.12,165,,,Fee Schedule,165% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,487.65,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,668.78,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,837.71,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,141.54,14,,,percent of total billed charges,14% of total billed charges,141.54,837.71,
11950 - Subcutaneous injection filling material,3572729,CDM,983,RC,11950,HCPCS,Outpatient,,,67.12,33.56,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
11950- Subq inj/fill material/1cc or <,3431566,CDM,761,RC,11950,HCPCS,Outpatient,,,1010.98,505.49,,758.24,75,,,percent of total billed charges,75% of total billed charges,758.24,75,,,percent of total billed charges,75% of total billed charges,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,37.94,102,,,Fee Schedule,102% of WV Medicaid Rate,280.12,165,,,Fee Schedule,165% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,487.65,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,668.77,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,837.71,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,37.2,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,141.54,14,,,percent of total billed charges,14% of total billed charges,37.2,837.71,
11951- Subq inj/fill material/1.1-5.0 cc,3431567,CDM,761,RC,11951,HCPCS,Outpatient,,,3171.52,1585.76,,2378.64,75,,,percent of total billed charges,75% of total billed charges,2378.64,75,,,percent of total billed charges,75% of total billed charges,546.17,100,,,Fee Schedule,100% of CMS OPPS Rate,48.32,102,,,Fee Schedule,102% of WV Medicaid Rate,901.2,165,,,Fee Schedule,165% of CMS OPPS Rate,566.07,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1568.84,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2151.55,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,2695.04,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,47.37,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,546.17,100,,,Fee Schedule,100% of CMS OPPS Rate,566.07,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,444.01,14,,,percent of total billed charges,14% of total billed charges,47.37,2695.04,
11980- Hormone pellet implant/subq,3431570,CDM,510,RC,11980,HCPCS,Outpatient,,,2037.53,1018.77,,1528.15,75,,,percent of total billed charges,75% of total billed charges,1528.15,75,,,percent of total billed charges,75% of total billed charges,354.97,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,585.71,165,,,Fee Schedule,165% of CMS OPPS Rate,367.9,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1019.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1398.33,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1751.55,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,354.97,100,,,Fee Schedule,100% of CMS OPPS Rate,367.9,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,285.25,14,,,percent of total billed charges,14% of total billed charges,285.25,1751.55,
11981- Insert/drug delivery implant,3431571,CDM,510,RC,11981,HCPCS,Outpatient,,,89.11,44.56,,66.83,75,,,percent of total billed charges,75% of total billed charges,66.83,75,,,percent of total billed charges,75% of total billed charges,109.16,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,180.11,165,,,Fee Schedule,165% of CMS OPPS Rate,113.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,313.55,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,430.01,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,538.63,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,109.16,100,,,Fee Schedule,100% of CMS OPPS Rate,113.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,12.48,14,,,percent of total billed charges,14% of total billed charges,12.48,538.63,
11982- Remove/drug delivery implant,3431572,CDM,510,RC,11982,HCPCS,Outpatient,,,1819.23,909.62,,1364.42,75,,,percent of total billed charges,75% of total billed charges,1364.42,75,,,percent of total billed charges,75% of total billed charges,354.97,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,585.71,165,,,Fee Schedule,165% of CMS OPPS Rate,367.9,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1019.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1398.33,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1751.55,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,354.97,100,,,Fee Schedule,100% of CMS OPPS Rate,367.9,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,254.69,14,,,percent of total billed charges,14% of total billed charges,254.69,1751.55,
12001 - SIMPLE REPAIR SCALP/NECK/AX/GENIT/TRUNK 2.5CM/<,4037467,CDM,510,RC,12001,HCPCS,Outpatient,,,1010.98,505.49,,758.24,75,,,percent of total billed charges,75% of total billed charges,758.24,75,,,percent of total billed charges,75% of total billed charges,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,280.12,165,,,Fee Schedule,165% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,487.65,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,668.78,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,837.71,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,141.54,14,,,percent of total billed charges,14% of total billed charges,141.54,837.71,
12002- Rep Superfic Wound 2.6-7.5Cm,3431575,CDM,761,RC,12002,HCPCS,Outpatient,,,1010.98,505.49,,758.24,75,,,percent of total billed charges,75% of total billed charges,758.24,75,,,percent of total billed charges,75% of total billed charges,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,280.12,165,,,Fee Schedule,165% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,487.65,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,668.78,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,837.71,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,141.54,14,,,percent of total billed charges,14% of total billed charges,141.54,837.71,
12004- Rep Superific Wound 7.6-12.5 cm,3431576,CDM,761,RC,12004,HCPCS,Outpatient,,,1010.98,505.49,,758.24,75,,,percent of total billed charges,75% of total billed charges,758.24,75,,,percent of total billed charges,75% of total billed charges,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,280.12,165,,,Fee Schedule,165% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,487.65,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,668.78,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,837.71,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,141.54,14,,,percent of total billed charges,14% of total billed charges,141.54,837.71,
12005- Rep Superfic Wound 12.6-20.0Cm,3431577,CDM,761,RC,12005,HCPCS,Outpatient,,,2013.58,1006.79,,1510.19,75,,,percent of total billed charges,75% of total billed charges,1510.19,75,,,percent of total billed charges,75% of total billed charges,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,141.09,102,,,Fee Schedule,102% of WV Medicaid Rate,578.73,165,,,Fee Schedule,165% of CMS OPPS Rate,363.52,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1007.47,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1381.67,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1730.68,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,138.32,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,363.52,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,281.9,14,,,percent of total billed charges,14% of total billed charges,138.32,1730.68,
"12006- Simple Repair, scalp/neck/axillae/trunk/genital/extrem, 2.5 - 7.5 cm",3428737,CDM,510,RC,12006,HCPCS,Outpatient,,,2013.58,1006.79,,1510.19,75,,,percent of total billed charges,75% of total billed charges,1510.19,75,,,percent of total billed charges,75% of total billed charges,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,141.09,102,,,Fee Schedule,102% of WV Medicaid Rate,578.73,165,,,Fee Schedule,165% of CMS OPPS Rate,363.52,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1007.47,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1381.67,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1730.68,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,138.32,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,363.52,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,281.9,14,,,percent of total billed charges,14% of total billed charges,138.32,1730.68,
12007- Smpl rpr/scalp/neck/ax/ext genit/trnk/extrem/inc hnd/ft/>30cm,3431578,CDM,761,RC,12007,HCPCS,Outpatient,,,1010.98,505.49,,758.24,75,,,percent of total billed charges,75% of total billed charges,758.24,75,,,percent of total billed charges,75% of total billed charges,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,73.31,102,,,Fee Schedule,102% of WV Medicaid Rate,280.12,165,,,Fee Schedule,165% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,487.65,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,668.77,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,837.71,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,71.87,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,141.54,14,,,percent of total billed charges,14% of total billed charges,71.87,837.71,
12011-EYE RPR SPR WND FACE <2.5CM,3428738,CDM,510,RC,12011,HCPCS,Outpatient,,,1010.98,505.49,,758.24,75,,,percent of total billed charges,75% of total billed charges,758.24,75,,,percent of total billed charges,75% of total billed charges,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,280.12,165,,,Fee Schedule,165% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,487.65,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,668.78,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,837.71,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,141.54,14,,,percent of total billed charges,14% of total billed charges,141.54,837.71,
12011-OCC EYE RPR SPR WND FACE <2.5CM,3536972,CDM,983,RC,12011,HCPCS,Outpatient,,,790.68,395.34,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
12013- Rep Superfic Wounds 2.6-5.0Cm,3431580,CDM,761,RC,12013,HCPCS,Outpatient,,,1010.98,505.49,,758.24,75,,,percent of total billed charges,75% of total billed charges,758.24,75,,,percent of total billed charges,75% of total billed charges,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,280.12,165,,,Fee Schedule,165% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,487.65,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,668.78,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,837.71,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,141.54,14,,,percent of total billed charges,14% of total billed charges,141.54,837.71,
12014 - Simple repair of superficial wound of eyelid,3428739,CDM,983,RC,12014,HCPCS,Outpatient,,,163.46,81.73,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
12015- Rep Superfic Wounds 7.6-12.5Cm,3431581,CDM,761,RC,12015,HCPCS,Outpatient,,,1010.98,505.49,,758.24,75,,,percent of total billed charges,75% of total billed charges,758.24,75,,,percent of total billed charges,75% of total billed charges,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,73.31,102,,,Fee Schedule,102% of WV Medicaid Rate,280.12,165,,,Fee Schedule,165% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,487.65,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,668.78,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,837.71,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,71.87,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,141.54,14,,,percent of total billed charges,14% of total billed charges,71.87,837.71,
12016- Smp rp fac/ear/no/lip/lid 12.6-20,3428740,CDM,510,RC,12016,HCPCS,Outpatient,,,2013.58,1006.79,,1510.19,75,,,percent of total billed charges,75% of total billed charges,1510.19,75,,,percent of total billed charges,75% of total billed charges,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,141.09,102,,,Fee Schedule,102% of WV Medicaid Rate,578.73,165,,,Fee Schedule,165% of CMS OPPS Rate,363.52,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1007.47,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1381.67,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1730.68,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,138.32,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,363.52,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,281.9,14,,,percent of total billed charges,14% of total billed charges,138.32,1730.68,
12018- Smpl rpr/face/ear/lid/nose/lip/>30.0cm,3431582,CDM,761,RC,12018,HCPCS,Outpatient,,,1010.98,505.49,,758.24,75,,,percent of total billed charges,75% of total billed charges,758.24,75,,,percent of total billed charges,75% of total billed charges,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,73.31,102,,,Fee Schedule,102% of WV Medicaid Rate,280.12,165,,,Fee Schedule,165% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,487.65,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,668.78,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,837.71,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,71.87,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,141.54,14,,,percent of total billed charges,14% of total billed charges,71.87,837.71,
12020 - Treatment of superficial wound dehiscence; simple cl,4231108,CDM,510,RC,12020,HCPCS,Outpatient,,,3171.52,1585.76,,2378.64,75,,,percent of total billed charges,75% of total billed charges,2378.64,75,,,percent of total billed charges,75% of total billed charges,546.17,100,,,Fee Schedule,100% of CMS OPPS Rate,213.77,102,,,Fee Schedule,102% of WV Medicaid Rate,901.2,165,,,Fee Schedule,165% of CMS OPPS Rate,566.07,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1568.84,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2151.55,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,2695.04,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,209.58,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,546.17,100,,,Fee Schedule,100% of CMS OPPS Rate,566.07,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,444.01,14,,,percent of total billed charges,14% of total billed charges,209.58,2695.04,
12020 -OCC CLOSURE OF SPLIT WOUND,3568838,CDM,983,RC,12020,HCPCS,Outpatient,,,273.19,136.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
12020- Tx superfic wnd dehise/smp close,3431583,CDM,761,RC,12020,HCPCS,Outpatient,,,3171.52,1585.76,,2378.64,75,,,percent of total billed charges,75% of total billed charges,2378.64,75,,,percent of total billed charges,75% of total billed charges,546.17,100,,,Fee Schedule,100% of CMS OPPS Rate,213.77,102,,,Fee Schedule,102% of WV Medicaid Rate,901.2,165,,,Fee Schedule,165% of CMS OPPS Rate,566.07,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1568.84,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2151.55,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,2695.04,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,209.58,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,546.17,100,,,Fee Schedule,100% of CMS OPPS Rate,566.07,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,444.01,14,,,percent of total billed charges,14% of total billed charges,209.58,2695.04,
12021- Tx superficial wnd dehise/smp/pack,3431584,CDM,761,RC,12021,HCPCS,Outpatient,,,2013.58,1006.79,,1510.19,75,,,percent of total billed charges,75% of total billed charges,1510.19,75,,,percent of total billed charges,75% of total billed charges,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,141.09,102,,,Fee Schedule,102% of WV Medicaid Rate,578.72,165,,,Fee Schedule,165% of CMS OPPS Rate,363.51,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1007.47,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1381.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1730.67,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,138.32,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,363.51,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,281.9,14,,,percent of total billed charges,14% of total billed charges,138.32,1730.67,
12031- Int rp scalp/ax/trunk/ext 2.5 or <,3428743,CDM,761,RC,12031,HCPCS,Outpatient,,,2013.58,1006.79,,1510.19,75,,,percent of total billed charges,75% of total billed charges,1510.19,75,,,percent of total billed charges,75% of total billed charges,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,141.09,102,,,Fee Schedule,102% of WV Medicaid Rate,578.72,165,,,Fee Schedule,165% of CMS OPPS Rate,363.51,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1007.47,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1381.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1730.67,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,138.32,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,363.51,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,281.9,14,,,percent of total billed charges,14% of total billed charges,138.32,1730.67,
"12032- Intermed Rpr, Scalp, Axillae, Trunk, Extremities 2.6-7.5cm",3431585,CDM,761,RC,12032,HCPCS,Outpatient,,,2013.58,1006.79,,1510.19,75,,,percent of total billed charges,75% of total billed charges,1510.19,75,,,percent of total billed charges,75% of total billed charges,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,141.09,102,,,Fee Schedule,102% of WV Medicaid Rate,578.72,165,,,Fee Schedule,165% of CMS OPPS Rate,363.51,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1007.47,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1381.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1730.67,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,138.32,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,363.51,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,281.9,14,,,percent of total billed charges,14% of total billed charges,138.32,1730.67,
12034- Itmed rpr/scalp/ax/trnk/extrem/exclu hnd/ft/7.6-12.5c,3431586,CDM,761,RC,12034,HCPCS,Outpatient,,,2013.58,1006.79,,1510.19,75,,,percent of total billed charges,75% of total billed charges,1510.19,75,,,percent of total billed charges,75% of total billed charges,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,141.09,102,,,Fee Schedule,102% of WV Medicaid Rate,578.72,165,,,Fee Schedule,165% of CMS OPPS Rate,363.51,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1007.47,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1381.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1730.67,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,138.32,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,363.51,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,281.9,14,,,percent of total billed charges,14% of total billed charges,138.32,1730.67,
12035- Int rp scalp/ax/trunk/ext 12.6-20,3428744,CDM,510,RC,12035,HCPCS,Outpatient,,,2013.58,1006.79,,1510.19,75,,,percent of total billed charges,75% of total billed charges,1510.19,75,,,percent of total billed charges,75% of total billed charges,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,141.09,102,,,Fee Schedule,102% of WV Medicaid Rate,578.72,165,,,Fee Schedule,165% of CMS OPPS Rate,363.51,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1007.47,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1381.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1730.67,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,138.32,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,363.51,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,281.9,14,,,percent of total billed charges,14% of total billed charges,138.32,1730.67,
"12037 - Repair, intermediate, wounds of scalp, axillae, trunk and/or extremities (excluding hands an",3715279,CDM,510,RC,12037,HCPCS,Outpatient,,,9208.91,4604.46,,6906.68,75,,,percent of total billed charges,75% of total billed charges,6906.68,75,,,percent of total billed charges,75% of total billed charges,1622.59,100,,,Fee Schedule,100% of CMS OPPS Rate,699.11,102,,,Fee Schedule,102% of WV Medicaid Rate,2677.27,165,,,Fee Schedule,165% of CMS OPPS Rate,1681.67,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4660.68,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,6391.75,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,8006.31,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,685.4,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1622.59,100,,,Fee Schedule,100% of CMS OPPS Rate,1681.67,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1289.25,14,,,percent of total billed charges,14% of total billed charges,685.4,8006.31,
12041- Itmed rpr/neck/hand/ft/ext genit/2.5 cm or <,3431587,CDM,761,RC,12041,HCPCS,Outpatient,,,2013.58,1006.79,,1510.19,75,,,percent of total billed charges,75% of total billed charges,1510.19,75,,,percent of total billed charges,75% of total billed charges,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,141.09,102,,,Fee Schedule,102% of WV Medicaid Rate,578.73,165,,,Fee Schedule,165% of CMS OPPS Rate,363.52,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1007.47,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1381.67,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1730.68,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,138.32,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,363.52,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,281.9,14,,,percent of total billed charges,14% of total billed charges,138.32,1730.68,
12042- Itmed rpr/neck/hand/ft/ext genit/2.6-7.5 cm,3431588,CDM,761,RC,12042,HCPCS,Outpatient,,,2013.58,1006.79,,1510.19,75,,,percent of total billed charges,75% of total billed charges,1510.19,75,,,percent of total billed charges,75% of total billed charges,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,141.09,102,,,Fee Schedule,102% of WV Medicaid Rate,578.72,165,,,Fee Schedule,165% of CMS OPPS Rate,363.51,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1007.47,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1381.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1730.67,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,138.32,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,363.51,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,281.9,14,,,percent of total billed charges,14% of total billed charges,138.32,1730.67,
12044- Int rp neck/hand/feet/gen 7.6-12.5,3428745,CDM,510,RC,12044,HCPCS,Outpatient,,,3171.52,1585.76,,2378.64,75,,,percent of total billed charges,75% of total billed charges,2378.64,75,,,percent of total billed charges,75% of total billed charges,546.17,100,,,Fee Schedule,100% of CMS OPPS Rate,213.77,102,,,Fee Schedule,102% of WV Medicaid Rate,901.2,165,,,Fee Schedule,165% of CMS OPPS Rate,566.07,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1568.84,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2151.55,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,2695.04,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,209.58,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,546.17,100,,,Fee Schedule,100% of CMS OPPS Rate,566.07,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,444.01,14,,,percent of total billed charges,14% of total billed charges,209.58,2695.04,
12045- Itmed rpr/neck/hnd/ft/ext genit/12.6-20.0cm,3431589,CDM,761,RC,12045,HCPCS,Outpatient,,,3171.52,1585.76,,2378.64,75,,,percent of total billed charges,75% of total billed charges,2378.64,75,,,percent of total billed charges,75% of total billed charges,546.17,100,,,Fee Schedule,100% of CMS OPPS Rate,213.77,102,,,Fee Schedule,102% of WV Medicaid Rate,901.2,165,,,Fee Schedule,165% of CMS OPPS Rate,566.07,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1568.84,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2151.55,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,2695.04,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,209.58,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,546.17,100,,,Fee Schedule,100% of CMS OPPS Rate,566.07,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,444.01,14,,,percent of total billed charges,14% of total billed charges,209.58,2695.04,
12046- Itmed rpr/neck/hnd/ft/ext genit/20.1-30.0cm,3431590,CDM,761,RC,12046,HCPCS,Outpatient,,,3171.52,1585.76,,2378.64,75,,,percent of total billed charges,75% of total billed charges,2378.64,75,,,percent of total billed charges,75% of total billed charges,546.17,100,,,Fee Schedule,100% of CMS OPPS Rate,213.77,102,,,Fee Schedule,102% of WV Medicaid Rate,901.2,165,,,Fee Schedule,165% of CMS OPPS Rate,566.07,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1568.84,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2151.55,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,2695.04,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,209.58,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,546.17,100,,,Fee Schedule,100% of CMS OPPS Rate,566.07,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,444.01,14,,,percent of total billed charges,14% of total billed charges,209.58,2695.04,
12047- Itmed rpr/neck/hnd/ft/ext genit/> 30.0 cm,3431591,CDM,761,RC,12047,HCPCS,Outpatient,,,9208.91,4604.46,,6906.68,75,,,percent of total billed charges,75% of total billed charges,6906.68,75,,,percent of total billed charges,75% of total billed charges,1622.59,100,,,Fee Schedule,100% of CMS OPPS Rate,699.11,102,,,Fee Schedule,102% of WV Medicaid Rate,2677.27,165,,,Fee Schedule,165% of CMS OPPS Rate,1681.67,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4660.68,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,6391.75,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,8006.31,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,685.4,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1622.59,100,,,Fee Schedule,100% of CMS OPPS Rate,1681.67,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1289.25,14,,,percent of total billed charges,14% of total billed charges,685.4,8006.31,
12051- Itmed rpr/face/ear/lid/nose/lip/2.5 cm or<,3431592,CDM,761,RC,12051,HCPCS,Outpatient,,,2013.58,1006.79,,1510.19,75,,,percent of total billed charges,75% of total billed charges,1510.19,75,,,percent of total billed charges,75% of total billed charges,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,141.09,102,,,Fee Schedule,102% of WV Medicaid Rate,578.72,165,,,Fee Schedule,165% of CMS OPPS Rate,363.51,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1007.47,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1381.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1730.67,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,138.32,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,363.51,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,281.9,14,,,percent of total billed charges,14% of total billed charges,138.32,1730.67,
12052- Itmed rpr/face/ear/lid/nose/lip/2.6-5.0 cm,3431593,CDM,761,RC,12052,HCPCS,Outpatient,,,2013.58,1006.79,,1510.19,75,,,percent of total billed charges,75% of total billed charges,1510.19,75,,,percent of total billed charges,75% of total billed charges,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,141.09,102,,,Fee Schedule,102% of WV Medicaid Rate,578.72,165,,,Fee Schedule,165% of CMS OPPS Rate,363.51,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1007.47,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1381.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1730.67,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,138.32,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,363.51,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,281.9,14,,,percent of total billed charges,14% of total billed charges,138.32,1730.67,
12053- Int rp fac/ear/lid/nos/lip 5.1-7.5,3428750,CDM,761,RC,12053,HCPCS,Outpatient,,,2013.58,1006.79,,1510.19,75,,,percent of total billed charges,75% of total billed charges,1510.19,75,,,percent of total billed charges,75% of total billed charges,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,141.09,102,,,Fee Schedule,102% of WV Medicaid Rate,578.72,165,,,Fee Schedule,165% of CMS OPPS Rate,363.51,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1007.47,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1381.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1730.67,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,138.32,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,363.51,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,281.9,14,,,percent of total billed charges,14% of total billed charges,138.32,1730.67,
12054- In rp fac/ear/lid/nos/lip 7.6-12.5,3428751,CDM,510,RC,12054,HCPCS,Outpatient,,,2013.58,1006.79,,1510.19,75,,,percent of total billed charges,75% of total billed charges,1510.19,75,,,percent of total billed charges,75% of total billed charges,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,141.09,102,,,Fee Schedule,102% of WV Medicaid Rate,578.73,165,,,Fee Schedule,165% of CMS OPPS Rate,363.52,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1007.47,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1381.67,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1730.68,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,138.32,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,363.52,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,281.9,14,,,percent of total billed charges,14% of total billed charges,138.32,1730.68,
12055- Itmed rpr/face 2.6-20.0cm,3428752,CDM,510,RC,12055,HCPCS,Outpatient,,,2013.58,1006.79,,1510.19,75,,,percent of total billed charges,75% of total billed charges,1510.19,75,,,percent of total billed charges,75% of total billed charges,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,141.09,102,,,Fee Schedule,102% of WV Medicaid Rate,578.72,165,,,Fee Schedule,165% of CMS OPPS Rate,363.51,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1007.47,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1381.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1730.67,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,138.32,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,363.51,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,281.9,14,,,percent of total billed charges,14% of total billed charges,138.32,1730.67,
12056- Int rp fac/ear/lid/nos/lip 20.1-30,3428755,CDM,510,RC,12056,HCPCS,Outpatient,,,2013.58,1006.79,,1510.19,75,,,percent of total billed charges,75% of total billed charges,1510.19,75,,,percent of total billed charges,75% of total billed charges,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,141.09,102,,,Fee Schedule,102% of WV Medicaid Rate,578.73,165,,,Fee Schedule,165% of CMS OPPS Rate,363.52,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1007.47,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1381.67,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1730.68,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,138.32,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,363.52,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,281.9,14,,,percent of total billed charges,14% of total billed charges,138.32,1730.68,
12057- Itmed rpr/face/ear/lid/nose/lip/>30.0cm,3431594,CDM,761,RC,12057,HCPCS,Outpatient,,,2013.58,1006.79,,1510.19,75,,,percent of total billed charges,75% of total billed charges,1510.19,75,,,percent of total billed charges,75% of total billed charges,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,141.09,102,,,Fee Schedule,102% of WV Medicaid Rate,578.72,165,,,Fee Schedule,165% of CMS OPPS Rate,363.51,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1007.47,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1381.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1730.67,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,138.32,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,363.51,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,281.9,14,,,percent of total billed charges,14% of total billed charges,138.32,1730.67,
13101- Complex repair/trunk/2.6-7.5 cm,3431595,CDM,761,RC,13101,HCPCS,Outpatient,,,3171.52,1585.76,,2378.64,75,,,percent of total billed charges,75% of total billed charges,2378.64,75,,,percent of total billed charges,75% of total billed charges,546.17,100,,,Fee Schedule,100% of CMS OPPS Rate,213.77,102,,,Fee Schedule,102% of WV Medicaid Rate,901.2,165,,,Fee Schedule,165% of CMS OPPS Rate,566.07,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1568.84,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2151.55,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,2695.04,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,209.58,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,546.17,100,,,Fee Schedule,100% of CMS OPPS Rate,566.07,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,444.01,14,,,percent of total billed charges,14% of total billed charges,209.58,2695.04,
"13102 - Repair, complex, trunk; each additional 5 cm or less",4037473,CDM,510,RC,13102,HCPCS,Outpatient,,,1780.8,890.4,,1335.6,75,,,percent of total billed charges,75% of total billed charges,1335.6,75,,,percent of total billed charges,75% of total billed charges,569.86,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,249.31,14,,,percent of total billed charges,14% of total billed charges,249.31,1335.6,
13120- Repair/comp/scalp/arm/leg/1.1-2.5c,3431596,CDM,761,RC,13120,HCPCS,Outpatient,,,3171.52,1585.76,,2378.64,75,,,percent of total billed charges,75% of total billed charges,2378.64,75,,,percent of total billed charges,75% of total billed charges,546.17,100,,,Fee Schedule,100% of CMS OPPS Rate,213.77,102,,,Fee Schedule,102% of WV Medicaid Rate,901.2,165,,,Fee Schedule,165% of CMS OPPS Rate,566.07,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1568.84,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2151.55,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,2695.04,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,209.58,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,546.17,100,,,Fee Schedule,100% of CMS OPPS Rate,566.07,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,444.01,14,,,percent of total billed charges,14% of total billed charges,209.58,2695.04,
13121- Cmplx rpr s/a/l 2.6-7.5 cm,3431597,CDM,761,RC,13121,HCPCS,Outpatient,,,3171.52,1585.76,,2378.64,75,,,percent of total billed charges,75% of total billed charges,2378.64,75,,,percent of total billed charges,75% of total billed charges,546.17,100,,,Fee Schedule,100% of CMS OPPS Rate,213.77,102,,,Fee Schedule,102% of WV Medicaid Rate,901.2,165,,,Fee Schedule,165% of CMS OPPS Rate,566.07,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1568.84,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2151.55,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,2695.04,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,209.58,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,546.17,100,,,Fee Schedule,100% of CMS OPPS Rate,566.07,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,444.01,14,,,percent of total billed charges,14% of total billed charges,209.58,2695.04,
"13122 - Repair, complex, scalp, arms, and/or legs; each additional 5 cm or less (List separately in",3715283,CDM,510,RC,13122,HCPCS,Outpatient,,,1780.8,890.4,,1335.6,75,,,percent of total billed charges,75% of total billed charges,1335.6,75,,,percent of total billed charges,75% of total billed charges,569.86,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,249.31,14,,,percent of total billed charges,14% of total billed charges,249.31,1335.6,
13131- Cmplx rpr f/c/c/m/n/ax/g/h/f; 1.1 cm to 2.5 cm,3431598,CDM,761,RC,13131,HCPCS,Outpatient,,,2013.58,1006.79,,1510.19,75,,,percent of total billed charges,75% of total billed charges,1510.19,75,,,percent of total billed charges,75% of total billed charges,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,141.09,102,,,Fee Schedule,102% of WV Medicaid Rate,578.72,165,,,Fee Schedule,165% of CMS OPPS Rate,363.51,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1007.47,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1381.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1730.67,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,138.32,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,363.51,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,281.9,14,,,percent of total billed charges,14% of total billed charges,138.32,1730.67,
13132- Cmplx rpr f/c/c/m/n/ax/g/h/f; 2.6 cm to 7.5 cm,3431599,CDM,761,RC,13132,HCPCS,Outpatient,,,3171.52,1585.76,,2378.64,75,,,percent of total billed charges,75% of total billed charges,2378.64,75,,,percent of total billed charges,75% of total billed charges,546.17,100,,,Fee Schedule,100% of CMS OPPS Rate,213.77,102,,,Fee Schedule,102% of WV Medicaid Rate,901.2,165,,,Fee Schedule,165% of CMS OPPS Rate,566.07,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1568.84,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2151.55,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,2695.04,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,209.58,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,546.17,100,,,Fee Schedule,100% of CMS OPPS Rate,566.07,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,444.01,14,,,percent of total billed charges,14% of total billed charges,209.58,2695.04,
13151- Cmplx rpr e/n/e/l; 1.1-2.5 cm,3431601,CDM,761,RC,13151,HCPCS,Outpatient,,,3171.52,1585.76,,2378.64,75,,,percent of total billed charges,75% of total billed charges,2378.64,75,,,percent of total billed charges,75% of total billed charges,546.17,100,,,Fee Schedule,100% of CMS OPPS Rate,213.77,102,,,Fee Schedule,102% of WV Medicaid Rate,901.2,165,,,Fee Schedule,165% of CMS OPPS Rate,566.07,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1568.84,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2151.55,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,2695.04,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,209.58,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,546.17,100,,,Fee Schedule,100% of CMS OPPS Rate,566.07,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,444.01,14,,,percent of total billed charges,14% of total billed charges,209.58,2695.04,
13152- Cmplx rpr e/n/e/l; 2.6-7.5 cm,3431602,CDM,761,RC,13152,HCPCS,Outpatient,,,3171.52,1585.76,,2378.64,75,,,percent of total billed charges,75% of total billed charges,2378.64,75,,,percent of total billed charges,75% of total billed charges,546.17,100,,,Fee Schedule,100% of CMS OPPS Rate,213.77,102,,,Fee Schedule,102% of WV Medicaid Rate,901.2,165,,,Fee Schedule,165% of CMS OPPS Rate,566.07,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1568.84,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2151.55,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,2695.04,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,209.58,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,546.17,100,,,Fee Schedule,100% of CMS OPPS Rate,566.07,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,444.01,14,,,percent of total billed charges,14% of total billed charges,209.58,2695.04,
13160- Secondary clos/surg wound/ext/comp,3431603,CDM,761,RC,13160,HCPCS,Outpatient,,,9208.91,4604.46,,6906.68,75,,,percent of total billed charges,75% of total billed charges,6906.68,75,,,percent of total billed charges,75% of total billed charges,1622.59,100,,,Fee Schedule,100% of CMS OPPS Rate,699.11,102,,,Fee Schedule,102% of WV Medicaid Rate,2677.27,165,,,Fee Schedule,165% of CMS OPPS Rate,1681.67,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4660.68,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,6391.75,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,8006.31,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,685.4,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1622.59,100,,,Fee Schedule,100% of CMS OPPS Rate,1681.67,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1289.25,14,,,percent of total billed charges,14% of total billed charges,685.4,8006.31,
14001- Skin Tiss Transfer 10.1-30Sq Cm,3431604,CDM,761,RC,14001,HCPCS,Outpatient,,,9208.91,4604.46,,6906.68,75,,,percent of total billed charges,75% of total billed charges,6906.68,75,,,percent of total billed charges,75% of total billed charges,1622.59,100,,,Fee Schedule,100% of CMS OPPS Rate,699.11,102,,,Fee Schedule,102% of WV Medicaid Rate,2677.27,165,,,Fee Schedule,165% of CMS OPPS Rate,1681.67,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4660.68,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,6391.75,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,8006.31,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,685.4,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1622.59,100,,,Fee Schedule,100% of CMS OPPS Rate,1681.67,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1289.25,14,,,percent of total billed charges,14% of total billed charges,685.4,8006.31,
14020- Skin Tissue Trnfr 10Sq Cm Less,3431605,CDM,761,RC,14020,HCPCS,Outpatient,,,9208.91,4604.46,,6906.68,75,,,percent of total billed charges,75% of total billed charges,6906.68,75,,,percent of total billed charges,75% of total billed charges,1622.59,100,,,Fee Schedule,100% of CMS OPPS Rate,699.11,102,,,Fee Schedule,102% of WV Medicaid Rate,2677.27,165,,,Fee Schedule,165% of CMS OPPS Rate,1681.67,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4660.68,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,6391.75,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,8006.31,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,685.4,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1622.59,100,,,Fee Schedule,100% of CMS OPPS Rate,1681.67,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1289.25,14,,,percent of total billed charges,14% of total billed charges,685.4,8006.31,
14021- Skin Tissue Trnfr 10.1-30Sq Cm,3431606,CDM,761,RC,14021,HCPCS,Outpatient,,,9208.91,4604.46,,6906.68,75,,,percent of total billed charges,75% of total billed charges,6906.68,75,,,percent of total billed charges,75% of total billed charges,1622.59,100,,,Fee Schedule,100% of CMS OPPS Rate,699.11,102,,,Fee Schedule,102% of WV Medicaid Rate,2677.27,165,,,Fee Schedule,165% of CMS OPPS Rate,1681.67,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4660.68,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,6391.75,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,8006.31,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,685.4,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1622.59,100,,,Fee Schedule,100% of CMS OPPS Rate,1681.67,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1289.25,14,,,percent of total billed charges,14% of total billed charges,685.4,8006.31,
14040- Tis trnfr f/c/c/m/n/a/g/h/f; defect 10 sq cm or less,3431607,CDM,761,RC,14040,HCPCS,Outpatient,,,9208.91,4604.46,,6906.68,75,,,percent of total billed charges,75% of total billed charges,6906.68,75,,,percent of total billed charges,75% of total billed charges,1622.59,100,,,Fee Schedule,100% of CMS OPPS Rate,699.11,102,,,Fee Schedule,102% of WV Medicaid Rate,2677.27,165,,,Fee Schedule,165% of CMS OPPS Rate,1681.67,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4660.68,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,6391.75,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,8006.31,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,685.4,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1622.59,100,,,Fee Schedule,100% of CMS OPPS Rate,1681.67,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1289.25,14,,,percent of total billed charges,14% of total billed charges,685.4,8006.31,
14041- Adj tis trans/see area/10.1-30sqcm,3431608,CDM,761,RC,14041,HCPCS,Outpatient,,,9208.91,4604.46,,6906.68,75,,,percent of total billed charges,75% of total billed charges,6906.68,75,,,percent of total billed charges,75% of total billed charges,1622.59,100,,,Fee Schedule,100% of CMS OPPS Rate,699.11,102,,,Fee Schedule,102% of WV Medicaid Rate,2677.27,165,,,Fee Schedule,165% of CMS OPPS Rate,1681.67,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4660.68,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,6391.75,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,8006.31,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,685.4,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1622.59,100,,,Fee Schedule,100% of CMS OPPS Rate,1681.67,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1289.25,14,,,percent of total billed charges,14% of total billed charges,685.4,8006.31,
14060- Tis trnfr e/n/e/l 10 sq cm/<,3431609,CDM,761,RC,14060,HCPCS,Outpatient,,,9208.91,4604.46,,6906.68,75,,,percent of total billed charges,75% of total billed charges,6906.68,75,,,percent of total billed charges,75% of total billed charges,1622.59,100,,,Fee Schedule,100% of CMS OPPS Rate,699.11,102,,,Fee Schedule,102% of WV Medicaid Rate,2677.27,165,,,Fee Schedule,165% of CMS OPPS Rate,1681.67,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4660.68,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,6391.75,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,8006.31,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,685.4,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1622.59,100,,,Fee Schedule,100% of CMS OPPS Rate,1681.67,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1289.25,14,,,percent of total billed charges,14% of total billed charges,685.4,8006.31,
"15040 - Harvest of skin for tissue cultured skin autograft, 100 sq cm or less",3715286,CDM,510,RC,15040,HCPCS,Outpatient,,,9208.91,4604.46,,6906.68,75,,,percent of total billed charges,75% of total billed charges,6906.68,75,,,percent of total billed charges,75% of total billed charges,1622.59,100,,,Fee Schedule,100% of CMS OPPS Rate,699.11,102,,,Fee Schedule,102% of WV Medicaid Rate,2677.27,165,,,Fee Schedule,165% of CMS OPPS Rate,1681.67,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4660.68,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,6391.75,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,8006.31,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,685.4,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1622.59,100,,,Fee Schedule,100% of CMS OPPS Rate,1681.67,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1289.25,14,,,percent of total billed charges,14% of total billed charges,685.4,8006.31,
15101- Skin Split Graft Addl 100Sq Cm,3431614,CDM,761,RC,15101,HCPCS,Outpatient,,,4604.46,2302.23,,3453.35,75,,,percent of total billed charges,75% of total billed charges,3453.35,75,,,percent of total billed charges,75% of total billed charges,1473.43,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,644.62,14,,,percent of total billed charges,14% of total billed charges,644.62,3453.35,
15110- Epidrm Autogrft Trnk/Arm/Leg,3431615,CDM,761,RC,15110,HCPCS,Outpatient,,,9208.91,4604.46,,6906.68,75,,,percent of total billed charges,75% of total billed charges,6906.68,75,,,percent of total billed charges,75% of total billed charges,1622.59,100,,,Fee Schedule,100% of CMS OPPS Rate,699.11,102,,,Fee Schedule,102% of WV Medicaid Rate,2677.27,165,,,Fee Schedule,165% of CMS OPPS Rate,1681.67,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4660.68,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,6391.75,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,8006.31,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,685.4,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1622.59,100,,,Fee Schedule,100% of CMS OPPS Rate,1681.67,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1289.25,14,,,percent of total billed charges,14% of total billed charges,685.4,8006.31,
15111- Epiderm autograft/specified areas/ea add 100sq cm/ea add 1% body area infant/child,3431616,CDM,761,RC,15111,HCPCS,Outpatient,,,4604.46,2302.23,,3453.35,75,,,percent of total billed charges,75% of total billed charges,3453.35,75,,,percent of total billed charges,75% of total billed charges,1473.43,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,644.62,14,,,percent of total billed charges,14% of total billed charges,644.62,3453.35,
15115- Epiderm autograft/specified areas/first 100sq cm or </1% body area/infant/child,3431617,CDM,761,RC,15115,HCPCS,Outpatient,,,9208.91,4604.46,,6906.68,75,,,percent of total billed charges,75% of total billed charges,6906.68,75,,,percent of total billed charges,75% of total billed charges,1622.59,100,,,Fee Schedule,100% of CMS OPPS Rate,699.11,102,,,Fee Schedule,102% of WV Medicaid Rate,2677.27,165,,,Fee Schedule,165% of CMS OPPS Rate,1681.67,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4660.68,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,6391.75,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,8006.31,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,685.4,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1622.59,100,,,Fee Schedule,100% of CMS OPPS Rate,1681.67,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1289.25,14,,,percent of total billed charges,14% of total billed charges,685.4,8006.31,
15120 - SPLIT AGRFT F/S/N/H/F/G/M/D GT 1ST 100 CM/,4037474,CDM,510,RC,15120,HCPCS,Outpatient,,,18116.78,9058.39,,13587.59,75,,,percent of total billed charges,75% of total billed charges,13587.59,75,,,percent of total billed charges,75% of total billed charges,3058.39,100,,,Fee Schedule,100% of CMS OPPS Rate,1437.27,102,,,Fee Schedule,102% of WV Medicaid Rate,5046.34,165,,,Fee Schedule,165% of CMS OPPS Rate,3169.76,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8784.82,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,12047.69,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,15090.95,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1409.09,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,3058.39,100,,,Fee Schedule,100% of CMS OPPS Rate,3169.76,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,2536.35,14,,,percent of total billed charges,14% of total billed charges,1409.09,15090.95,
15200- Full thick graft/trunk/</=20 sq cm,3431619,CDM,761,RC,15200,HCPCS,Outpatient,,,9208.91,4604.46,,6906.68,75,,,percent of total billed charges,75% of total billed charges,6906.68,75,,,percent of total billed charges,75% of total billed charges,1622.59,100,,,Fee Schedule,100% of CMS OPPS Rate,699.11,102,,,Fee Schedule,102% of WV Medicaid Rate,2677.27,165,,,Fee Schedule,165% of CMS OPPS Rate,1681.67,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4660.68,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,6391.75,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,8006.31,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,685.4,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1622.59,100,,,Fee Schedule,100% of CMS OPPS Rate,1681.67,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1289.25,14,,,percent of total billed charges,14% of total billed charges,685.4,8006.31,
15220- Full thick gft/scalp/arm/leg/20sqcm or<,3431620,CDM,761,RC,15220,HCPCS,Outpatient,,,9208.91,4604.46,,6906.68,75,,,percent of total billed charges,75% of total billed charges,6906.68,75,,,percent of total billed charges,75% of total billed charges,1622.59,100,,,Fee Schedule,100% of CMS OPPS Rate,699.11,102,,,Fee Schedule,102% of WV Medicaid Rate,2677.27,165,,,Fee Schedule,165% of CMS OPPS Rate,1681.67,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4660.68,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,6391.75,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,8006.31,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,685.4,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1622.59,100,,,Fee Schedule,100% of CMS OPPS Rate,1681.67,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1289.25,14,,,percent of total billed charges,14% of total billed charges,685.4,8006.31,
15221- Full thick gft/scalp/arm/leg/add 20sqcm,3431621,CDM,761,RC,15221,HCPCS,Outpatient,,,4604.46,2302.23,,3453.35,75,,,percent of total billed charges,75% of total billed charges,3453.35,75,,,percent of total billed charges,75% of total billed charges,1473.43,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,644.62,14,,,percent of total billed charges,14% of total billed charges,644.62,3453.35,
15240- Full Thick Graft w/close donor site face/neck/ax/genit/hnd/ft <=20sqcm,3431622,CDM,761,RC,15240,HCPCS,Outpatient,,,9208.91,4604.46,,6906.68,75,,,percent of total billed charges,75% of total billed charges,6906.68,75,,,percent of total billed charges,75% of total billed charges,1622.59,100,,,Fee Schedule,100% of CMS OPPS Rate,699.11,102,,,Fee Schedule,102% of WV Medicaid Rate,2677.27,165,,,Fee Schedule,165% of CMS OPPS Rate,1681.67,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4660.68,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,6391.75,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,8006.31,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,685.4,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1622.59,100,,,Fee Schedule,100% of CMS OPPS Rate,1681.67,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1289.25,14,,,percent of total billed charges,14% of total billed charges,685.4,8006.31,
15241- Skin Full Graft Add 20Sq Cm,3431623,CDM,761,RC,15241,HCPCS,Outpatient,,,4604.46,2302.23,,3453.35,75,,,percent of total billed charges,75% of total billed charges,3453.35,75,,,percent of total billed charges,75% of total billed charges,1473.43,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,644.62,14,,,percent of total billed charges,14% of total billed charges,644.62,3453.35,
15260- Full thick gft/nose/ear/lid/lip/20sqcm or<,3431624,CDM,761,RC,15260,HCPCS,Outpatient,,,9208.91,4604.46,,6906.68,75,,,percent of total billed charges,75% of total billed charges,6906.68,75,,,percent of total billed charges,75% of total billed charges,1622.59,100,,,Fee Schedule,100% of CMS OPPS Rate,699.11,102,,,Fee Schedule,102% of WV Medicaid Rate,2677.27,165,,,Fee Schedule,165% of CMS OPPS Rate,1681.67,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4660.68,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,6391.75,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,8006.31,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,685.4,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1622.59,100,,,Fee Schedule,100% of CMS OPPS Rate,1681.67,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1289.25,14,,,percent of total billed charges,14% of total billed charges,685.4,8006.31,
15261- Skin Full Graft Add 20 Sq Cm,3431625,CDM,761,RC,15261,HCPCS,Outpatient,,,4604.46,2302.23,,3453.35,75,,,percent of total billed charges,75% of total billed charges,3453.35,75,,,percent of total billed charges,75% of total billed charges,1473.43,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,644.62,14,,,percent of total billed charges,14% of total billed charges,644.62,3453.35,
15271 App Skn Sub Grft T/A/L Area/100 Sq Cm/<1st 25,3436028,CDM,761,RC,15271,HCPCS,Outpatient,,,9208.91,4604.46,,6906.68,75,,,percent of total billed charges,75% of total billed charges,6906.68,75,,,percent of total billed charges,75% of total billed charges,1622.59,100,,,Fee Schedule,100% of CMS OPPS Rate,699.11,102,,,Fee Schedule,102% of WV Medicaid Rate,2677.27,165,,,Fee Schedule,165% of CMS OPPS Rate,1681.67,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4660.68,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,6391.75,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,8006.31,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,685.4,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1622.59,100,,,Fee Schedule,100% of CMS OPPS Rate,1681.67,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1289.25,14,,,percent of total billed charges,14% of total billed charges,685.4,8006.31,
15272 App Skn Sub Grft T/A/L Area/100 Sq Cm Ea Adl 25sqc,3436030,CDM,761,RC,15272,HCPCS,Outpatient,,,4604.46,2302.23,,3453.35,75,,,percent of total billed charges,75% of total billed charges,3453.35,75,,,percent of total billed charges,75% of total billed charges,1473.43,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,644.62,14,,,percent of total billed charges,14% of total billed charges,644.62,3453.35,
15273 App Skn Subgrft T/A/L Area 100 Sq Cm 1st 100 Sq Cm,3549201,CDM,761,RC,15273,HCPCS,Outpatient,,,18116.78,9058.39,,13587.59,75,,,percent of total billed charges,75% of total billed charges,13587.59,75,,,percent of total billed charges,75% of total billed charges,3058.39,100,,,Fee Schedule,100% of CMS OPPS Rate,1437.27,102,,,Fee Schedule,102% of WV Medicaid Rate,5046.34,165,,,Fee Schedule,165% of CMS OPPS Rate,3169.76,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8784.82,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,12047.69,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,15090.95,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1409.09,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,3058.39,100,,,Fee Schedule,100% of CMS OPPS Rate,3169.76,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,2536.35,14,,,percent of total billed charges,14% of total billed charges,1409.09,15090.95,
15273- Skin Sub Grft Trnk Arm Lg Child,3431626,CDM,761,RC,15273,HCPCS,Outpatient,,,18116.78,9058.39,,13587.59,75,,,percent of total billed charges,75% of total billed charges,13587.59,75,,,percent of total billed charges,75% of total billed charges,3058.39,100,,,Fee Schedule,100% of CMS OPPS Rate,1437.27,102,,,Fee Schedule,102% of WV Medicaid Rate,5046.34,165,,,Fee Schedule,165% of CMS OPPS Rate,3169.76,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8784.82,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,12047.69,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,15090.95,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1409.09,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,3058.39,100,,,Fee Schedule,100% of CMS OPPS Rate,3169.76,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,2536.35,14,,,percent of total billed charges,14% of total billed charges,1409.09,15090.95,
15274 App Skn Sub Grft T/A/L Area>=100sqc Adl 100sqc,3549034,CDM,761,RC,15274,HCPCS,Outpatient,,,9058.39,4529.2,,6793.79,75,,,percent of total billed charges,75% of total billed charges,6793.79,75,,,percent of total billed charges,75% of total billed charges,2898.68,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1268.17,14,,,percent of total billed charges,14% of total billed charges,1268.17,6793.79,
"15275 Application of skin substitute graft to face, scalp, eyelids, mouth, neck, ears, orbits, genit",3621205,CDM,510,RC,15275,HCPCS,Outpatient,,,9208.91,4604.46,,6906.68,75,,,percent of total billed charges,75% of total billed charges,6906.68,75,,,percent of total billed charges,75% of total billed charges,1622.59,100,,,Fee Schedule,100% of CMS OPPS Rate,699.11,102,,,Fee Schedule,102% of WV Medicaid Rate,2677.27,165,,,Fee Schedule,165% of CMS OPPS Rate,1681.67,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4660.68,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,6391.75,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,8006.31,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,685.4,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1622.59,100,,,Fee Schedule,100% of CMS OPPS Rate,1681.67,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1289.25,14,,,percent of total billed charges,14% of total billed charges,685.4,8006.31,
15275 Sub Grft F/S/N/H/F/G/M/D <100 Sq Cm 1st 25 Sq Cm,3436032,CDM,761,RC,15275,HCPCS,Outpatient,,,9208.91,4604.46,,6906.68,75,,,percent of total billed charges,75% of total billed charges,6906.68,75,,,percent of total billed charges,75% of total billed charges,1622.59,100,,,Fee Schedule,100% of CMS OPPS Rate,699.11,102,,,Fee Schedule,102% of WV Medicaid Rate,2677.27,165,,,Fee Schedule,165% of CMS OPPS Rate,1681.67,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4660.68,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,6391.75,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,8006.31,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,685.4,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1622.59,100,,,Fee Schedule,100% of CMS OPPS Rate,1681.67,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1289.25,14,,,percent of total billed charges,14% of total billed charges,685.4,8006.31,
15276 Sub Grft F/S/N/H/F/G/M/D<100 Sq Cm Ea Addl 25sqc,3436033,CDM,761,RC,15276,HCPCS,Outpatient,,,4604.46,2302.23,,3453.35,75,,,percent of total billed charges,75% of total billed charges,3453.35,75,,,percent of total billed charges,75% of total billed charges,1473.43,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,644.62,14,,,percent of total billed charges,14% of total billed charges,644.62,3453.35,
15760- Composite graft/pri close/don area,3431628,CDM,761,RC,15760,HCPCS,Outpatient,,,9208.91,4604.46,,6906.68,75,,,percent of total billed charges,75% of total billed charges,6906.68,75,,,percent of total billed charges,75% of total billed charges,1622.59,100,,,Fee Schedule,100% of CMS OPPS Rate,699.11,102,,,Fee Schedule,102% of WV Medicaid Rate,2677.27,165,,,Fee Schedule,165% of CMS OPPS Rate,1681.67,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4660.68,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,6391.75,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,8006.31,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,685.4,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1622.59,100,,,Fee Schedule,100% of CMS OPPS Rate,1681.67,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1289.25,14,,,percent of total billed charges,14% of total billed charges,685.4,8006.31,
"15788 - Chemical peel, facial; epidermal",3715288,CDM,510,RC,15788,HCPCS,Outpatient,,,2013.58,1006.79,,1510.19,75,,,percent of total billed charges,75% of total billed charges,1510.19,75,,,percent of total billed charges,75% of total billed charges,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,578.73,165,,,Fee Schedule,165% of CMS OPPS Rate,363.52,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1007.47,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1381.67,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1730.68,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,363.52,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,281.9,14,,,percent of total billed charges,14% of total billed charges,281.9,1730.68,
"15789 - Chemical peel, facial; dermal",3715293,CDM,510,RC,15789,HCPCS,Outpatient,,,3171.52,1585.76,,2378.64,75,,,percent of total billed charges,75% of total billed charges,2378.64,75,,,percent of total billed charges,75% of total billed charges,546.17,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,901.2,165,,,Fee Schedule,165% of CMS OPPS Rate,566.07,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1568.84,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2151.55,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,2695.04,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,546.17,100,,,Fee Schedule,100% of CMS OPPS Rate,566.07,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,444.01,14,,,percent of total billed charges,14% of total billed charges,444.01,2695.04,
"15792 -Chemical peel, nonfacial; epidermal",3715294,CDM,510,RC,15792,HCPCS,Outpatient,,,3171.52,1585.76,,2378.64,75,,,percent of total billed charges,75% of total billed charges,2378.64,75,,,percent of total billed charges,75% of total billed charges,546.17,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,901.21,165,,,Fee Schedule,165% of CMS OPPS Rate,566.07,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1568.85,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2151.55,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,2695.04,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,546.17,100,,,Fee Schedule,100% of CMS OPPS Rate,566.07,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,444.01,14,,,percent of total billed charges,14% of total billed charges,444.01,2695.04,
"15793 - Chemical peel, nonfacial; dermal",3715296,CDM,510,RC,15793,HCPCS,Outpatient,,,2013.58,1006.79,,1510.19,75,,,percent of total billed charges,75% of total billed charges,1510.19,75,,,percent of total billed charges,75% of total billed charges,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,578.73,165,,,Fee Schedule,165% of CMS OPPS Rate,363.52,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1007.47,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1381.67,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1730.68,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,363.52,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,281.9,14,,,percent of total billed charges,14% of total billed charges,281.9,1730.68,
"15820 - Blepharoplasty, lower eyelid;",3712914,CDM,510,RC,15820,HCPCS,Outpatient,,,9208.91,4604.46,,6906.68,75,,,percent of total billed charges,75% of total billed charges,6906.68,75,,,percent of total billed charges,75% of total billed charges,1622.59,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,2677.27,165,,,Fee Schedule,165% of CMS OPPS Rate,1681.67,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4660.68,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,6391.75,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,8006.31,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,1622.59,100,,,Fee Schedule,100% of CMS OPPS Rate,1681.67,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1289.25,14,,,percent of total billed charges,14% of total billed charges,1289.25,8006.31,
"15851 - Removal of sutures under anesthesia (other than local), other surgeon",3715463,CDM,510,RC,15851,HCPCS,Outpatient,,,9208.91,4604.46,,6906.68,75,,,percent of total billed charges,75% of total billed charges,6906.68,75,,,percent of total billed charges,75% of total billed charges,1622.59,100,,,Fee Schedule,100% of CMS OPPS Rate,61.42,102,,,Fee Schedule,102% of WV Medicaid Rate,2677.27,165,,,Fee Schedule,165% of CMS OPPS Rate,1681.67,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4660.68,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,6391.75,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,8006.31,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,60.22,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1622.59,100,,,Fee Schedule,100% of CMS OPPS Rate,1681.67,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1289.25,14,,,percent of total billed charges,14% of total billed charges,60.22,8006.31,
16020- Dress/debride pt-thick burn/<5% BS,3431631,CDM,761,RC,16020,HCPCS,Outpatient,,,1010.98,505.49,,758.24,75,,,percent of total billed charges,75% of total billed charges,758.24,75,,,percent of total billed charges,75% of total billed charges,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,280.12,165,,,Fee Schedule,165% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,487.65,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,668.78,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,837.71,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,141.54,14,,,percent of total billed charges,14% of total billed charges,141.54,837.71,
16025- Dress/debride pt-tck burn/5-10% BS,3431632,CDM,761,RC,16025,HCPCS,Outpatient,,,1010.98,505.49,,758.24,75,,,percent of total billed charges,75% of total billed charges,758.24,75,,,percent of total billed charges,75% of total billed charges,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,73.31,102,,,Fee Schedule,102% of WV Medicaid Rate,280.12,165,,,Fee Schedule,165% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,487.65,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,668.77,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,837.71,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,71.87,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,141.54,14,,,percent of total billed charges,14% of total billed charges,71.87,837.71,
17000- Destruct premalig lesion/1st les,3431633,CDM,761,RC,17000,HCPCS,Outpatient,,,1010.98,505.49,,758.24,75,,,percent of total billed charges,75% of total billed charges,758.24,75,,,percent of total billed charges,75% of total billed charges,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,280.12,165,,,Fee Schedule,165% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,487.65,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,668.78,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,837.71,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,141.54,14,,,percent of total billed charges,14% of total billed charges,141.54,837.71,
17003- DERM DESTRUCT PREMALG LES 2-14,3514645,CDM,761,RC,17003,HCPCS,Outpatient,,,505.49,252.75,,379.12,75,,,percent of total billed charges,75% of total billed charges,379.12,75,,,percent of total billed charges,75% of total billed charges,161.76,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,70.77,14,,,percent of total billed charges,14% of total billed charges,70.77,379.12,
17004- Destroy premal lesions 15/>,3428770,CDM,510,RC,17004,HCPCS,Outpatient,,,2013.58,1006.79,,1510.19,75,,,percent of total billed charges,75% of total billed charges,1510.19,75,,,percent of total billed charges,75% of total billed charges,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,95.82,102,,,Fee Schedule,102% of WV Medicaid Rate,578.72,165,,,Fee Schedule,165% of CMS OPPS Rate,363.51,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1007.47,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1381.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1730.67,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,93.94,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,363.51,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,281.9,14,,,percent of total billed charges,14% of total billed charges,93.94,1730.67,
17110- Destruct benign lesion 1-14,3431075,CDM,761,RC,17110,HCPCS,Outpatient,,,1010.98,505.49,,758.24,75,,,percent of total billed charges,75% of total billed charges,758.24,75,,,percent of total billed charges,75% of total billed charges,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,280.12,165,,,Fee Schedule,165% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,487.65,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,668.78,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,837.71,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,141.54,14,,,percent of total billed charges,14% of total billed charges,141.54,837.71,
17111- Destruct lesion 15 or more,3431076,CDM,761,RC,17111,HCPCS,Outpatient,,,1010.98,505.49,,758.24,75,,,percent of total billed charges,75% of total billed charges,758.24,75,,,percent of total billed charges,75% of total billed charges,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,280.12,165,,,Fee Schedule,165% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,487.65,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,668.78,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,837.71,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,141.54,14,,,percent of total billed charges,14% of total billed charges,141.54,837.71,
17250 Chemical Cauterization if Granulation Tissue,3436034,CDM,761,RC,17250,HCPCS,Outpatient,,,1010.98,505.49,,758.24,75,,,percent of total billed charges,75% of total billed charges,758.24,75,,,percent of total billed charges,75% of total billed charges,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,280.12,165,,,Fee Schedule,165% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,487.65,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,668.78,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,837.71,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,141.54,14,,,percent of total billed charges,14% of total billed charges,141.54,837.71,
17250- Chemical cautery of granulated tissue,3431077,CDM,761,RC,17250,HCPCS,Outpatient,,,1010.98,505.49,,758.24,75,,,percent of total billed charges,75% of total billed charges,758.24,75,,,percent of total billed charges,75% of total billed charges,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,280.12,165,,,Fee Schedule,165% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,487.65,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,668.78,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,837.71,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,141.54,14,,,percent of total billed charges,14% of total billed charges,141.54,837.71,
17260- Destruction of skin lesions,3431078,CDM,761,RC,17260,HCPCS,Outpatient,,,1010.98,505.49,,758.24,75,,,percent of total billed charges,75% of total billed charges,758.24,75,,,percent of total billed charges,75% of total billed charges,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,280.12,165,,,Fee Schedule,165% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,487.65,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,668.78,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,837.71,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,141.54,14,,,percent of total billed charges,14% of total billed charges,141.54,837.71,
17261- Destruction of skin lesions,3431079,CDM,761,RC,17261,HCPCS,Outpatient,,,1010.98,505.49,,758.24,75,,,percent of total billed charges,75% of total billed charges,758.24,75,,,percent of total billed charges,75% of total billed charges,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,280.12,165,,,Fee Schedule,165% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,487.65,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,668.78,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,837.71,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,141.54,14,,,percent of total billed charges,14% of total billed charges,141.54,837.71,
17262- Destruction of skin lesions,3431080,CDM,761,RC,17262,HCPCS,Outpatient,,,1010.98,505.49,,758.24,75,,,percent of total billed charges,75% of total billed charges,758.24,75,,,percent of total billed charges,75% of total billed charges,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,280.12,165,,,Fee Schedule,165% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,487.65,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,668.78,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,837.71,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,141.54,14,,,percent of total billed charges,14% of total billed charges,141.54,837.71,
17263- Destruction of skin lesions,3431081,CDM,761,RC,17263,HCPCS,Outpatient,,,1010.98,505.49,,758.24,75,,,percent of total billed charges,75% of total billed charges,758.24,75,,,percent of total billed charges,75% of total billed charges,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,280.12,165,,,Fee Schedule,165% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,487.65,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,668.78,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,837.71,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,141.54,14,,,percent of total billed charges,14% of total billed charges,141.54,837.71,
17264- Destruction of skin lesions,3431082,CDM,761,RC,17264,HCPCS,Outpatient,,,2013.58,1006.79,,1510.19,75,,,percent of total billed charges,75% of total billed charges,1510.19,75,,,percent of total billed charges,75% of total billed charges,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,107.56,102,,,Fee Schedule,102% of WV Medicaid Rate,578.72,165,,,Fee Schedule,165% of CMS OPPS Rate,363.51,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1007.47,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1381.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1730.67,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,105.45,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,363.51,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,281.9,14,,,percent of total billed charges,14% of total billed charges,105.45,1730.67,
17266- Destruction of skin lesions,3431083,CDM,761,RC,17266,HCPCS,Outpatient,,,2013.58,1006.79,,1510.19,75,,,percent of total billed charges,75% of total billed charges,1510.19,75,,,percent of total billed charges,75% of total billed charges,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,118.47,102,,,Fee Schedule,102% of WV Medicaid Rate,578.72,165,,,Fee Schedule,165% of CMS OPPS Rate,363.51,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1007.47,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1381.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1730.67,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,116.15,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,363.51,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,281.9,14,,,percent of total billed charges,14% of total billed charges,116.15,1730.67,
17270- Destruction of skin lesions,3431084,CDM,761,RC,17270,HCPCS,Outpatient,,,1010.98,505.49,,758.24,75,,,percent of total billed charges,75% of total billed charges,758.24,75,,,percent of total billed charges,75% of total billed charges,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,73.31,102,,,Fee Schedule,102% of WV Medicaid Rate,280.12,165,,,Fee Schedule,165% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,487.65,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,668.77,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,837.71,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,71.87,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,141.54,14,,,percent of total billed charges,14% of total billed charges,71.87,837.71,
17271- Destruction of skin lesions,3431085,CDM,761,RC,17271,HCPCS,Outpatient,,,1010.98,505.49,,758.24,75,,,percent of total billed charges,75% of total billed charges,758.24,75,,,percent of total billed charges,75% of total billed charges,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,73.31,102,,,Fee Schedule,102% of WV Medicaid Rate,280.12,165,,,Fee Schedule,165% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,487.65,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,668.77,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,837.71,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,71.87,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,141.54,14,,,percent of total billed charges,14% of total billed charges,71.87,837.71,
17272- Destruction of skin lesions,3431086,CDM,761,RC,17272,HCPCS,Outpatient,,,1010.98,505.49,,758.24,75,,,percent of total billed charges,75% of total billed charges,758.24,75,,,percent of total billed charges,75% of total billed charges,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,280.12,165,,,Fee Schedule,165% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,487.65,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,668.78,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,837.71,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,141.54,14,,,percent of total billed charges,14% of total billed charges,141.54,837.71,
17273- Destruction of skin lesions,3431087,CDM,761,RC,17273,HCPCS,Outpatient,,,2013.58,1006.79,,1510.19,75,,,percent of total billed charges,75% of total billed charges,1510.19,75,,,percent of total billed charges,75% of total billed charges,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,105.92,102,,,Fee Schedule,102% of WV Medicaid Rate,578.72,165,,,Fee Schedule,165% of CMS OPPS Rate,363.51,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1007.47,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1381.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1730.67,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,103.84,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,363.51,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,281.9,14,,,percent of total billed charges,14% of total billed charges,103.84,1730.67,
17274- Destruction of skin lesions,3431088,CDM,761,RC,17274,HCPCS,Outpatient,,,2013.58,1006.79,,1510.19,75,,,percent of total billed charges,75% of total billed charges,1510.19,75,,,percent of total billed charges,75% of total billed charges,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,118.47,102,,,Fee Schedule,102% of WV Medicaid Rate,578.72,165,,,Fee Schedule,165% of CMS OPPS Rate,363.51,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1007.47,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1381.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1730.67,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,116.15,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,363.51,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,281.9,14,,,percent of total billed charges,14% of total billed charges,116.15,1730.67,
17276- Destruction of skin lesions,3431089,CDM,761,RC,17276,HCPCS,Outpatient,,,2013.58,1006.79,,1510.19,75,,,percent of total billed charges,75% of total billed charges,1510.19,75,,,percent of total billed charges,75% of total billed charges,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,131.86,102,,,Fee Schedule,102% of WV Medicaid Rate,578.72,165,,,Fee Schedule,165% of CMS OPPS Rate,363.51,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1007.47,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1381.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1730.67,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,129.27,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,363.51,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,281.9,14,,,percent of total billed charges,14% of total billed charges,129.27,1730.67,
17280- Destruction of skin lesions,3431090,CDM,761,RC,17280,HCPCS,Outpatient,,,1010.98,505.49,,758.24,75,,,percent of total billed charges,75% of total billed charges,758.24,75,,,percent of total billed charges,75% of total billed charges,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,280.12,165,,,Fee Schedule,165% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,487.65,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,668.78,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,837.71,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,141.54,14,,,percent of total billed charges,14% of total billed charges,141.54,837.71,
17281- Destruction of skin lesions,3431091,CDM,761,RC,17281,HCPCS,Outpatient,,,2013.58,1006.79,,1510.19,75,,,percent of total billed charges,75% of total billed charges,1510.19,75,,,percent of total billed charges,75% of total billed charges,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,92.27,102,,,Fee Schedule,102% of WV Medicaid Rate,578.72,165,,,Fee Schedule,165% of CMS OPPS Rate,363.51,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1007.47,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1381.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1730.67,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,90.46,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,363.51,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,281.9,14,,,percent of total billed charges,14% of total billed charges,90.46,1730.67,
17282- Destruction of skin lesions,3431092,CDM,761,RC,17282,HCPCS,Outpatient,,,2013.58,1006.79,,1510.19,75,,,percent of total billed charges,75% of total billed charges,1510.19,75,,,percent of total billed charges,75% of total billed charges,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,103.47,102,,,Fee Schedule,102% of WV Medicaid Rate,578.72,165,,,Fee Schedule,165% of CMS OPPS Rate,363.51,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1007.47,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1381.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1730.67,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,101.44,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,363.51,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,281.9,14,,,percent of total billed charges,14% of total billed charges,101.44,1730.67,
"17283- Destruct Skin Lesions,2.1-3.0 cm",3431634,CDM,761,RC,17283,HCPCS,Outpatient,,,2013.58,1006.79,,1510.19,75,,,percent of total billed charges,75% of total billed charges,1510.19,75,,,percent of total billed charges,75% of total billed charges,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,115.46,102,,,Fee Schedule,102% of WV Medicaid Rate,578.72,165,,,Fee Schedule,165% of CMS OPPS Rate,363.51,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1007.47,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1381.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1730.67,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,113.2,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,363.51,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,281.9,14,,,percent of total billed charges,14% of total billed charges,113.2,1730.67,
17284- Destruction of skin lesions,3431093,CDM,761,RC,17284,HCPCS,Outpatient,,,3171.52,1585.76,,2378.64,75,,,percent of total billed charges,75% of total billed charges,2378.64,75,,,percent of total billed charges,75% of total billed charges,546.17,100,,,Fee Schedule,100% of CMS OPPS Rate,126.94,102,,,Fee Schedule,102% of WV Medicaid Rate,901.2,165,,,Fee Schedule,165% of CMS OPPS Rate,566.07,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1568.84,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2151.55,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,2695.04,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,124.45,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,546.17,100,,,Fee Schedule,100% of CMS OPPS Rate,566.07,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,444.01,14,,,percent of total billed charges,14% of total billed charges,124.45,2695.04,
17286- Destruction of skin lesions,3431094,CDM,761,RC,17286,HCPCS,Outpatient,,,3171.52,1585.76,,2378.64,75,,,percent of total billed charges,75% of total billed charges,2378.64,75,,,percent of total billed charges,75% of total billed charges,546.17,100,,,Fee Schedule,100% of CMS OPPS Rate,151.24,102,,,Fee Schedule,102% of WV Medicaid Rate,901.2,165,,,Fee Schedule,165% of CMS OPPS Rate,566.07,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1568.84,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2151.55,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,2695.04,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,148.27,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,546.17,100,,,Fee Schedule,100% of CMS OPPS Rate,566.07,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,444.01,14,,,percent of total billed charges,14% of total billed charges,148.27,2695.04,
"17999 Unlisted procedure, skin, mucous membrane and subcutan",3623321,CDM,510,RC,17999,HCPCS,Outpatient,,,1010.98,505.49,,758.24,75,,,percent of total billed charges,75% of total billed charges,758.24,75,,,percent of total billed charges,75% of total billed charges,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,280.12,165,,,Fee Schedule,165% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,487.65,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,668.78,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,837.71,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,141.54,14,,,percent of total billed charges,14% of total billed charges,141.54,837.71,
19000- Drainage Of Breast Lesion,3431635,CDM,360,RC,19000,HCPCS,Outpatient,,,144.51,72.26,,108.38,75,,,percent of total billed charges,75% of total billed charges,108.38,75,,,percent of total billed charges,75% of total billed charges,610.13,100,,,Fee Schedule,100% of CMS OPPS Rate,58.43,102,,,Fee Schedule,102% of WV Medicaid Rate,1006.72,165,,,Fee Schedule,165% of CMS OPPS Rate,632.35,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1752.53,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2403.46,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,3010.58,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,57.28,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,610.13,100,,,Fee Schedule,100% of CMS OPPS Rate,632.35,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,20.23,14,,,percent of total billed charges,14% of total billed charges,20.23,3010.58,
19001- Punc asp breast cyst ea additional,3428771,CDM,360,RC,19001,HCPCS,Outpatient,,,13.43,6.72,,10.07,75,,,percent of total billed charges,75% of total billed charges,10.07,75,,,percent of total billed charges,75% of total billed charges,4.3,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.88,14,,,percent of total billed charges,14% of total billed charges,1.88,10.07,
19020-,3428772,CDM,361,RC,19020,HCPCS,Outpatient,,,383.74,191.87,,287.81,75,,,percent of total billed charges,75% of total billed charges,287.81,75,,,percent of total billed charges,75% of total billed charges,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,479.67,102,,,Fee Schedule,102% of WV Medicaid Rate,2326.19,165,,,Fee Schedule,165% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4049.52,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5553.61,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6956.46,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,470.26,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,53.72,14,,,percent of total billed charges,14% of total billed charges,53.72,6956.46,
19081- Bx breast 1st lesion w/o US,3428775,CDM,320,RC,19081,HCPCS,Outpatient,,,7311.24,3655.62,,5483.43,75,,,percent of total billed charges,75% of total billed charges,5483.43,75,,,percent of total billed charges,75% of total billed charges,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,479.67,102,,,Fee Schedule,102% of WV Medicaid Rate,2326.19,165,,,Fee Schedule,165% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4049.52,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5553.61,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6956.46,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,470.26,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1023.57,14,,,percent of total billed charges,14% of total billed charges,470.26,6956.46,
"19082 Biopsy, breast, with placement of breast localization device(s) (eg, clip, metallic pellet), w",3621196,CDM,510,RC,19082,HCPCS,Outpatient,,,758.04,379.02,,568.53,75,,,percent of total billed charges,75% of total billed charges,568.53,75,,,percent of total billed charges,75% of total billed charges,242.57,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,106.13,14,,,percent of total billed charges,14% of total billed charges,106.13,568.53,
19083- Biopsy/breast/1st lesion/US guide,3431636,CDM,401,RC,19083,HCPCS,Outpatient,,,867.8,433.9,,650.85,75,,,percent of total billed charges,75% of total billed charges,650.85,75,,,percent of total billed charges,75% of total billed charges,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,479.67,102,,,Fee Schedule,102% of WV Medicaid Rate,2326.19,165,,,Fee Schedule,165% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4049.52,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5553.61,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6956.46,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,470.26,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,121.49,14,,,percent of total billed charges,14% of total billed charges,121.49,6956.46,
SCSN US Guided Mammotome Breast Biopsy,3370946,CDM,402,RC,19083,HCPCS,Outpatient,,,867.8,433.9,,650.85,75,,,percent of total billed charges,75% of total billed charges,650.85,75,,,percent of total billed charges,75% of total billed charges,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,479.67,102,,,Fee Schedule,102% of WV Medicaid Rate,2326.19,165,,,Fee Schedule,165% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4049.52,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5553.61,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6956.46,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,470.26,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,121.49,14,,,percent of total billed charges,14% of total billed charges,121.49,6956.46,
"19084 Biopsy, breast, with placement of breast localization device(s)",3621149,CDM,510,RC,19084,HCPCS,Outpatient,,,761.19,380.6,,570.89,75,,,percent of total billed charges,75% of total billed charges,570.89,75,,,percent of total billed charges,75% of total billed charges,243.58,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,106.57,14,,,percent of total billed charges,14% of total billed charges,106.57,570.89,
19100- Bx breast percut w/o image,3428778,CDM,401,RC,19100,HCPCS,Outpatient,,,204.53,102.27,,153.4,75,,,percent of total billed charges,75% of total billed charges,153.4,75,,,percent of total billed charges,75% of total billed charges,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,479.67,102,,,Fee Schedule,102% of WV Medicaid Rate,2326.19,165,,,Fee Schedule,165% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4049.52,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5553.61,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6956.46,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,470.26,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,28.63,14,,,percent of total billed charges,14% of total billed charges,28.63,6956.46,
"19110 Nipple exploration, with or without excision of a solitary lactiferous duct or a papilloma lac",3621652,CDM,510,RC,19110,HCPCS,Outpatient,,,333.21,166.61,,249.91,75,,,percent of total billed charges,75% of total billed charges,249.91,75,,,percent of total billed charges,75% of total billed charges,3232.09,100,,,Fee Schedule,100% of CMS OPPS Rate,950.21,102,,,Fee Schedule,102% of WV Medicaid Rate,5332.96,165,,,Fee Schedule,165% of CMS OPPS Rate,3349.79,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,9283.77,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,12731.95,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,15948.06,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,931.58,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,3232.09,100,,,Fee Schedule,100% of CMS OPPS Rate,3349.79,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,46.65,14,,,percent of total billed charges,14% of total billed charges,46.65,15948.06,
21011- Ex SQ tumor/face or scalp < 2 cm,3434682,CDM,510,RC,21011,HCPCS,Outpatient,,,8187.18,4093.59,,6140.39,75,,,percent of total billed charges,75% of total billed charges,6140.39,75,,,percent of total billed charges,75% of total billed charges,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,208.83,102,,,Fee Schedule,102% of WV Medicaid Rate,2326.19,165,,,Fee Schedule,165% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4049.52,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5553.61,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6956.46,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,204.74,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1146.21,14,,,percent of total billed charges,14% of total billed charges,204.74,6956.46,
21012- Ex SQ tumor/face or scalp 2 cm/>,3434683,CDM,510,RC,21012,HCPCS,Outpatient,,,8187.18,4093.59,,6140.39,75,,,percent of total billed charges,75% of total billed charges,6140.39,75,,,percent of total billed charges,75% of total billed charges,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,479.67,102,,,Fee Schedule,102% of WV Medicaid Rate,2326.19,165,,,Fee Schedule,165% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4049.52,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5553.61,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6956.46,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,470.26,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1146.21,14,,,percent of total billed charges,14% of total billed charges,470.26,6956.46,
21013- Exc IM tumor/face & scalp < 2 cm,3434684,CDM,510,RC,21013,HCPCS,Outpatient,,,8187.18,4093.59,,6140.39,75,,,percent of total billed charges,75% of total billed charges,6140.39,75,,,percent of total billed charges,75% of total billed charges,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,263.15,102,,,Fee Schedule,102% of WV Medicaid Rate,2326.19,165,,,Fee Schedule,165% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4049.52,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5553.61,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6956.46,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,257.99,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1146.21,14,,,percent of total billed charges,14% of total billed charges,257.99,6956.46,
21552- Exc SQ tum/neck/ant thorax 3cm/>,3434705,CDM,510,RC,21552,HCPCS,Outpatient,,,12446.68,6223.34,,9335.01,75,,,percent of total billed charges,75% of total billed charges,9335.01,75,,,percent of total billed charges,75% of total billed charges,2428.67,100,,,Fee Schedule,100% of CMS OPPS Rate,803.83,102,,,Fee Schedule,102% of WV Medicaid Rate,4007.32,165,,,Fee Schedule,165% of CMS OPPS Rate,2517.11,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,6976.06,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,9567.11,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,11983.78,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,788.07,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2428.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2517.11,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1742.54,14,,,percent of total billed charges,14% of total billed charges,788.07,11983.78,
24065 Biopsy arm/elbow soft tissue  (the CPT code is built without a description),3428318,CDM,360,RC,24065,HCPCS,Outpatient,,,223.48,111.74,,167.61,75,,,percent of total billed charges,75% of total billed charges,167.61,75,,,percent of total billed charges,75% of total billed charges,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,147.41,102,,,Fee Schedule,102% of WV Medicaid Rate,2326.19,165,,,Fee Schedule,165% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4049.52,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5553.61,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6956.46,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,144.52,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,31.29,14,,,percent of total billed charges,14% of total billed charges,31.29,6956.46,
25075- Exc SQ tumor/forearm/wrist/<3cm,3434889,CDM,960,RC,25075,HCPCS,Outpatient,,,7225.17,3612.59,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
26115- Exc hand les sc < 1.5 cm,3434907,CDM,960,RC,26115,HCPCS,Outpatient,,,530.61,265.31,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
"27040 - Biopsy, soft tissue of pelvis and hip area; superficial",4037478,CDM,983,RC,27040,HCPCS,Outpatient,,,343.48,171.74,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
"27613 - Biopsy, soft tissue of leg or ankle area; superficial",3715297,CDM,510,RC,27613,HCPCS,Outpatient,,,222.7,111.35,,167.03,75,,,percent of total billed charges,75% of total billed charges,167.03,75,,,percent of total billed charges,75% of total billed charges,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,137.59,102,,,Fee Schedule,102% of WV Medicaid Rate,2326.19,165,,,Fee Schedule,165% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4049.52,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5553.61,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6956.46,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,134.89,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,31.18,14,,,percent of total billed charges,14% of total billed charges,31.18,6956.46,
28190- Remove foreign body/foot/subq,3435165,CDM,360,RC,28190,HCPCS,Outpatient,,,263.75,131.88,,197.81,75,,,percent of total billed charges,75% of total billed charges,197.81,75,,,percent of total billed charges,75% of total billed charges,610.13,100,,,Fee Schedule,100% of CMS OPPS Rate,137.04,102,,,Fee Schedule,102% of WV Medicaid Rate,1006.72,165,,,Fee Schedule,165% of CMS OPPS Rate,632.35,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1752.53,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2403.46,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,3010.58,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,134.35,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,610.13,100,,,Fee Schedule,100% of CMS OPPS Rate,632.35,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,36.93,14,,,percent of total billed charges,14% of total billed charges,36.93,3010.58,
29260 Strapping Elbow/Wrist,4305638,CDM,761,RC,29260,HCPCS,Outpatient,,,308.88,154.44,,231.66,75,,,percent of total billed charges,75% of total billed charges,231.66,75,,,percent of total billed charges,75% of total billed charges,54.04,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,89.16,165,,,Fee Schedule,165% of CMS OPPS Rate,56,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,155.22,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,212.87,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,266.65,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,54.04,100,,,Fee Schedule,100% of CMS OPPS Rate,56,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,43.24,14,,,percent of total billed charges,14% of total billed charges,43.24,266.65,
29280 Strapping Hand/Finger,4305639,CDM,761,RC,29280,HCPCS,Outpatient,,,308.88,154.44,,231.66,75,,,percent of total billed charges,75% of total billed charges,231.66,75,,,percent of total billed charges,75% of total billed charges,54.04,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,89.16,165,,,Fee Schedule,165% of CMS OPPS Rate,56,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,155.22,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,212.87,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,266.65,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,54.04,100,,,Fee Schedule,100% of CMS OPPS Rate,56,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,43.24,14,,,percent of total billed charges,14% of total billed charges,43.24,266.65,
29405 Application Short Leg Cast Below Knee-Toe,3436035,CDM,761,RC,29405,HCPCS,Outpatient,,,1356.16,678.08,,1017.12,75,,,percent of total billed charges,75% of total billed charges,1017.12,75,,,percent of total billed charges,75% of total billed charges,225.55,100,,,Fee Schedule,100% of CMS OPPS Rate,38.49,102,,,Fee Schedule,102% of WV Medicaid Rate,372.16,165,,,Fee Schedule,165% of CMS OPPS Rate,233.76,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,647.87,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,888.5,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1112.94,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,37.74,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,225.55,100,,,Fee Schedule,100% of CMS OPPS Rate,233.76,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,189.86,14,,,percent of total billed charges,14% of total billed charges,37.74,1112.94,
29425 Application Short Leg Cast Walking/Ambulatory,3549204,CDM,761,RC,29425,HCPCS,Outpatient,,,1356.16,678.08,,1017.12,75,,,percent of total billed charges,75% of total billed charges,1017.12,75,,,percent of total billed charges,75% of total billed charges,225.55,100,,,Fee Schedule,100% of CMS OPPS Rate,35.49,102,,,Fee Schedule,102% of WV Medicaid Rate,372.16,165,,,Fee Schedule,165% of CMS OPPS Rate,233.76,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,647.87,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,888.5,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1112.94,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,34.79,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,225.55,100,,,Fee Schedule,100% of CMS OPPS Rate,233.76,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,189.86,14,,,percent of total billed charges,14% of total billed charges,34.79,1112.94,
29445 Application Rigid Total Contact Leg Cast,3436037,CDM,761,RC,29445,HCPCS,Outpatient,,,1356.16,678.08,,1017.12,75,,,percent of total billed charges,75% of total billed charges,1017.12,75,,,percent of total billed charges,75% of total billed charges,225.55,100,,,Fee Schedule,100% of CMS OPPS Rate,48.87,102,,,Fee Schedule,102% of WV Medicaid Rate,372.16,165,,,Fee Schedule,165% of CMS OPPS Rate,233.76,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,647.87,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,888.5,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1112.94,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,47.91,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,225.55,100,,,Fee Schedule,100% of CMS OPPS Rate,233.76,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,189.86,14,,,percent of total billed charges,14% of total billed charges,47.91,1112.94,
29540 Strapping Ankle &/Foot,3436039,CDM,761,RC,29540,HCPCS,Outpatient,,,795.69,397.85,,596.77,75,,,percent of total billed charges,75% of total billed charges,596.77,75,,,percent of total billed charges,75% of total billed charges,137.03,100,,,Fee Schedule,100% of CMS OPPS Rate,10.65,102,,,Fee Schedule,102% of WV Medicaid Rate,226.1,165,,,Fee Schedule,165% of CMS OPPS Rate,142.02,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,393.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,539.8,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,676.18,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,10.44,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,137.03,100,,,Fee Schedule,100% of CMS OPPS Rate,142.02,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,111.4,14,,,percent of total billed charges,14% of total billed charges,10.44,676.18,
29580 Application of Paste Boot,3436042,CDM,761,RC,29580,HCPCS,Outpatient,,,795.69,397.85,,596.77,75,,,percent of total billed charges,75% of total billed charges,596.77,75,,,percent of total billed charges,75% of total billed charges,137.03,100,,,Fee Schedule,100% of CMS OPPS Rate,34.67,102,,,Fee Schedule,102% of WV Medicaid Rate,226.1,165,,,Fee Schedule,165% of CMS OPPS Rate,142.02,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,393.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,539.8,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,676.18,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,33.99,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,137.03,100,,,Fee Schedule,100% of CMS OPPS Rate,142.02,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,111.4,14,,,percent of total billed charges,14% of total billed charges,33.99,676.18,
29580 Application of Paste Boot - Bilateral,3436041,CDM,761,RC,29580,HCPCS,Outpatient,,,795.69,397.85,,596.77,75,,,percent of total billed charges,75% of total billed charges,596.77,75,,,percent of total billed charges,75% of total billed charges,137.03,100,,,Fee Schedule,100% of CMS OPPS Rate,34.67,102,,,Fee Schedule,102% of WV Medicaid Rate,226.1,165,,,Fee Schedule,165% of CMS OPPS Rate,142.02,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,393.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,539.8,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,676.18,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,33.99,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,137.03,100,,,Fee Schedule,100% of CMS OPPS Rate,142.02,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,111.4,14,,,percent of total billed charges,14% of total billed charges,33.99,676.18,
29580 Application of Unna Boot,4135334,CDM,510,RC,29580,HCPCS,Outpatient,,,795.69,397.85,,596.77,75,,,percent of total billed charges,75% of total billed charges,596.77,75,,,percent of total billed charges,75% of total billed charges,137.03,100,,,Fee Schedule,100% of CMS OPPS Rate,34.67,102,,,Fee Schedule,102% of WV Medicaid Rate,226.1,165,,,Fee Schedule,165% of CMS OPPS Rate,142.02,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,393.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,539.8,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,676.18,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,33.99,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,137.03,100,,,Fee Schedule,100% of CMS OPPS Rate,142.02,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,111.4,14,,,percent of total billed charges,14% of total billed charges,33.99,676.18,
29581 Appl Mltlayr Compres Leg Below Knee W/Ankle Foot,3436046,CDM,761,RC,29581,HCPCS,Outpatient,,,795.69,397.85,,596.77,75,,,percent of total billed charges,75% of total billed charges,596.77,75,,,percent of total billed charges,75% of total billed charges,137.03,100,,,Fee Schedule,100% of CMS OPPS Rate,55.69,102,,,Fee Schedule,102% of WV Medicaid Rate,226.1,165,,,Fee Schedule,165% of CMS OPPS Rate,142.02,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,393.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,539.8,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,676.18,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,54.6,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,137.03,100,,,Fee Schedule,100% of CMS OPPS Rate,142.02,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,111.4,14,,,percent of total billed charges,14% of total billed charges,54.6,676.18,
29581 Appl Mltlayr Compres Leg Below Knee W/Ankle Foot - Bil,3436045,CDM,761,RC,29581,HCPCS,Outpatient,,,795.69,397.85,,596.77,75,,,percent of total billed charges,75% of total billed charges,596.77,75,,,percent of total billed charges,75% of total billed charges,137.03,100,,,Fee Schedule,100% of CMS OPPS Rate,55.69,102,,,Fee Schedule,102% of WV Medicaid Rate,226.1,165,,,Fee Schedule,165% of CMS OPPS Rate,142.02,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,393.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,539.8,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,676.18,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,54.6,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,137.03,100,,,Fee Schedule,100% of CMS OPPS Rate,142.02,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,111.4,14,,,percent of total billed charges,14% of total billed charges,54.6,676.18,
29581- Apply multi-lay compres/lower leg,3436044,CDM,761,RC,29581,HCPCS,Outpatient,,,795.69,397.85,,596.77,75,,,percent of total billed charges,75% of total billed charges,596.77,75,,,percent of total billed charges,75% of total billed charges,137.03,100,,,Fee Schedule,100% of CMS OPPS Rate,55.69,102,,,Fee Schedule,102% of WV Medicaid Rate,226.1,165,,,Fee Schedule,165% of CMS OPPS Rate,142.02,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,393.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,539.8,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,676.18,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,54.6,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,137.03,100,,,Fee Schedule,100% of CMS OPPS Rate,142.02,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,111.4,14,,,percent of total billed charges,14% of total billed charges,54.6,676.18,
29584 Appl Mltlayr Compres Sys Uparm Lwarm Hand&Fing,4305637,CDM,761,RC,29584,HCPCS,Outpatient,,,795.69,397.85,,596.77,75,,,percent of total billed charges,75% of total billed charges,596.77,75,,,percent of total billed charges,75% of total billed charges,137.03,100,,,Fee Schedule,100% of CMS OPPS Rate,57.33,102,,,Fee Schedule,102% of WV Medicaid Rate,226.1,165,,,Fee Schedule,165% of CMS OPPS Rate,142.02,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,393.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,539.8,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,676.18,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,56.21,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,137.03,100,,,Fee Schedule,100% of CMS OPPS Rate,142.02,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,111.4,14,,,percent of total billed charges,14% of total billed charges,56.21,676.18,
31231- Nasal endoscopy dx,3431300,CDM,510,RC,31231,HCPCS,Outpatient,,,131.25,65.63,,98.44,75,,,percent of total billed charges,75% of total billed charges,98.44,75,,,percent of total billed charges,75% of total billed charges,168.05,100,,,Fee Schedule,100% of CMS OPPS Rate,67.2,102,,,Fee Schedule,102% of WV Medicaid Rate,277.27,165,,,Fee Schedule,165% of CMS OPPS Rate,174.17,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,482.7,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,661.99,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,829.22,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,65.88,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,168.05,100,,,Fee Schedule,100% of CMS OPPS Rate,174.17,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,18.38,14,,,percent of total billed charges,14% of total billed charges,18.38,829.22,
31254 - NASAL/SINUS NDSC W/PARTIAL ETHMOIDECTOMY,4037482,CDM,983,RC,31254,HCPCS,Outpatient,,,476.93,238.47,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
31575 - DIAGNOSTIC LARYNGOSCOPY,3908940,CDM,761,RC,31575,HCPCS,Outpatient,,,812.13,406.07,,609.1,75,,,percent of total billed charges,75% of total billed charges,609.1,75,,,percent of total billed charges,75% of total billed charges,168.05,100,,,Fee Schedule,100% of CMS OPPS Rate,67.2,102,,,Fee Schedule,102% of WV Medicaid Rate,277.27,165,,,Fee Schedule,165% of CMS OPPS Rate,174.17,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,482.7,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,661.99,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,829.22,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,65.88,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,168.05,100,,,Fee Schedule,100% of CMS OPPS Rate,174.17,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,113.7,14,,,percent of total billed charges,14% of total billed charges,65.88,829.22,
"31575 Laryngoscopy, flexible; diagnostic",3584895,CDM,510,RC,31575,HCPCS,Outpatient,,,713.51,356.76,,535.13,75,,,percent of total billed charges,75% of total billed charges,535.13,75,,,percent of total billed charges,75% of total billed charges,168.05,100,,,Fee Schedule,100% of CMS OPPS Rate,67.2,102,,,Fee Schedule,102% of WV Medicaid Rate,277.27,165,,,Fee Schedule,165% of CMS OPPS Rate,174.17,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,482.7,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,661.99,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,829.22,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,65.88,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,168.05,100,,,Fee Schedule,100% of CMS OPPS Rate,174.17,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,99.89,14,,,percent of total billed charges,14% of total billed charges,65.88,829.22,
"36010 - PF - Introduction of catheter, superior or inferior vena cava",3640894,CDM,510,RC,36010,HCPCS,Outpatient,,,1082.56,541.28,,811.92,75,,,percent of total billed charges,75% of total billed charges,811.92,75,,,percent of total billed charges,75% of total billed charges,346.42,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,151.56,14,,,percent of total billed charges,14% of total billed charges,151.56,811.92,
"36012 - PF - Selective catheter placement, venous system; second order, or more selective, branch (e",3640913,CDM,510,RC,36012,HCPCS,Outpatient,,,1640.01,820.01,,1230.01,75,,,percent of total billed charges,75% of total billed charges,1230.01,75,,,percent of total billed charges,75% of total billed charges,524.8,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,229.6,14,,,percent of total billed charges,14% of total billed charges,229.6,1230.01,
"36248 - (PF) Selective catheter placement, arterial system; additional second order, third order,",3634905,CDM,510,RC,36248,HCPCS,Outpatient,,,169.77,84.89,,127.33,75,,,percent of total billed charges,75% of total billed charges,127.33,75,,,percent of total billed charges,75% of total billed charges,54.33,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.77,14,,,percent of total billed charges,14% of total billed charges,23.77,127.33,
36410 - Non-routine bl draw 3/> yrs,4241827,CDM,960,RC,36410,HCPCS,Outpatient,,,38.9,19.45,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
36465 NJX Noncmpnd Sclerosant Single Incmptnt Vein,3436048,CDM,761,RC,36465,HCPCS,Outpatient,,,9208.91,4604.46,,6906.68,75,,,percent of total billed charges,75% of total billed charges,6906.68,75,,,percent of total billed charges,75% of total billed charges,1622.59,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,2677.27,165,,,Fee Schedule,165% of CMS OPPS Rate,1681.67,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4660.68,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,6391.75,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,8006.31,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,1622.59,100,,,Fee Schedule,100% of CMS OPPS Rate,1681.67,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1289.25,14,,,percent of total billed charges,14% of total billed charges,1289.25,8006.31,
36466 NJX Noncmpnd Sclerosant Multiple Incmptnt Veins,3436049,CDM,761,RC,36466,HCPCS,Outpatient,,,9208.91,4604.46,,6906.68,75,,,percent of total billed charges,75% of total billed charges,6906.68,75,,,percent of total billed charges,75% of total billed charges,1622.59,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,2677.27,165,,,Fee Schedule,165% of CMS OPPS Rate,1681.67,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4660.68,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,6391.75,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,8006.31,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,1622.59,100,,,Fee Schedule,100% of CMS OPPS Rate,1681.67,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1289.25,14,,,percent of total billed charges,14% of total billed charges,1289.25,8006.31,
36468 Tx of symptomatic spider veins sclerotherapy,4117375,CDM,761,RC,36468,HCPCS,Outpatient,,,2013.58,1006.79,,1510.19,75,,,percent of total billed charges,75% of total billed charges,1510.19,75,,,percent of total billed charges,75% of total billed charges,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,578.73,165,,,Fee Schedule,165% of CMS OPPS Rate,363.52,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1007.47,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1381.67,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1730.68,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,363.52,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,281.9,14,,,percent of total billed charges,14% of total billed charges,281.9,1730.68,
36470 Injection Sclerosant Single Incmptnt Vein,3436050,CDM,761,RC,36470,HCPCS,Outpatient,,,2013.58,1006.79,,1510.19,75,,,percent of total billed charges,75% of total billed charges,1510.19,75,,,percent of total billed charges,75% of total billed charges,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,69.62,102,,,Fee Schedule,102% of WV Medicaid Rate,578.72,165,,,Fee Schedule,165% of CMS OPPS Rate,363.51,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1007.47,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1381.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1730.67,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,68.25,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,363.51,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,281.9,14,,,percent of total billed charges,14% of total billed charges,68.25,1730.67,
36471 Injection Sclerosant Multiple Incmptnt Veins,3436052,CDM,761,RC,36471,HCPCS,Outpatient,,,2013.58,1006.79,,1510.19,75,,,percent of total billed charges,75% of total billed charges,1510.19,75,,,percent of total billed charges,75% of total billed charges,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,114.66,102,,,Fee Schedule,102% of WV Medicaid Rate,578.72,165,,,Fee Schedule,165% of CMS OPPS Rate,363.51,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1007.47,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1381.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1730.67,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,112.41,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,363.51,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,281.9,14,,,percent of total billed charges,14% of total billed charges,112.41,1730.67,
36475 - Radiofrequency ablation vein,4023140,CDM,761,RC,36475,HCPCS,Outpatient,,,16096.15,8048.08,,12072.11,75,,,percent of total billed charges,75% of total billed charges,12072.11,75,,,percent of total billed charges,75% of total billed charges,2800.71,100,,,Fee Schedule,100% of CMS OPPS Rate,1102.62,102,,,Fee Schedule,102% of WV Medicaid Rate,4621.18,165,,,Fee Schedule,165% of CMS OPPS Rate,2902.7,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8044.7,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11032.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13819.53,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1081,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2800.71,100,,,Fee Schedule,100% of CMS OPPS Rate,2902.7,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,2253.46,14,,,percent of total billed charges,14% of total billed charges,1081,13819.53,
36475- Endo abl/incom vein/ext/rad fre/#1,3430716,CDM,761,RC,36475,HCPCS,Outpatient,,,16096.15,8048.08,,12072.11,75,,,percent of total billed charges,75% of total billed charges,12072.11,75,,,percent of total billed charges,75% of total billed charges,2800.71,100,,,Fee Schedule,100% of CMS OPPS Rate,1102.62,102,,,Fee Schedule,102% of WV Medicaid Rate,4621.18,165,,,Fee Schedule,165% of CMS OPPS Rate,2902.7,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8044.7,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11032.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13819.53,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1081,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2800.71,100,,,Fee Schedule,100% of CMS OPPS Rate,2902.7,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,2253.46,14,,,percent of total billed charges,14% of total billed charges,1081,13819.53,
36475 Endovenous rf 1st vein,3428319,CDM,510,RC,36475,HCPCS,Outpatient,,,1880.93,940.47,,1410.7,75,,,percent of total billed charges,75% of total billed charges,1410.7,75,,,percent of total billed charges,75% of total billed charges,2800.71,100,,,Fee Schedule,100% of CMS OPPS Rate,1102.62,102,,,Fee Schedule,102% of WV Medicaid Rate,4621.18,165,,,Fee Schedule,165% of CMS OPPS Rate,2902.7,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8044.7,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11032.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13819.53,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1081,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2800.71,100,,,Fee Schedule,100% of CMS OPPS Rate,2902.7,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,263.33,14,,,percent of total billed charges,14% of total billed charges,263.33,13819.53,
36478 Endoven AbltJ Incmptnt Vein XTR Laser 1st Vein,3436053,CDM,761,RC,36478,HCPCS,Outpatient,,,16096.15,8048.08,,12072.11,75,,,percent of total billed charges,75% of total billed charges,12072.11,75,,,percent of total billed charges,75% of total billed charges,2800.71,100,,,Fee Schedule,100% of CMS OPPS Rate,1102.62,102,,,Fee Schedule,102% of WV Medicaid Rate,4621.18,165,,,Fee Schedule,165% of CMS OPPS Rate,2902.7,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8044.7,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11032.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13819.53,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1081,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2800.71,100,,,Fee Schedule,100% of CMS OPPS Rate,2902.7,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,2253.46,14,,,percent of total billed charges,14% of total billed charges,1081,13819.53,
36482 Endoven Ablti Ther Chem Adhesive 1st Vein,3549208,CDM,761,RC,36482,HCPCS,Outpatient,,,27750.38,13875.19,,20812.79,75,,,percent of total billed charges,75% of total billed charges,20812.79,75,,,percent of total billed charges,75% of total billed charges,4832.22,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,7973.16,165,,,Fee Schedule,165% of CMS OPPS Rate,5008.18,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,13879.91,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,19035.18,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,23843.51,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,4832.22,100,,,Fee Schedule,100% of CMS OPPS Rate,5008.18,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,3885.05,14,,,percent of total billed charges,14% of total billed charges,3885.05,23843.51,
36483 Endoven Ablti Ther Chem Adhesive Sbsq Vein,3549209,CDM,761,RC,36483,HCPCS,Outpatient,,,5019.1,2509.55,,3764.33,75,,,percent of total billed charges,75% of total billed charges,3764.33,75,,,percent of total billed charges,75% of total billed charges,1606.11,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,702.67,14,,,percent of total billed charges,14% of total billed charges,702.67,3764.33,
36561- Insert tunn CVC w/sub-q port 5yr>,3430722,CDM,510,RC,36561,HCPCS,Outpatient,,,1645.54,822.77,,1234.16,75,,,percent of total billed charges,75% of total billed charges,1234.16,75,,,percent of total billed charges,75% of total billed charges,2800.71,100,,,Fee Schedule,100% of CMS OPPS Rate,1102.62,102,,,Fee Schedule,102% of WV Medicaid Rate,4621.18,165,,,Fee Schedule,165% of CMS OPPS Rate,2902.7,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8044.7,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11032.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13819.53,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1081,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2800.71,100,,,Fee Schedule,100% of CMS OPPS Rate,2902.7,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,230.38,14,,,percent of total billed charges,14% of total billed charges,230.38,13819.53,
"36571 - (PF) Insertion of peripherally inserted central venous access device, with subcutaneous port",3634907,CDM,510,RC,36571,HCPCS,Outpatient,,,2415.42,1207.71,,1811.57,75,,,percent of total billed charges,75% of total billed charges,1811.57,75,,,percent of total billed charges,75% of total billed charges,2800.71,100,,,Fee Schedule,100% of CMS OPPS Rate,1102.62,102,,,Fee Schedule,102% of WV Medicaid Rate,4621.18,165,,,Fee Schedule,165% of CMS OPPS Rate,2902.7,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8044.7,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11032.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13819.53,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1081,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2800.71,100,,,Fee Schedule,100% of CMS OPPS Rate,2902.7,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,338.16,14,,,percent of total billed charges,14% of total billed charges,338.16,13819.53,
"36575 - (PF) Repair of tunneled or non-tunneled central venous access catheter, without subcutaneous",3634908,CDM,510,RC,36575,HCPCS,Outpatient,,,281.09,140.55,,210.82,75,,,percent of total billed charges,75% of total billed charges,210.82,75,,,percent of total billed charges,75% of total billed charges,543.88,100,,,Fee Schedule,100% of CMS OPPS Rate,220.64,102,,,Fee Schedule,102% of WV Medicaid Rate,897.4,165,,,Fee Schedule,165% of CMS OPPS Rate,563.67,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1562.23,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2142.48,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,2683.68,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,216.31,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,543.88,100,,,Fee Schedule,100% of CMS OPPS Rate,563.67,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,39.35,14,,,percent of total billed charges,14% of total billed charges,39.35,2683.68,
"36582 - (PF) Replacement, complete, of a tunneled centrally inserted central venous access device,",3634909,CDM,510,RC,36582,HCPCS,Outpatient,,,1499.5,749.75,,1124.63,75,,,percent of total billed charges,75% of total billed charges,1124.63,75,,,percent of total billed charges,75% of total billed charges,2800.71,100,,,Fee Schedule,100% of CMS OPPS Rate,1102.62,102,,,Fee Schedule,102% of WV Medicaid Rate,4621.18,165,,,Fee Schedule,165% of CMS OPPS Rate,2902.7,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8044.7,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11032.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13819.53,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1081,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2800.71,100,,,Fee Schedule,100% of CMS OPPS Rate,2902.7,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,209.93,14,,,percent of total billed charges,14% of total billed charges,209.93,13819.53,
36589- Rmv tunnel cent ven access cath,3430724,CDM,361,RC,36589,HCPCS,Outpatient,,,72.62,36.31,,54.47,75,,,percent of total billed charges,75% of total billed charges,54.47,75,,,percent of total billed charges,75% of total billed charges,543.88,100,,,Fee Schedule,100% of CMS OPPS Rate,220.64,102,,,Fee Schedule,102% of WV Medicaid Rate,897.41,165,,,Fee Schedule,165% of CMS OPPS Rate,563.69,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1562.23,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2142.48,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,2683.68,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,216.31,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,543.88,100,,,Fee Schedule,100% of CMS OPPS Rate,563.69,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,10.17,14,,,percent of total billed charges,14% of total billed charges,10.17,2683.68,
36590- Rmv tun cen ven acces cath/SQ port,3430725,CDM,361,RC,36590,HCPCS,Outpatient,,,86.86,43.43,,65.15,75,,,percent of total billed charges,75% of total billed charges,65.15,75,,,percent of total billed charges,75% of total billed charges,1398.82,100,,,Fee Schedule,100% of CMS OPPS Rate,440.05,102,,,Fee Schedule,102% of WV Medicaid Rate,2308.06,165,,,Fee Schedule,165% of CMS OPPS Rate,1449.76,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4017.93,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5510.28,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6902.18,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,431.42,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1398.82,100,,,Fee Schedule,100% of CMS OPPS Rate,1449.76,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,12.16,14,,,percent of total billed charges,14% of total billed charges,12.16,6902.18,
"36595 Mechanical removal of pericatheter obstructive material (eg, fibrin sheath) from central venou",3621453,CDM,510,RC,36595,HCPCS,Outpatient,,,1033.6,516.8,,775.2,75,,,percent of total billed charges,75% of total billed charges,775.2,75,,,percent of total billed charges,75% of total billed charges,2800.71,100,,,Fee Schedule,100% of CMS OPPS Rate,1432.13,102,,,Fee Schedule,102% of WV Medicaid Rate,4621.18,165,,,Fee Schedule,165% of CMS OPPS Rate,2902.7,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8044.7,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11032.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13819.53,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1404.05,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2800.71,100,,,Fee Schedule,100% of CMS OPPS Rate,2902.7,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,144.7,14,,,percent of total billed charges,14% of total billed charges,144.7,13819.53,
"36901 - PF - Introduction of needle(s) and/or catheter(s), dialysis circuit, with diagnostic angiogr",3640895,CDM,510,RC,36901,HCPCS,Outpatient,,,1331.29,665.65,,998.47,75,,,percent of total billed charges,75% of total billed charges,998.47,75,,,percent of total billed charges,75% of total billed charges,1398.82,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,2308.05,165,,,Fee Schedule,165% of CMS OPPS Rate,1449.76,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4017.93,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5510.28,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6902.18,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,1398.82,100,,,Fee Schedule,100% of CMS OPPS Rate,1449.76,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,186.38,14,,,percent of total billed charges,14% of total billed charges,186.38,6902.18,
"36902 - PF - Introduction of needle(s) and/or catheter(s), dialysis circuit, with diagnostic angiogr",3640896,CDM,510,RC,36902,HCPCS,Outpatient,,,2402.79,1201.4,,1802.09,75,,,percent of total billed charges,75% of total billed charges,1802.09,75,,,percent of total billed charges,75% of total billed charges,4903.32,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,8090.5,165,,,Fee Schedule,165% of CMS OPPS Rate,5081.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,14084.18,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,19315.33,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,24194.41,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,4903.32,100,,,Fee Schedule,100% of CMS OPPS Rate,5081.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,336.39,14,,,percent of total billed charges,14% of total billed charges,336.39,24194.41,
"36903 - PF - Introduction of needle(s) and/or catheter(s), dialysis circuit, with diagnostic angiogr",3640897,CDM,510,RC,36903,HCPCS,Outpatient,,,9908.01,4954.01,,7431.01,75,,,percent of total billed charges,75% of total billed charges,7431.01,75,,,percent of total billed charges,75% of total billed charges,9980.15,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,16467.25,165,,,Fee Schedule,165% of CMS OPPS Rate,10343.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,28666.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,39314,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,49244.77,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,9980.15,100,,,Fee Schedule,100% of CMS OPPS Rate,10343.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1387.12,14,,,percent of total billed charges,14% of total billed charges,1387.12,49244.77,
36904 - PERQ THRMBC/NFS DIALYSIS CIRCUIT IMG DX ANGRPH,4037512,CDM,983,RC,36904,HCPCS,Outpatient,,,3566.67,1783.34,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
"36905 - PF - Percutaneous transluminal mechanical thrombectomy and/or infusion for thrombolysis, dia",3640914,CDM,510,RC,36905,HCPCS,Outpatient,,,4572.63,2286.32,,3429.47,75,,,percent of total billed charges,75% of total billed charges,3429.47,75,,,percent of total billed charges,75% of total billed charges,9980.15,100,,,Fee Schedule,100% of CMS OPPS Rate,4471.74,102,,,Fee Schedule,102% of WV Medicaid Rate,16467.25,165,,,Fee Schedule,165% of CMS OPPS Rate,10343.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,28666.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,39314,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,49244.77,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,4384.06,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,9980.15,100,,,Fee Schedule,100% of CMS OPPS Rate,10343.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,640.17,14,,,percent of total billed charges,14% of total billed charges,640.17,49244.77,
36906 - PERQ THRMBC/NFS DIAL CIRCUIT TCAT PLMT IV STENT,4037522,CDM,983,RC,36906,HCPCS,Outpatient,,,12275.31,6137.66,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
"36908 - (PF) Transcatheter placement of intravascular stent(s), central dialysis segment, performed",3634910,CDM,510,RC,36908,HCPCS,Outpatient,,,3015.52,1507.76,,2261.64,75,,,percent of total billed charges,75% of total billed charges,2261.64,75,,,percent of total billed charges,75% of total billed charges,964.97,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,422.17,14,,,percent of total billed charges,14% of total billed charges,422.17,2261.64,
"37222 - PF - Revascularization, endovascular, open or percutaneous, iliac artery, each additional ip",3640916,CDM,510,RC,37222,HCPCS,Outpatient,,,1065.19,532.6,,798.89,75,,,percent of total billed charges,75% of total billed charges,798.89,75,,,percent of total billed charges,75% of total billed charges,340.86,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,149.13,14,,,percent of total billed charges,14% of total billed charges,149.13,798.89,
37226 - REVSC OPN/PRQ FEM/POP W/STNT/ANGIOP SM VSL,4037523,CDM,481,RC,37226,HCPCS,Outpatient,,,52157.48,26078.74,,39118.11,75,,,percent of total billed charges,75% of total billed charges,39118.11,75,,,percent of total billed charges,75% of total billed charges,9980.15,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,16467.25,165,,,Fee Schedule,165% of CMS OPPS Rate,10343.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,28666.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,39314,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,49244.77,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,9980.15,100,,,Fee Schedule,100% of CMS OPPS Rate,10343.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,7302.05,14,,,percent of total billed charges,14% of total billed charges,7302.05,49244.77,
37231 - REVSC OPN/PRQ TIB/PERO W/STNT/ATHR/ANGIOP SM VSL,4037542,CDM,481,RC,37231,HCPCS,Outpatient,,,83391.09,41695.55,,62543.32,75,,,percent of total billed charges,75% of total billed charges,62543.32,75,,,percent of total billed charges,75% of total billed charges,16149.79,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,26647.16,165,,,Fee Schedule,165% of CMS OPPS Rate,16737.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,46388.09,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,63617.56,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,79687.45,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,16149.79,100,,,Fee Schedule,100% of CMS OPPS Rate,16737.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,11674.75,14,,,percent of total billed charges,14% of total billed charges,11674.75,79687.45,
"37238 - PF - Transcatheter placement of an intravascular stent(s), open or percutaneous, including r",3640917,CDM,510,RC,37238,HCPCS,Outpatient,,,7785.55,3892.78,,5839.16,75,,,percent of total billed charges,75% of total billed charges,5839.16,75,,,percent of total billed charges,75% of total billed charges,9980.15,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,16467.25,165,,,Fee Schedule,165% of CMS OPPS Rate,10343.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,28666.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,39314,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,49244.77,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,9980.15,100,,,Fee Schedule,100% of CMS OPPS Rate,10343.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1089.98,14,,,percent of total billed charges,14% of total billed charges,1089.98,49244.77,
"37239 - PF - Transcatheter placement of an intravascular stent(s), open or percutaneous, including r",3640918,CDM,510,RC,37239,HCPCS,Outpatient,,,3849.36,1924.68,,2887.02,75,,,percent of total billed charges,75% of total billed charges,2887.02,75,,,percent of total billed charges,75% of total billed charges,1231.8,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,538.91,14,,,percent of total billed charges,14% of total billed charges,538.91,2887.02,
"37241 Vascular embolization or occlusion, inclusive of all radiological supervision and interpretati",3621881,CDM,510,RC,37241,HCPCS,Outpatient,,,10544.45,5272.23,,7908.34,75,,,percent of total billed charges,75% of total billed charges,7908.34,75,,,percent of total billed charges,75% of total billed charges,9980.15,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,16467.25,165,,,Fee Schedule,165% of CMS OPPS Rate,10343.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,28666.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,39314,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,49244.77,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,9980.15,100,,,Fee Schedule,100% of CMS OPPS Rate,10343.58,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1476.22,14,,,percent of total billed charges,14% of total billed charges,1476.22,49244.77,
37246 - PF - Transluminal balloon angioplasty (except lower extremity artery(ies) for occlusive dise,3640899,CDM,510,RC,37246,HCPCS,Outpatient,,,3689.07,1844.54,,2766.8,75,,,percent of total billed charges,75% of total billed charges,2766.8,75,,,percent of total billed charges,75% of total billed charges,4903.32,100,,,Fee Schedule,100% of CMS OPPS Rate,2268.13,102,,,Fee Schedule,102% of WV Medicaid Rate,8090.5,165,,,Fee Schedule,165% of CMS OPPS Rate,5081.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,14084.18,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,19315.33,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,24194.41,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,2223.66,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,4903.32,100,,,Fee Schedule,100% of CMS OPPS Rate,5081.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,516.47,14,,,percent of total billed charges,14% of total billed charges,516.47,24194.41,
37247 Transcatheter placement of an intravascular stent(s) (except lower extremity artery(s) for occ,3621308,CDM,510,RC,37247,HCPCS,Outpatient,,,940.44,470.22,,705.33,75,,,percent of total billed charges,75% of total billed charges,705.33,75,,,percent of total billed charges,75% of total billed charges,300.94,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,131.66,14,,,percent of total billed charges,14% of total billed charges,131.66,705.33,
"37248 - PF - Transluminal balloon angioplasty (except dialysis circuit), open or percutaneous, inclu",3640900,CDM,510,RC,37248,HCPCS,Outpatient,,,2660.21,1330.11,,1995.16,75,,,percent of total billed charges,75% of total billed charges,1995.16,75,,,percent of total billed charges,75% of total billed charges,4903.32,100,,,Fee Schedule,100% of CMS OPPS Rate,1740.26,102,,,Fee Schedule,102% of WV Medicaid Rate,8090.5,165,,,Fee Schedule,165% of CMS OPPS Rate,5081.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,14084.18,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,19315.33,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,24194.41,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1706.14,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,4903.32,100,,,Fee Schedule,100% of CMS OPPS Rate,5081.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,372.43,14,,,percent of total billed charges,14% of total billed charges,372.43,24194.41,
37252 - PF - Intravascular ultrasound (noncoronary vessel) during diagnostic evaluation and/or thera,3640919,CDM,510,RC,37252,HCPCS,Outpatient,,,2136.68,1068.34,,1602.51,75,,,percent of total billed charges,75% of total billed charges,1602.51,75,,,percent of total billed charges,75% of total billed charges,683.74,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,299.14,14,,,percent of total billed charges,14% of total billed charges,299.14,1602.51,
37253 - PF - Intravascular ultrasound (noncoronary vessel) during diagnostic evaluation and/or thera,3640920,CDM,510,RC,37253,HCPCS,Outpatient,,,238.46,119.23,,178.85,75,,,percent of total billed charges,75% of total billed charges,178.85,75,,,percent of total billed charges,75% of total billed charges,76.31,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.38,14,,,percent of total billed charges,14% of total billed charges,33.38,178.85,
37609- Ligation/biopsy/temporal artery,3430918,CDM,761,RC,37609,HCPCS,Outpatient,,,266.9,133.45,,200.18,75,,,percent of total billed charges,75% of total billed charges,200.18,75,,,percent of total billed charges,75% of total billed charges,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,479.67,102,,,Fee Schedule,102% of WV Medicaid Rate,2326.19,165,,,Fee Schedule,165% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4049.52,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5553.61,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6956.46,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,470.26,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,37.37,14,,,percent of total billed charges,14% of total billed charges,37.37,6956.46,
37765- Stab phlebectomy/1 ext/10-20 incis,3430749,CDM,360,RC,37765,HCPCS,Outpatient,,,388.48,194.24,,291.36,75,,,percent of total billed charges,75% of total billed charges,291.36,75,,,percent of total billed charges,75% of total billed charges,2800.71,100,,,Fee Schedule,100% of CMS OPPS Rate,192.19,102,,,Fee Schedule,102% of WV Medicaid Rate,4621.18,165,,,Fee Schedule,165% of CMS OPPS Rate,2902.7,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8044.7,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11032.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13819.53,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,188.42,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2800.71,100,,,Fee Schedule,100% of CMS OPPS Rate,2902.7,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,54.39,14,,,percent of total billed charges,14% of total billed charges,54.39,13819.53,
37799- Vasc Surg/Unlisted Procedure,3430751,CDM,360,RC,37799,HCPCS,Outpatient,,,2672.39,1336.2,,2004.29,75,,,percent of total billed charges,75% of total billed charges,2004.29,75,,,percent of total billed charges,75% of total billed charges,543.88,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,897.4,165,,,Fee Schedule,165% of CMS OPPS Rate,563.67,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1562.23,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2142.48,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,2683.68,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,543.88,100,,,Fee Schedule,100% of CMS OPPS Rate,563.67,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,374.13,14,,,percent of total billed charges,14% of total billed charges,374.13,2683.68,
38505 - BX/EXC LYMPH NODE NEEDLE SUPERFICIAL,4037465,CDM,510,RC,38505,HCPCS,Outpatient,,,199.52,99.76,,149.64,75,,,percent of total billed charges,75% of total billed charges,149.64,75,,,percent of total billed charges,75% of total billed charges,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,479.67,102,,,Fee Schedule,102% of WV Medicaid Rate,2326.19,165,,,Fee Schedule,165% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4049.52,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5553.61,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6956.46,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,470.26,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,27.93,14,,,percent of total billed charges,14% of total billed charges,27.93,6956.46,
38505- Bx/exc lymph node/needle/superfic,3431451,CDM,320,RC,38505,HCPCS,Outpatient,,,223.47,111.74,,167.6,75,,,percent of total billed charges,75% of total billed charges,167.6,75,,,percent of total billed charges,75% of total billed charges,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,479.67,102,,,Fee Schedule,102% of WV Medicaid Rate,2326.19,165,,,Fee Schedule,165% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4049.52,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5553.61,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6956.46,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,470.26,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,31.29,14,,,percent of total billed charges,14% of total billed charges,31.29,6956.46,
38525- Bx/exc lymph node/open/deep axilla,3431453,CDM,510,RC,38525,HCPCS,Outpatient,,,6857.27,3428.64,,5142.95,75,,,percent of total billed charges,75% of total billed charges,5142.95,75,,,percent of total billed charges,75% of total billed charges,3232.09,100,,,Fee Schedule,100% of CMS OPPS Rate,950.21,102,,,Fee Schedule,102% of WV Medicaid Rate,5332.96,165,,,Fee Schedule,165% of CMS OPPS Rate,3349.79,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,9283.77,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,12731.95,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,15948.06,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,931.58,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,3232.09,100,,,Fee Schedule,100% of CMS OPPS Rate,3349.79,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,960.02,14,,,percent of total billed charges,14% of total billed charges,931.58,15948.06,
38792- Lymphangiography/sentinel node,3431465,CDM,510,RC,38792,HCPCS,Outpatient,,,117.67,58.84,,88.25,75,,,percent of total billed charges,75% of total billed charges,88.25,75,,,percent of total billed charges,75% of total billed charges,365.42,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,602.94,165,,,Fee Schedule,165% of CMS OPPS Rate,378.73,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1049.63,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1439.48,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1803.09,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,365.42,100,,,Fee Schedule,100% of CMS OPPS Rate,378.73,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,16.47,14,,,percent of total billed charges,14% of total billed charges,16.47,1803.09,
43239- EGD w/biopsy/single/multiple,3431169,CDM,510,RC,43239,HCPCS,Outpatient,,,599.31,299.66,,449.48,75,,,percent of total billed charges,75% of total billed charges,449.48,75,,,percent of total billed charges,75% of total billed charges,776.11,100,,,Fee Schedule,100% of CMS OPPS Rate,330.28,102,,,Fee Schedule,102% of WV Medicaid Rate,1280.58,165,,,Fee Schedule,165% of CMS OPPS Rate,804.37,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,2229.28,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,3057.28,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,3829.56,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,323.8,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,776.11,100,,,Fee Schedule,100% of CMS OPPS Rate,804.37,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,83.9,14,,,percent of total billed charges,14% of total billed charges,83.9,3829.56,
43251- EGD/remove tumor/polyp/w snare,3431180,CDM,510,RC,43251,HCPCS,Outpatient,,,756.47,378.24,,567.35,75,,,percent of total billed charges,75% of total billed charges,567.35,75,,,percent of total billed charges,75% of total billed charges,1637.37,100,,,Fee Schedule,100% of CMS OPPS Rate,557.09,102,,,Fee Schedule,102% of WV Medicaid Rate,2701.67,165,,,Fee Schedule,165% of CMS OPPS Rate,1697,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4703.14,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,6450,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,8079.28,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,546.17,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1637.37,100,,,Fee Schedule,100% of CMS OPPS Rate,1697,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,105.91,14,,,percent of total billed charges,14% of total billed charges,105.91,8079.28,
43450- Dilate esoph/unguide sound/bougie,3431204,CDM,510,RC,43450,HCPCS,Outpatient,,,267.69,133.85,,200.77,75,,,percent of total billed charges,75% of total billed charges,200.77,75,,,percent of total billed charges,75% of total billed charges,776.11,100,,,Fee Schedule,100% of CMS OPPS Rate,330.28,102,,,Fee Schedule,102% of WV Medicaid Rate,1280.58,165,,,Fee Schedule,165% of CMS OPPS Rate,804.37,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,2229.28,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,3057.28,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,3829.56,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,323.8,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,776.11,100,,,Fee Schedule,100% of CMS OPPS Rate,804.37,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,37.48,14,,,percent of total billed charges,14% of total billed charges,37.48,3829.56,
43762-MSA CHANGE GASTROSTOMY TUBE W/O REV,3429902,CDM,360,RC,43762,HCPCS,Outpatient,,,1312.82,656.41,,984.62,75,,,percent of total billed charges,75% of total billed charges,984.62,75,,,percent of total billed charges,75% of total billed charges,202.01,100,,,Fee Schedule,100% of CMS OPPS Rate,108.62,102,,,Fee Schedule,102% of WV Medicaid Rate,333.31,165,,,Fee Schedule,165% of CMS OPPS Rate,209.36,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,580.25,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,795.77,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,996.78,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,106.49,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,202.01,100,,,Fee Schedule,100% of CMS OPPS Rate,209.36,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,183.79,14,,,percent of total billed charges,14% of total billed charges,106.49,996.78,
Clinic Adjustment Gastric Band - S2083,4311851,CDM,510,RC,43999,HCPCS,Outpatient,,,3977.49,1988.75,,2983.12,75,,,percent of total billed charges,75% of total billed charges,2983.12,75,,,percent of total billed charges,75% of total billed charges,776.11,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1280.58,165,,,Fee Schedule,165% of CMS OPPS Rate,804.37,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,2229.28,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,3057.28,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,3829.56,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,776.11,100,,,Fee Schedule,100% of CMS OPPS Rate,804.37,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,556.85,14,,,percent of total billed charges,14% of total billed charges,556.85,3829.56,
"44380 - (PF) Ileoscopy, through stoma; diagnostic, including collection of specimen(s) by brushing",3635066,CDM,510,RC,44380,HCPCS,Outpatient,,,341.91,170.96,,256.43,75,,,percent of total billed charges,75% of total billed charges,256.43,75,,,percent of total billed charges,75% of total billed charges,776.11,100,,,Fee Schedule,100% of CMS OPPS Rate,330.28,102,,,Fee Schedule,102% of WV Medicaid Rate,1280.58,165,,,Fee Schedule,165% of CMS OPPS Rate,804.37,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,2229.28,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,3057.28,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,3829.56,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,323.8,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,776.11,100,,,Fee Schedule,100% of CMS OPPS Rate,804.37,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,47.87,14,,,percent of total billed charges,14% of total billed charges,47.87,3829.56,
"44388 - Colonoscopy through stoma; diagnostic, including collection of specimen(s) by brushing or wa",3572804,CDM,510,RC,44388,HCPCS,Outpatient,,,397.16,198.58,,297.87,75,,,percent of total billed charges,75% of total billed charges,297.87,75,,,percent of total billed charges,75% of total billed charges,781.31,100,,,Fee Schedule,100% of CMS OPPS Rate,323.92,102,,,Fee Schedule,102% of WV Medicaid Rate,1289.16,165,,,Fee Schedule,165% of CMS OPPS Rate,809.76,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,2244.21,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,3077.76,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,3855.21,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,317.57,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,781.31,100,,,Fee Schedule,100% of CMS OPPS Rate,809.76,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,55.6,14,,,percent of total billed charges,14% of total billed charges,55.6,3855.21,
"44394 - (PF) Colonoscopy through stoma; with removal of tumor(s), polyp(s), or other lesion(s) by",3635067,CDM,510,RC,44394,HCPCS,Outpatient,,,534.57,267.29,,400.93,75,,,percent of total billed charges,75% of total billed charges,400.93,75,,,percent of total billed charges,75% of total billed charges,1018.11,100,,,Fee Schedule,100% of CMS OPPS Rate,423.26,102,,,Fee Schedule,102% of WV Medicaid Rate,1679.88,165,,,Fee Schedule,165% of CMS OPPS Rate,1055.19,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,2924.39,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,4010.57,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,5023.64,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,414.96,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1018.11,100,,,Fee Schedule,100% of CMS OPPS Rate,1055.19,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,74.84,14,,,percent of total billed charges,14% of total billed charges,74.84,5023.64,
44404 - COLONOSCOPY STOMA W/SUBMUCOSAL INJECTION,4037561,CDM,983,RC,44404,HCPCS,Outpatient,,,626.14,313.07,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
"45300 - Proctosigmoidoscopy, rigid; diagnostic, with or without collection of specimen(s) by brushin",3572805,CDM,510,RC,45300,HCPCS,Outpatient,,,196.6,98.3,,147.45,75,,,percent of total billed charges,75% of total billed charges,147.45,75,,,percent of total billed charges,75% of total billed charges,781.31,100,,,Fee Schedule,100% of CMS OPPS Rate,81.36,102,,,Fee Schedule,102% of WV Medicaid Rate,1289.16,165,,,Fee Schedule,165% of CMS OPPS Rate,809.76,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,2244.21,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,3077.76,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,3855.21,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,79.76,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,781.31,100,,,Fee Schedule,100% of CMS OPPS Rate,809.76,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,27.52,14,,,percent of total billed charges,14% of total billed charges,27.52,3855.21,
"45303 - (PF) Proctosigmoidoscopy, rigid; with dilation",3635073,CDM,510,RC,45303,HCPCS,Outpatient,,,2149.32,1074.66,,1611.99,75,,,percent of total billed charges,75% of total billed charges,1611.99,75,,,percent of total billed charges,75% of total billed charges,1018.11,100,,,Fee Schedule,100% of CMS OPPS Rate,423.26,102,,,Fee Schedule,102% of WV Medicaid Rate,1679.88,165,,,Fee Schedule,165% of CMS OPPS Rate,1055.19,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,2924.39,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,4010.57,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,5023.64,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,414.96,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1018.11,100,,,Fee Schedule,100% of CMS OPPS Rate,1055.19,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,300.9,14,,,percent of total billed charges,14% of total billed charges,300.9,5023.64,
"45305 Proctosigmoidoscopy, rigid; with biopsy, single or multiple",3621146,CDM,510,RC,45305,HCPCS,Outpatient,,,267.67,133.84,,200.75,75,,,percent of total billed charges,75% of total billed charges,200.75,75,,,percent of total billed charges,75% of total billed charges,1018.11,100,,,Fee Schedule,100% of CMS OPPS Rate,423.26,102,,,Fee Schedule,102% of WV Medicaid Rate,1679.88,165,,,Fee Schedule,165% of CMS OPPS Rate,1055.19,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,2924.39,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,4010.57,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,5023.64,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,414.96,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1018.11,100,,,Fee Schedule,100% of CMS OPPS Rate,1055.19,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,37.47,14,,,percent of total billed charges,14% of total billed charges,37.47,5023.64,
"45338 - (PF) Sigmoidoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by",3635074,CDM,510,RC,45338,HCPCS,Outpatient,,,446.12,223.06,,334.59,75,,,percent of total billed charges,75% of total billed charges,334.59,75,,,percent of total billed charges,75% of total billed charges,1018.11,100,,,Fee Schedule,100% of CMS OPPS Rate,423.26,102,,,Fee Schedule,102% of WV Medicaid Rate,1679.88,165,,,Fee Schedule,165% of CMS OPPS Rate,1055.19,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,2924.39,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,4010.57,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,5023.64,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,414.96,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1018.11,100,,,Fee Schedule,100% of CMS OPPS Rate,1055.19,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,62.46,14,,,percent of total billed charges,14% of total billed charges,62.46,5023.64,
"45381 COLONSCOPE, SUBMUCOUS INJ",3429965,CDM,510,RC,45381,HCPCS,Outpatient,,,608.8,304.4,,456.6,75,,,percent of total billed charges,75% of total billed charges,456.6,75,,,percent of total billed charges,75% of total billed charges,1018.11,100,,,Fee Schedule,100% of CMS OPPS Rate,423.26,102,,,Fee Schedule,102% of WV Medicaid Rate,1679.88,165,,,Fee Schedule,165% of CMS OPPS Rate,1055.19,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,2924.39,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,4010.57,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,5023.64,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,414.96,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1018.11,100,,,Fee Schedule,100% of CMS OPPS Rate,1055.19,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,85.23,14,,,percent of total billed charges,14% of total billed charges,85.23,5023.64,
45385- Colonoscopy/snare rmv/tumor/polyp,3431250,CDM,510,RC,45385,HCPCS,Outpatient,,,503.75,251.88,,377.81,75,,,percent of total billed charges,75% of total billed charges,377.81,75,,,percent of total billed charges,75% of total billed charges,1018.11,100,,,Fee Schedule,100% of CMS OPPS Rate,423.26,102,,,Fee Schedule,102% of WV Medicaid Rate,1679.88,165,,,Fee Schedule,165% of CMS OPPS Rate,1055.19,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,2924.39,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,4010.57,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,5023.64,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,414.96,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1018.11,100,,,Fee Schedule,100% of CMS OPPS Rate,1055.19,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,70.53,14,,,percent of total billed charges,14% of total billed charges,70.53,5023.64,
46050-MSA INCISION OF ANAL ABSCESS,3429979,CDM,361,RC,46050,HCPCS,Outpatient,,,332.42,166.21,,249.32,75,,,percent of total billed charges,75% of total billed charges,249.32,75,,,percent of total billed charges,75% of total billed charges,781.31,100,,,Fee Schedule,100% of CMS OPPS Rate,323.92,102,,,Fee Schedule,102% of WV Medicaid Rate,1289.16,165,,,Fee Schedule,165% of CMS OPPS Rate,809.76,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,2244.21,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,3077.76,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,3855.21,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,317.57,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,781.31,100,,,Fee Schedule,100% of CMS OPPS Rate,809.76,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,46.54,14,,,percent of total billed charges,14% of total billed charges,46.54,3855.21,
"46080- Sphincterotomy, anal, division of sphincter (separate procedure)",3621307,CDM,510,RC,46080,HCPCS,Outpatient,,,319.02,159.51,,239.27,75,,,percent of total billed charges,75% of total billed charges,239.27,75,,,percent of total billed charges,75% of total billed charges,2415.71,100,,,Fee Schedule,100% of CMS OPPS Rate,926.81,102,,,Fee Schedule,102% of WV Medicaid Rate,3985.94,165,,,Fee Schedule,165% of CMS OPPS Rate,2503.69,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,6938.85,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,9516.07,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,11919.85,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,908.64,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2415.71,100,,,Fee Schedule,100% of CMS OPPS Rate,2503.69,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,44.66,14,,,percent of total billed charges,14% of total billed charges,44.66,11919.85,
46083-Incise external hemorrhoid,3431258,CDM,510,RC,46083,HCPCS,Outpatient,,,1171.77,585.89,,878.83,75,,,percent of total billed charges,75% of total billed charges,878.83,75,,,percent of total billed charges,75% of total billed charges,202.01,100,,,Fee Schedule,100% of CMS OPPS Rate,108.62,102,,,Fee Schedule,102% of WV Medicaid Rate,333.31,165,,,Fee Schedule,165% of CMS OPPS Rate,209.36,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,580.25,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,795.77,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,996.78,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,106.49,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,202.01,100,,,Fee Schedule,100% of CMS OPPS Rate,209.36,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,164.05,14,,,percent of total billed charges,14% of total billed charges,106.49,996.78,
"46200- Fissurectomy, including sphincterotomy, when performed",3621646,CDM,510,RC,46200,HCPCS,Outpatient,,,337.95,168.98,,253.46,75,,,percent of total billed charges,75% of total billed charges,253.46,75,,,percent of total billed charges,75% of total billed charges,2415.71,100,,,Fee Schedule,100% of CMS OPPS Rate,926.81,102,,,Fee Schedule,102% of WV Medicaid Rate,3985.94,165,,,Fee Schedule,165% of CMS OPPS Rate,2503.69,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,6938.85,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,9516.07,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,11919.85,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,908.64,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2415.71,100,,,Fee Schedule,100% of CMS OPPS Rate,2503.69,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,47.31,14,,,percent of total billed charges,14% of total billed charges,47.31,11919.85,
46220-HKBT EXC PERIANAL SKIN TAG,3435933,CDM,510,RC,46220,HCPCS,Outpatient,,,4568.35,2284.18,,3426.26,75,,,percent of total billed charges,75% of total billed charges,3426.26,75,,,percent of total billed charges,75% of total billed charges,1018.11,100,,,Fee Schedule,100% of CMS OPPS Rate,423.26,102,,,Fee Schedule,102% of WV Medicaid Rate,1679.88,165,,,Fee Schedule,165% of CMS OPPS Rate,1055.19,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,2924.39,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,4010.57,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,5023.64,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,414.96,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1018.11,100,,,Fee Schedule,100% of CMS OPPS Rate,1055.19,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,639.57,14,,,percent of total billed charges,14% of total billed charges,414.96,5023.64,
46221-Ligation of hemorrhoid(s),3431259,CDM,361,RC,46221,HCPCS,Outpatient,,,223.47,111.74,,167.6,75,,,percent of total billed charges,75% of total billed charges,167.6,75,,,percent of total billed charges,75% of total billed charges,781.31,100,,,Fee Schedule,100% of CMS OPPS Rate,161.33,102,,,Fee Schedule,102% of WV Medicaid Rate,1289.16,165,,,Fee Schedule,165% of CMS OPPS Rate,809.76,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,2244.21,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,3077.76,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,3855.21,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,158.17,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,781.31,100,,,Fee Schedule,100% of CMS OPPS Rate,809.76,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,31.29,14,,,percent of total billed charges,14% of total billed charges,31.29,3855.21,
"46255 - Hemorrhoidectomy, internal and external, single column/group;",3572807,CDM,510,RC,46255,HCPCS,Outpatient,,,360.98,180.49,,270.74,75,,,percent of total billed charges,75% of total billed charges,270.74,75,,,percent of total billed charges,75% of total billed charges,2415.71,100,,,Fee Schedule,100% of CMS OPPS Rate,926.81,102,,,Fee Schedule,102% of WV Medicaid Rate,3985.94,165,,,Fee Schedule,165% of CMS OPPS Rate,2503.69,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,6938.85,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,9516.07,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,11919.85,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,908.64,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2415.71,100,,,Fee Schedule,100% of CMS OPPS Rate,2503.69,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,50.54,14,,,percent of total billed charges,14% of total billed charges,50.54,11919.85,
46270- Surgical treatment of anal fistula (fistulectomy/fistulotomy); subcutaneous,3566791,CDM,510,RC,46270,HCPCS,Outpatient,,,599.01,299.51,,449.26,75,,,percent of total billed charges,75% of total billed charges,449.26,75,,,percent of total billed charges,75% of total billed charges,2415.71,100,,,Fee Schedule,100% of CMS OPPS Rate,926.81,102,,,Fee Schedule,102% of WV Medicaid Rate,3985.94,165,,,Fee Schedule,165% of CMS OPPS Rate,2503.69,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,6938.85,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,9516.07,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,11919.85,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,908.64,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2415.71,100,,,Fee Schedule,100% of CMS OPPS Rate,2503.69,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,83.86,14,,,percent of total billed charges,14% of total billed charges,83.86,11919.85,
46320-Removal of hemorrhoid clot,3431262,CDM,361,RC,46320,HCPCS,Outpatient,,,244.79,122.4,,183.59,75,,,percent of total billed charges,75% of total billed charges,183.59,75,,,percent of total billed charges,75% of total billed charges,1018.11,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1679.88,165,,,Fee Schedule,165% of CMS OPPS Rate,1055.19,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,2924.39,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,4010.57,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,5023.64,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,1018.11,100,,,Fee Schedule,100% of CMS OPPS Rate,1055.19,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,34.27,14,,,percent of total billed charges,14% of total billed charges,34.27,5023.64,
46600-Diagnostic anoscopy spx,3430923,CDM,361,RC,46600,HCPCS,Outpatient,,,194.27,97.14,,145.7,75,,,percent of total billed charges,75% of total billed charges,145.7,75,,,percent of total billed charges,75% of total billed charges,109.16,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,180.11,165,,,Fee Schedule,165% of CMS OPPS Rate,113.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,313.55,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,430.01,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,538.63,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,109.16,100,,,Fee Schedule,100% of CMS OPPS Rate,113.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,27.2,14,,,percent of total billed charges,14% of total billed charges,27.2,538.63,
46606- Anoscopy/diag/w biopsy/single/mult,3431263,CDM,510,RC,46606,HCPCS,Outpatient,,,510.11,255.06,,382.58,75,,,percent of total billed charges,75% of total billed charges,382.58,75,,,percent of total billed charges,75% of total billed charges,1018.11,100,,,Fee Schedule,100% of CMS OPPS Rate,198.46,102,,,Fee Schedule,102% of WV Medicaid Rate,1679.88,165,,,Fee Schedule,165% of CMS OPPS Rate,1055.19,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,2924.39,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,4010.57,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,5023.64,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,194.57,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1018.11,100,,,Fee Schedule,100% of CMS OPPS Rate,1055.19,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,71.42,14,,,percent of total billed charges,14% of total billed charges,71.42,5023.64,
46916 - Cryosurgery Anal Les,4327324,CDM,510,RC,46916,HCPCS,Outpatient,,,1010.98,505.49,,758.24,75,,,percent of total billed charges,75% of total billed charges,758.24,75,,,percent of total billed charges,75% of total billed charges,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,73.31,102,,,Fee Schedule,102% of WV Medicaid Rate,280.12,165,,,Fee Schedule,165% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,487.65,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,668.77,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,837.71,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,71.87,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,141.54,14,,,percent of total billed charges,14% of total billed charges,71.87,837.71,
49411-Fiducial Placement -Pelvic,3916937,CDM,510,RC,49411,HCPCS,Outpatient,,,6230.02,3115.01,,4672.52,75,,,percent of total billed charges,75% of total billed charges,4672.52,75,,,percent of total billed charges,75% of total billed charges,1260.44,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,2079.73,165,,,Fee Schedule,165% of CMS OPPS Rate,1306.33,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,3620.47,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,4965.18,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6219.4,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,1260.44,100,,,Fee Schedule,100% of CMS OPPS Rate,1306.33,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,872.2,14,,,percent of total billed charges,14% of total billed charges,872.2,6219.4,
"50432 - PF Placement of nephrostomy catheter, percutaneous, including diagnostic nephrostogram and/o",3641210,CDM,510,RC,50432,HCPCS,Outpatient,,,1745.03,872.52,,1308.77,75,,,percent of total billed charges,75% of total billed charges,1308.77,75,,,percent of total billed charges,75% of total billed charges,1743.88,100,,,Fee Schedule,100% of CMS OPPS Rate,643.69,102,,,Fee Schedule,102% of WV Medicaid Rate,2877.42,165,,,Fee Schedule,165% of CMS OPPS Rate,1807.39,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,5009.09,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,6869.58,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,8604.84,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,631.07,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1743.88,100,,,Fee Schedule,100% of CMS OPPS Rate,1807.39,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,244.3,14,,,percent of total billed charges,14% of total billed charges,244.3,8604.84,
50694 - PLMT URTRL STNT PRQ NEW ACESS W/O SEP NFROS CATH,4037566,CDM,983,RC,50694,HCPCS,Outpatient,,,2110.63,1055.32,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
51700- Bladder irrigate/lavage/instill,3435948,CDM,510,RC,51700,HCPCS,Outpatient,,,1159.52,579.76,,869.64,75,,,percent of total billed charges,75% of total billed charges,869.64,75,,,percent of total billed charges,75% of total billed charges,202.01,100,,,Fee Schedule,100% of CMS OPPS Rate,43.68,102,,,Fee Schedule,102% of WV Medicaid Rate,333.31,165,,,Fee Schedule,165% of CMS OPPS Rate,209.36,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,580.25,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,795.77,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,996.78,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,42.82,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,202.01,100,,,Fee Schedule,100% of CMS OPPS Rate,209.36,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,162.33,14,,,percent of total billed charges,14% of total billed charges,42.82,996.78,
AMB alprostidil Admin Charge:Admin alprostadil Charge 51700,3444221,CDM,510,RC,51700,HCPCS,Outpatient,,,1159.52,579.76,,869.64,75,,,percent of total billed charges,75% of total billed charges,869.64,75,,,percent of total billed charges,75% of total billed charges,202.01,100,,,Fee Schedule,100% of CMS OPPS Rate,43.68,102,,,Fee Schedule,102% of WV Medicaid Rate,333.31,165,,,Fee Schedule,165% of CMS OPPS Rate,209.36,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,580.25,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,795.77,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,996.78,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,42.82,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,202.01,100,,,Fee Schedule,100% of CMS OPPS Rate,209.36,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,162.33,14,,,percent of total billed charges,14% of total billed charges,42.82,996.78,
AMB Bladder Irrigation Charge:Bladder Irrigation- 51700,3444232,CDM,510,RC,51700,HCPCS,Outpatient,,,1159.52,579.76,,869.64,75,,,percent of total billed charges,75% of total billed charges,869.64,75,,,percent of total billed charges,75% of total billed charges,202.01,100,,,Fee Schedule,100% of CMS OPPS Rate,43.68,102,,,Fee Schedule,102% of WV Medicaid Rate,333.31,165,,,Fee Schedule,165% of CMS OPPS Rate,209.36,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,580.25,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,795.77,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,996.78,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,42.82,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,202.01,100,,,Fee Schedule,100% of CMS OPPS Rate,209.36,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,162.33,14,,,percent of total billed charges,14% of total billed charges,42.82,996.78,
51701- Insert/non-indwelling bladder cath,3435949,CDM,510,RC,51701,HCPCS,Outpatient,,,626.6,313.3,,469.95,75,,,percent of total billed charges,75% of total billed charges,469.95,75,,,percent of total billed charges,75% of total billed charges,109.16,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,180.11,165,,,Fee Schedule,165% of CMS OPPS Rate,113.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,313.55,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,430.01,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,538.63,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,109.16,100,,,Fee Schedule,100% of CMS OPPS Rate,113.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,87.72,14,,,percent of total billed charges,14% of total billed charges,87.72,538.63,
51702- Insert temp indwell blad cath/simp,3435950,CDM,510,RC,51702,HCPCS,Outpatient,,,626.6,313.3,,469.95,75,,,percent of total billed charges,75% of total billed charges,469.95,75,,,percent of total billed charges,75% of total billed charges,109.16,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,180.11,165,,,Fee Schedule,165% of CMS OPPS Rate,113.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,313.55,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,430.01,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,538.63,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,109.16,100,,,Fee Schedule,100% of CMS OPPS Rate,113.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,87.72,14,,,percent of total billed charges,14% of total billed charges,87.72,538.63,
51703- Insert temp indwell blad cath/comp,3435951,CDM,510,RC,51703,HCPCS,Outpatient,,,784.78,392.39,,588.59,75,,,percent of total billed charges,75% of total billed charges,588.59,75,,,percent of total billed charges,75% of total billed charges,136.72,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,225.58,165,,,Fee Schedule,165% of CMS OPPS Rate,141.69,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,392.72,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,538.59,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,674.64,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,136.72,100,,,Fee Schedule,100% of CMS OPPS Rate,141.69,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,109.87,14,,,percent of total billed charges,14% of total billed charges,109.87,674.64,
51705- Change Cystostomy (Bladder) Tube,4363185,CDM,510,RC,51705,HCPCS,Outpatient,,,1159.53,579.77,,869.65,75,,,percent of total billed charges,75% of total billed charges,869.65,75,,,percent of total billed charges,75% of total billed charges,202.01,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,333.31,165,,,Fee Schedule,165% of CMS OPPS Rate,209.36,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,580.25,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,795.77,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,996.78,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,202.01,100,,,Fee Schedule,100% of CMS OPPS Rate,209.36,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,162.33,14,,,percent of total billed charges,14% of total billed charges,162.33,996.78,
51720- Bladder instill/anticancer agent,3435955,CDM,510,RC,51720,HCPCS,Outpatient,,,3374.57,1687.29,,2530.93,75,,,percent of total billed charges,75% of total billed charges,2530.93,75,,,percent of total billed charges,75% of total billed charges,587.91,100,,,Fee Schedule,100% of CMS OPPS Rate,44.22,102,,,Fee Schedule,102% of WV Medicaid Rate,970.06,165,,,Fee Schedule,165% of CMS OPPS Rate,609.32,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1688.72,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2315.94,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,2900.97,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,43.35,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,587.91,100,,,Fee Schedule,100% of CMS OPPS Rate,609.32,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,472.44,14,,,percent of total billed charges,14% of total billed charges,43.35,2900.97,
AMB Bladder Instill/Anticarcin:Bladder Instill/Anticarcin-51720,3444225,CDM,510,RC,51720,HCPCS,Outpatient,,,3374.57,1687.29,,2530.93,75,,,percent of total billed charges,75% of total billed charges,2530.93,75,,,percent of total billed charges,75% of total billed charges,587.91,100,,,Fee Schedule,100% of CMS OPPS Rate,44.22,102,,,Fee Schedule,102% of WV Medicaid Rate,970.06,165,,,Fee Schedule,165% of CMS OPPS Rate,609.32,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1688.72,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2315.94,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,2900.97,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,43.35,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,587.91,100,,,Fee Schedule,100% of CMS OPPS Rate,609.32,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,472.44,14,,,percent of total billed charges,14% of total billed charges,43.35,2900.97,
Clinic Cystometrogram Simple,3550630,CDM,510,RC,51725,HCPCS,Outpatient,,,1159.53,579.77,,869.65,75,,,percent of total billed charges,75% of total billed charges,869.65,75,,,percent of total billed charges,75% of total billed charges,202.01,100,,,Fee Schedule,100% of CMS OPPS Rate,108.62,102,,,Fee Schedule,102% of WV Medicaid Rate,333.31,165,,,Fee Schedule,165% of CMS OPPS Rate,209.36,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,580.25,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,795.77,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,996.78,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,106.49,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,202.01,100,,,Fee Schedule,100% of CMS OPPS Rate,209.36,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,162.33,14,,,percent of total billed charges,14% of total billed charges,106.49,996.78,
Clinic Cystometrogram Complex,3550631,CDM,510,RC,51726,HCPCS,Outpatient,,,1159.53,579.77,,869.65,75,,,percent of total billed charges,75% of total billed charges,869.65,75,,,percent of total billed charges,75% of total billed charges,202.01,100,,,Fee Schedule,100% of CMS OPPS Rate,108.62,102,,,Fee Schedule,102% of WV Medicaid Rate,333.31,165,,,Fee Schedule,165% of CMS OPPS Rate,209.36,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,580.25,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,795.77,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,996.78,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,106.49,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,202.01,100,,,Fee Schedule,100% of CMS OPPS Rate,209.36,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,162.33,14,,,percent of total billed charges,14% of total billed charges,106.49,996.78,
Clinic Compl Cystometrogram Void Press Stu - 51728,4305354,CDM,510,RC,51728,HCPCS,Outpatient,,,3013.05,1506.53,,2259.79,75,,,percent of total billed charges,75% of total billed charges,2259.79,75,,,percent of total billed charges,75% of total billed charges,587.91,100,,,Fee Schedule,100% of CMS OPPS Rate,219.47,102,,,Fee Schedule,102% of WV Medicaid Rate,970.06,165,,,Fee Schedule,165% of CMS OPPS Rate,609.32,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1688.72,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2315.94,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,2900.97,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,215.17,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,587.91,100,,,Fee Schedule,100% of CMS OPPS Rate,609.32,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,421.83,14,,,percent of total billed charges,14% of total billed charges,215.17,2900.97,
51729- Comp cystometrogram/void/uret pres,3435958,CDM,510,RC,51729,HCPCS,Outpatient,,,3374.62,1687.31,,2530.97,75,,,percent of total billed charges,75% of total billed charges,2530.97,75,,,percent of total billed charges,75% of total billed charges,587.91,100,,,Fee Schedule,100% of CMS OPPS Rate,219.21,102,,,Fee Schedule,102% of WV Medicaid Rate,970.06,165,,,Fee Schedule,165% of CMS OPPS Rate,609.32,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1688.72,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2315.94,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,2900.97,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,214.91,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,587.91,100,,,Fee Schedule,100% of CMS OPPS Rate,609.32,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,472.45,14,,,percent of total billed charges,14% of total billed charges,214.91,2900.97,
51736 Urine flow measurement,4267409,CDM,510,RC,51736,HCPCS,Outpatient,,,626.61,313.31,,469.96,75,,,percent of total billed charges,75% of total billed charges,469.96,75,,,percent of total billed charges,75% of total billed charges,109.16,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,180.11,165,,,Fee Schedule,165% of CMS OPPS Rate,113.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,313.55,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,430.01,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,538.63,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,109.16,100,,,Fee Schedule,100% of CMS OPPS Rate,113.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,87.73,14,,,percent of total billed charges,14% of total billed charges,87.73,538.63,
Clinic Complex Uroflometry - 51741,4305355,CDM,510,RC,51741,HCPCS,Outpatient,,,700.71,350.36,,525.53,75,,,percent of total billed charges,75% of total billed charges,525.53,75,,,percent of total billed charges,75% of total billed charges,136.72,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,225.6,165,,,Fee Schedule,165% of CMS OPPS Rate,141.7,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,392.73,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,538.6,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,674.65,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,136.72,100,,,Fee Schedule,100% of CMS OPPS Rate,141.7,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,98.1,14,,,percent of total billed charges,14% of total billed charges,98.1,674.65,
Clinic EMG stds Anal/Urtl Sphnctr Other/Thn Ndl -51784,4305356,CDM,510,RC,51784,HCPCS,Outpatient,,,700.71,350.36,,525.53,75,,,percent of total billed charges,75% of total billed charges,525.53,75,,,percent of total billed charges,75% of total billed charges,136.72,100,,,Fee Schedule,100% of CMS OPPS Rate,21.84,102,,,Fee Schedule,102% of WV Medicaid Rate,225.58,165,,,Fee Schedule,165% of CMS OPPS Rate,141.69,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,392.72,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,538.59,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,674.64,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,21.41,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,136.72,100,,,Fee Schedule,100% of CMS OPPS Rate,141.69,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,98.1,14,,,percent of total billed charges,14% of total billed charges,21.41,674.64,
51798- PVR urine/bladder capacity/US,3435963,CDM,510,RC,51798,HCPCS,Outpatient,,,310.18,155.09,,232.64,75,,,percent of total billed charges,75% of total billed charges,232.64,75,,,percent of total billed charges,75% of total billed charges,54.04,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,89.16,165,,,Fee Schedule,165% of CMS OPPS Rate,56,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,155.22,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,212.87,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,266.65,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,54.04,100,,,Fee Schedule,100% of CMS OPPS Rate,56,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,43.43,14,,,percent of total billed charges,14% of total billed charges,43.43,266.65,
PVR POC,3444218,CDM,761,RC,51798,HCPCS,Outpatient,,,310.18,155.09,,232.64,75,,,percent of total billed charges,75% of total billed charges,232.64,75,,,percent of total billed charges,75% of total billed charges,54.04,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,89.16,165,,,Fee Schedule,165% of CMS OPPS Rate,56,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,155.22,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,212.87,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,266.65,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,54.04,100,,,Fee Schedule,100% of CMS OPPS Rate,56,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,43.43,14,,,percent of total billed charges,14% of total billed charges,43.43,266.65,
Clinic Cystoscopy,3550628,CDM,510,RC,52000,HCPCS,Outpatient,,,3374.62,1687.31,,2530.97,75,,,percent of total billed charges,75% of total billed charges,2530.97,75,,,percent of total billed charges,75% of total billed charges,587.91,100,,,Fee Schedule,100% of CMS OPPS Rate,234.83,102,,,Fee Schedule,102% of WV Medicaid Rate,970.06,165,,,Fee Schedule,165% of CMS OPPS Rate,609.32,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1688.72,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2315.94,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,2900.97,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,230.23,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,587.91,100,,,Fee Schedule,100% of CMS OPPS Rate,609.32,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,472.45,14,,,percent of total billed charges,14% of total billed charges,230.23,2900.97,
52005- Cystourethroscop/cath/exc rad serv,3435968,CDM,510,RC,52005,HCPCS,Outpatient,,,399.25,199.63,,299.44,75,,,percent of total billed charges,75% of total billed charges,299.44,75,,,percent of total billed charges,75% of total billed charges,1743.88,100,,,Fee Schedule,100% of CMS OPPS Rate,643.69,102,,,Fee Schedule,102% of WV Medicaid Rate,2877.42,165,,,Fee Schedule,165% of CMS OPPS Rate,1807.39,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,5009.09,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,6869.58,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,8604.84,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,631.07,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1743.88,100,,,Fee Schedule,100% of CMS OPPS Rate,1807.39,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,55.9,14,,,percent of total billed charges,14% of total billed charges,55.9,8604.84,
Clinic Cysto Calib Dilat Urtl Strix/Stenosis 52281,4301628,CDM,510,RC,52281,HCPCS,Outpatient,,,8937.23,4468.62,,6702.92,75,,,percent of total billed charges,75% of total billed charges,6702.92,75,,,percent of total billed charges,75% of total billed charges,1743.88,100,,,Fee Schedule,100% of CMS OPPS Rate,643.69,102,,,Fee Schedule,102% of WV Medicaid Rate,2877.42,165,,,Fee Schedule,165% of CMS OPPS Rate,1807.39,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,5009.09,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,6869.58,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,8604.84,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,631.07,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1743.88,100,,,Fee Schedule,100% of CMS OPPS Rate,1807.39,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1251.21,14,,,percent of total billed charges,14% of total billed charges,631.07,8604.84,
52287- Cystoscopy chemodenervation,3435976,CDM,510,RC,52287,HCPCS,Outpatient,,,10009.69,5004.85,,7507.27,75,,,percent of total billed charges,75% of total billed charges,7507.27,75,,,percent of total billed charges,75% of total billed charges,1743.88,100,,,Fee Schedule,100% of CMS OPPS Rate,643.69,102,,,Fee Schedule,102% of WV Medicaid Rate,2877.42,165,,,Fee Schedule,165% of CMS OPPS Rate,1807.39,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,5009.09,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,6869.58,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,8604.84,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,631.07,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1743.88,100,,,Fee Schedule,100% of CMS OPPS Rate,1807.39,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1401.36,14,,,percent of total billed charges,14% of total billed charges,631.07,8604.84,
Clinic Cystoscopy w/stent removal,3550633,CDM,510,RC,52310,HCPCS,Outpatient,,,10009.7,5004.85,,7507.28,75,,,percent of total billed charges,75% of total billed charges,7507.28,75,,,percent of total billed charges,75% of total billed charges,1743.88,100,,,Fee Schedule,100% of CMS OPPS Rate,643.69,102,,,Fee Schedule,102% of WV Medicaid Rate,2877.42,165,,,Fee Schedule,165% of CMS OPPS Rate,1807.39,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,5009.09,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,6869.58,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,8604.84,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,631.07,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1743.88,100,,,Fee Schedule,100% of CMS OPPS Rate,1807.39,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1401.36,14,,,percent of total billed charges,14% of total billed charges,631.07,8604.84,
53200 Biopsy of urethra,3621304,CDM,510,RC,53200,HCPCS,Outpatient,,,40.26,20.13,,30.2,75,,,percent of total billed charges,75% of total billed charges,30.2,75,,,percent of total billed charges,75% of total billed charges,1743.88,100,,,Fee Schedule,100% of CMS OPPS Rate,643.69,102,,,Fee Schedule,102% of WV Medicaid Rate,2877.42,165,,,Fee Schedule,165% of CMS OPPS Rate,1807.39,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,5009.09,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,6869.58,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,8604.84,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,631.07,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1743.88,100,,,Fee Schedule,100% of CMS OPPS Rate,1807.39,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,5.64,14,,,percent of total billed charges,14% of total billed charges,5.64,8604.84,
53600-Dilate urethra stricture,3435998,CDM,510,RC,53600,HCPCS,Outpatient,,,1159.53,579.77,,869.65,75,,,percent of total billed charges,75% of total billed charges,869.65,75,,,percent of total billed charges,75% of total billed charges,202.01,100,,,Fee Schedule,100% of CMS OPPS Rate,34.39,102,,,Fee Schedule,102% of WV Medicaid Rate,333.31,165,,,Fee Schedule,165% of CMS OPPS Rate,209.36,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,580.25,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,795.77,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,996.78,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,33.72,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,202.01,100,,,Fee Schedule,100% of CMS OPPS Rate,209.36,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,162.33,14,,,percent of total billed charges,14% of total billed charges,33.72,996.78,
53601 -Dilation Urethral Stricture Passage of Sound/Urethral,4271221,CDM,510,RC,53601,HCPCS,Outpatient,,,626.61,313.31,,469.96,75,,,percent of total billed charges,75% of total billed charges,469.96,75,,,percent of total billed charges,75% of total billed charges,109.16,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,180.11,165,,,Fee Schedule,165% of CMS OPPS Rate,113.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,313.55,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,430.01,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,538.63,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,109.16,100,,,Fee Schedule,100% of CMS OPPS Rate,113.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,87.73,14,,,percent of total billed charges,14% of total billed charges,87.73,538.63,
53605- Dilate urethral stricture/anesth,3435999,CDM,510,RC,53605,HCPCS,Outpatient,,,17296.19,8648.1,,12972.14,75,,,percent of total billed charges,75% of total billed charges,12972.14,75,,,percent of total billed charges,75% of total billed charges,3013.34,100,,,Fee Schedule,100% of CMS OPPS Rate,1126.95,102,,,Fee Schedule,102% of WV Medicaid Rate,4972.01,165,,,Fee Schedule,165% of CMS OPPS Rate,3123.07,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8655.42,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11870.22,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,14868.65,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1104.85,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,3013.34,100,,,Fee Schedule,100% of CMS OPPS Rate,3123.07,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,2421.47,14,,,percent of total billed charges,14% of total billed charges,1104.85,14868.65,
53620- Dilation/urethral strict/male/ini,3436000,CDM,510,RC,53620,HCPCS,Outpatient,,,3374.62,1687.31,,2530.97,75,,,percent of total billed charges,75% of total billed charges,2530.97,75,,,percent of total billed charges,75% of total billed charges,587.91,100,,,Fee Schedule,100% of CMS OPPS Rate,91.18,102,,,Fee Schedule,102% of WV Medicaid Rate,970.06,165,,,Fee Schedule,165% of CMS OPPS Rate,609.32,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1688.72,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2315.94,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,2900.97,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,89.39,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,587.91,100,,,Fee Schedule,100% of CMS OPPS Rate,609.32,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,472.45,14,,,percent of total billed charges,14% of total billed charges,89.39,2900.97,
53621- Dilation/urethral strict/male/subs,3436001,CDM,510,RC,53621,HCPCS,Outpatient,,,1159.53,579.77,,869.65,75,,,percent of total billed charges,75% of total billed charges,869.65,75,,,percent of total billed charges,75% of total billed charges,202.01,100,,,Fee Schedule,100% of CMS OPPS Rate,92.82,102,,,Fee Schedule,102% of WV Medicaid Rate,333.31,165,,,Fee Schedule,165% of CMS OPPS Rate,209.36,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,580.25,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,795.77,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,996.78,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,91,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,202.01,100,,,Fee Schedule,100% of CMS OPPS Rate,209.36,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,162.33,14,,,percent of total billed charges,14% of total billed charges,91,996.78,
53660- Dilation/female urethra/initial,3436002,CDM,510,RC,53660,HCPCS,Outpatient,,,784.8,392.4,,588.6,75,,,percent of total billed charges,75% of total billed charges,588.6,75,,,percent of total billed charges,75% of total billed charges,136.72,100,,,Fee Schedule,100% of CMS OPPS Rate,39.05,102,,,Fee Schedule,102% of WV Medicaid Rate,225.58,165,,,Fee Schedule,165% of CMS OPPS Rate,141.69,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,392.72,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,538.59,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,674.64,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,38.28,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,136.72,100,,,Fee Schedule,100% of CMS OPPS Rate,141.69,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,109.87,14,,,percent of total billed charges,14% of total billed charges,38.28,674.64,
53661- Dilation/female urethra/subsequent,3436003,CDM,510,RC,53661,HCPCS,Outpatient,,,626.6,313.3,,469.95,75,,,percent of total billed charges,75% of total billed charges,469.95,75,,,percent of total billed charges,75% of total billed charges,109.16,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,180.11,165,,,Fee Schedule,165% of CMS OPPS Rate,113.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,313.55,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,430.01,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,538.63,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,109.16,100,,,Fee Schedule,100% of CMS OPPS Rate,113.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,87.72,14,,,percent of total billed charges,14% of total billed charges,87.72,538.63,
54055- Destruct penis les/smp/electrodesi,3431643,CDM,510,RC,54055,HCPCS,Outpatient,,,9313.47,4656.74,,6985.1,75,,,percent of total billed charges,75% of total billed charges,6985.1,75,,,percent of total billed charges,75% of total billed charges,1622.59,100,,,Fee Schedule,100% of CMS OPPS Rate,72.07,102,,,Fee Schedule,102% of WV Medicaid Rate,2677.27,165,,,Fee Schedule,165% of CMS OPPS Rate,1681.67,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4660.68,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,6391.75,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,8006.31,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,70.66,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1622.59,100,,,Fee Schedule,100% of CMS OPPS Rate,1681.67,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1303.89,14,,,percent of total billed charges,14% of total billed charges,70.66,8006.31,
54056- Cryosurgery/penis lesion(s),3431644,CDM,510,RC,54056,HCPCS,Outpatient,,,974.51,487.26,,730.88,75,,,percent of total billed charges,75% of total billed charges,730.88,75,,,percent of total billed charges,75% of total billed charges,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,280.12,165,,,Fee Schedule,165% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,487.65,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,668.78,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,837.71,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,136.43,14,,,percent of total billed charges,14% of total billed charges,136.43,837.71,
54060- Destruct penis lesion/smp/excision,3431645,CDM,510,RC,54060,HCPCS,Outpatient,,,9313.47,4656.74,,6985.1,75,,,percent of total billed charges,75% of total billed charges,6985.1,75,,,percent of total billed charges,75% of total billed charges,1622.59,100,,,Fee Schedule,100% of CMS OPPS Rate,699.11,102,,,Fee Schedule,102% of WV Medicaid Rate,2677.27,165,,,Fee Schedule,165% of CMS OPPS Rate,1681.67,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4660.68,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,6391.75,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,8006.31,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,685.4,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1622.59,100,,,Fee Schedule,100% of CMS OPPS Rate,1681.67,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1303.89,14,,,percent of total billed charges,14% of total billed charges,685.4,8006.31,
54065 - Dstr lesion penis extensive,4241824,CDM,510,RC,54065,HCPCS,Outpatient,,,95.15,47.58,,71.36,75,,,percent of total billed charges,75% of total billed charges,71.36,75,,,percent of total billed charges,75% of total billed charges,1622.59,100,,,Fee Schedule,100% of CMS OPPS Rate,699.11,102,,,Fee Schedule,102% of WV Medicaid Rate,2677.27,165,,,Fee Schedule,165% of CMS OPPS Rate,1681.67,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4660.68,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,6391.75,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,8006.31,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,685.4,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1622.59,100,,,Fee Schedule,100% of CMS OPPS Rate,1681.67,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,13.32,14,,,percent of total billed charges,14% of total billed charges,13.32,8006.31,
54100- Biopsy of penis,3431646,CDM,510,RC,54100,HCPCS,Outpatient,,,8187.18,4093.59,,6140.39,75,,,percent of total billed charges,75% of total billed charges,6140.39,75,,,percent of total billed charges,75% of total billed charges,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,479.67,102,,,Fee Schedule,102% of WV Medicaid Rate,2326.19,165,,,Fee Schedule,165% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4049.52,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5553.61,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6956.46,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,470.26,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1146.21,14,,,percent of total billed charges,14% of total billed charges,470.26,6956.46,
54150- Circumcision/clamp/other device,3431648,CDM,510,RC,54150,HCPCS,Outpatient,,,10009.7,5004.85,,7507.28,75,,,percent of total billed charges,75% of total billed charges,7507.28,75,,,percent of total billed charges,75% of total billed charges,1743.88,100,,,Fee Schedule,100% of CMS OPPS Rate,643.69,102,,,Fee Schedule,102% of WV Medicaid Rate,2877.42,165,,,Fee Schedule,165% of CMS OPPS Rate,1807.39,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,5009.09,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,6869.58,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,8604.84,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,631.07,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1743.88,100,,,Fee Schedule,100% of CMS OPPS Rate,1807.39,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1401.36,14,,,percent of total billed charges,14% of total billed charges,631.07,8604.84,
54160- Circumcise/surg/28 days or <,3431649,CDM,510,RC,54160,HCPCS,Outpatient,,,3374.62,1687.31,,2530.97,75,,,percent of total billed charges,75% of total billed charges,2530.97,75,,,percent of total billed charges,75% of total billed charges,587.91,100,,,Fee Schedule,100% of CMS OPPS Rate,234.83,102,,,Fee Schedule,102% of WV Medicaid Rate,970.06,165,,,Fee Schedule,165% of CMS OPPS Rate,609.32,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1688.72,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2315.94,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,2900.97,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,230.23,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,587.91,100,,,Fee Schedule,100% of CMS OPPS Rate,609.32,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,472.45,14,,,percent of total billed charges,14% of total billed charges,230.23,2900.97,
54161- Circumcise/surg/> 28 days of age,3431650,CDM,510,RC,54161,HCPCS,Outpatient,,,10009.7,5004.85,,7507.28,75,,,percent of total billed charges,75% of total billed charges,7507.28,75,,,percent of total billed charges,75% of total billed charges,1743.88,100,,,Fee Schedule,100% of CMS OPPS Rate,643.69,102,,,Fee Schedule,102% of WV Medicaid Rate,2877.42,165,,,Fee Schedule,165% of CMS OPPS Rate,1807.39,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,5009.09,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,6869.58,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,8604.84,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,631.07,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1743.88,100,,,Fee Schedule,100% of CMS OPPS Rate,1807.39,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1401.36,14,,,percent of total billed charges,14% of total billed charges,631.07,8604.84,
54200- Peyronie disease/injection proc,3431654,CDM,510,RC,54200,HCPCS,Outpatient,,,70.28,35.14,,52.71,75,,,percent of total billed charges,75% of total billed charges,52.71,75,,,percent of total billed charges,75% of total billed charges,202.01,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,333.31,165,,,Fee Schedule,165% of CMS OPPS Rate,209.36,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,580.25,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,795.77,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,996.78,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,202.01,100,,,Fee Schedule,100% of CMS OPPS Rate,209.36,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,9.84,14,,,percent of total billed charges,14% of total billed charges,9.84,996.78,
AMB Injection Procedure -> Initial Admin: 54200,3561577,CDM,510,RC,54200,HCPCS,Outpatient,,,70.3,35.15,,52.73,75,,,percent of total billed charges,75% of total billed charges,52.73,75,,,percent of total billed charges,75% of total billed charges,202.01,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,333.31,165,,,Fee Schedule,165% of CMS OPPS Rate,209.36,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,580.25,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,795.77,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,996.78,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,202.01,100,,,Fee Schedule,100% of CMS OPPS Rate,209.36,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,9.84,14,,,percent of total billed charges,14% of total billed charges,9.84,996.78,
AMB Injection Procedure -> Subsequent Admin: 54200-58,3561578,CDM,510,RC,54200,HCPCS,Outpatient,,,70.3,35.15,,52.73,75,,,percent of total billed charges,75% of total billed charges,52.73,75,,,percent of total billed charges,75% of total billed charges,202.01,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,333.31,165,,,Fee Schedule,165% of CMS OPPS Rate,209.36,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,580.25,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,795.77,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,996.78,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,202.01,100,,,Fee Schedule,100% of CMS OPPS Rate,209.36,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,9.84,14,,,percent of total billed charges,14% of total billed charges,9.84,996.78,
54235- Corpora cavernosa injection,3431656,CDM,510,RC,54235,HCPCS,Outpatient,,,37.12,18.56,,27.84,75,,,percent of total billed charges,75% of total billed charges,27.84,75,,,percent of total billed charges,75% of total billed charges,202.01,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,333.31,165,,,Fee Schedule,165% of CMS OPPS Rate,209.36,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,580.25,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,795.77,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,996.78,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,202.01,100,,,Fee Schedule,100% of CMS OPPS Rate,209.36,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,5.2,14,,,percent of total billed charges,14% of total billed charges,5.2,996.78,
54450 - PF Foreskin manipulation including lysis of preputial adhesions and stretching,3699545,CDM,510,RC,54450,HCPCS,Outpatient,,,1035.3,517.65,,776.48,75,,,percent of total billed charges,75% of total billed charges,776.48,75,,,percent of total billed charges,75% of total billed charges,202.01,100,,,Fee Schedule,100% of CMS OPPS Rate,108.62,102,,,Fee Schedule,102% of WV Medicaid Rate,333.31,165,,,Fee Schedule,165% of CMS OPPS Rate,209.36,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,580.25,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,795.77,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,996.78,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,106.49,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,202.01,100,,,Fee Schedule,100% of CMS OPPS Rate,209.36,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,144.94,14,,,percent of total billed charges,14% of total billed charges,106.49,996.78,
Clinic Puncture Asp of Hydrocele,3550632,CDM,510,RC,55000,HCPCS,Outpatient,,,3502.12,1751.06,,2626.59,75,,,percent of total billed charges,75% of total billed charges,2626.59,75,,,percent of total billed charges,75% of total billed charges,610.13,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1006.72,165,,,Fee Schedule,165% of CMS OPPS Rate,632.35,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1752.53,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2403.46,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,3010.58,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,610.13,100,,,Fee Schedule,100% of CMS OPPS Rate,632.35,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,490.3,14,,,percent of total billed charges,14% of total billed charges,490.3,3010.58,
55100- Drainage of scrotal wall abscess,3430108,CDM,360,RC,55100,HCPCS,Outpatient,,,8092.19,4046.1,,6069.14,75,,,percent of total billed charges,75% of total billed charges,6069.14,75,,,percent of total billed charges,75% of total billed charges,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,479.67,102,,,Fee Schedule,102% of WV Medicaid Rate,2326.19,165,,,Fee Schedule,165% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4049.52,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5553.61,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6956.46,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,470.26,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1409.82,100,,,Fee Schedule,100% of CMS OPPS Rate,1461.16,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1132.91,14,,,percent of total billed charges,14% of total billed charges,470.26,6956.46,
Clinic Vasectomy,3550629,CDM,510,RC,55250,HCPCS,Outpatient,,,10009.7,5004.85,,7507.28,75,,,percent of total billed charges,75% of total billed charges,7507.28,75,,,percent of total billed charges,75% of total billed charges,1743.88,100,,,Fee Schedule,100% of CMS OPPS Rate,643.69,102,,,Fee Schedule,102% of WV Medicaid Rate,2877.42,165,,,Fee Schedule,165% of CMS OPPS Rate,1807.39,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,5009.09,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,6869.58,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,8604.84,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,631.07,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1743.88,100,,,Fee Schedule,100% of CMS OPPS Rate,1807.39,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1401.36,14,,,percent of total billed charges,14% of total billed charges,631.07,8604.84,
55700- Bx/prostate/needle/punch/sng/mul,3431675,CDM,510,RC,55700,HCPCS,Outpatient,,,10009.7,5004.85,,7507.28,75,,,percent of total billed charges,75% of total billed charges,7507.28,75,,,percent of total billed charges,75% of total billed charges,1743.88,100,,,Fee Schedule,100% of CMS OPPS Rate,643.69,102,,,Fee Schedule,102% of WV Medicaid Rate,2877.42,165,,,Fee Schedule,165% of CMS OPPS Rate,1807.39,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,5009.09,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,6869.58,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,8604.84,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,631.07,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1743.88,100,,,Fee Schedule,100% of CMS OPPS Rate,1807.39,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1401.36,14,,,percent of total billed charges,14% of total billed charges,631.07,8604.84,
URMC US Prostate w Biopsy w Nav PR:URMC US Exam,3575338,CDM,402,RC,55700,HCPCS,Outpatient,,,10009.7,5004.85,,7507.28,75,,,percent of total billed charges,75% of total billed charges,7507.28,75,,,percent of total billed charges,75% of total billed charges,1743.88,100,,,Fee Schedule,100% of CMS OPPS Rate,643.69,102,,,Fee Schedule,102% of WV Medicaid Rate,2877.42,165,,,Fee Schedule,165% of CMS OPPS Rate,1807.39,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,5009.09,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,6869.58,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,8604.84,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,631.07,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1743.88,100,,,Fee Schedule,100% of CMS OPPS Rate,1807.39,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1401.36,14,,,percent of total billed charges,14% of total billed charges,631.07,8604.84,
55876- Place interstitdevice/rad tx guide/prostate/sng/mult,3431680,CDM,510,RC,55876,HCPCS,Outpatient,,,7234.8,3617.4,,5426.1,75,,,percent of total billed charges,75% of total billed charges,5426.1,75,,,percent of total billed charges,75% of total billed charges,1260.44,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,2079.73,165,,,Fee Schedule,165% of CMS OPPS Rate,1306.33,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,3620.47,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,4965.18,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6219.4,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,1260.44,100,,,Fee Schedule,100% of CMS OPPS Rate,1306.33,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1012.87,14,,,percent of total billed charges,14% of total billed charges,1012.87,6219.4,
55876-PROSTATE FIDUCIAL,3565264,CDM,360,RC,55876,HCPCS,Outpatient,,,2474.12,1237.06,,1855.59,75,,,percent of total billed charges,75% of total billed charges,1855.59,75,,,percent of total billed charges,75% of total billed charges,1260.44,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,2079.73,165,,,Fee Schedule,165% of CMS OPPS Rate,1306.33,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,3620.47,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,4965.18,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6219.4,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,1260.44,100,,,Fee Schedule,100% of CMS OPPS Rate,1306.33,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,346.38,14,,,percent of total billed charges,14% of total billed charges,346.38,6219.4,
URMC US w Fiducial Marker Placement PR:URMC US Exam,3575344,CDM,402,RC,55876,HCPCS,Outpatient,,,7234.8,3617.4,,5426.1,75,,,percent of total billed charges,75% of total billed charges,5426.1,75,,,percent of total billed charges,75% of total billed charges,1260.44,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,2079.73,165,,,Fee Schedule,165% of CMS OPPS Rate,1306.33,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,3620.47,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,4965.18,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6219.4,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,1260.44,100,,,Fee Schedule,100% of CMS OPPS Rate,1306.33,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1012.87,14,,,percent of total billed charges,14% of total billed charges,1012.87,6219.4,
"55899 - PF Unlisted procedure, male genital system",3641214,CDM,510,RC,55899,HCPCS,Outpatient,,,2659.33,1329.67,,1994.5,75,,,percent of total billed charges,75% of total billed charges,1994.5,75,,,percent of total billed charges,75% of total billed charges,202.01,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,333.31,165,,,Fee Schedule,165% of CMS OPPS Rate,209.36,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,580.25,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,795.77,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,996.78,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,202.01,100,,,Fee Schedule,100% of CMS OPPS Rate,209.36,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,372.31,14,,,percent of total billed charges,14% of total billed charges,202.01,1994.5,
55899- Unlisted proc/male genital system,3431681,CDM,510,RC,55899,HCPCS,Outpatient,,,1159.53,579.77,,869.65,75,,,percent of total billed charges,75% of total billed charges,869.65,75,,,percent of total billed charges,75% of total billed charges,202.01,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,333.31,165,,,Fee Schedule,165% of CMS OPPS Rate,209.36,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,580.25,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,795.77,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,996.78,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,202.01,100,,,Fee Schedule,100% of CMS OPPS Rate,209.36,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,162.33,14,,,percent of total billed charges,14% of total billed charges,162.33,996.78,
56405- Vulva/perineal abscess/ I & D,3431352,CDM,360,RC,56405,HCPCS,Outpatient,,,52.93,26.47,,39.7,75,,,percent of total billed charges,75% of total billed charges,39.7,75,,,percent of total billed charges,75% of total billed charges,274.47,100,,,Fee Schedule,100% of CMS OPPS Rate,74.52,102,,,Fee Schedule,102% of WV Medicaid Rate,452.9,165,,,Fee Schedule,165% of CMS OPPS Rate,284.48,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,788.43,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1081.27,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1354.41,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,73.06,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,274.47,100,,,Fee Schedule,100% of CMS OPPS Rate,284.48,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,7.41,14,,,percent of total billed charges,14% of total billed charges,7.41,1354.41,
56420- Bartholin's gland abscess/I & D,3431353,CDM,510,RC,56420,HCPCS,Outpatient,,,961.27,480.64,,720.95,75,,,percent of total billed charges,75% of total billed charges,720.95,75,,,percent of total billed charges,75% of total billed charges,167.47,100,,,Fee Schedule,100% of CMS OPPS Rate,69.54,102,,,Fee Schedule,102% of WV Medicaid Rate,276.31,165,,,Fee Schedule,165% of CMS OPPS Rate,173.56,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,481.04,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,659.7,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,826.34,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,68.18,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,167.47,100,,,Fee Schedule,100% of CMS OPPS Rate,173.56,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,134.58,14,,,percent of total billed charges,14% of total billed charges,68.18,826.34,
"56501-MA DESTROY, VULVA LESIONS",3430122,CDM,510,RC,56501,HCPCS,Outpatient,,,9208.91,4604.46,,6906.68,75,,,percent of total billed charges,75% of total billed charges,6906.68,75,,,percent of total billed charges,75% of total billed charges,1622.59,100,,,Fee Schedule,100% of CMS OPPS Rate,109.48,102,,,Fee Schedule,102% of WV Medicaid Rate,2677.27,165,,,Fee Schedule,165% of CMS OPPS Rate,1681.67,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4660.68,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,6391.75,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,8006.31,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,107.33,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1622.59,100,,,Fee Schedule,100% of CMS OPPS Rate,1681.67,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1289.25,14,,,percent of total billed charges,14% of total billed charges,107.33,8006.31,
56605- BX vulva or perineum/1 lesion,3431357,CDM,360,RC,56605,HCPCS,Outpatient,,,90.79,45.4,,68.09,75,,,percent of total billed charges,75% of total billed charges,68.09,75,,,percent of total billed charges,75% of total billed charges,661.37,100,,,Fee Schedule,100% of CMS OPPS Rate,44.22,102,,,Fee Schedule,102% of WV Medicaid Rate,1091.26,165,,,Fee Schedule,165% of CMS OPPS Rate,685.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1899.71,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2605.3,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,3263.41,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,43.35,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,661.37,100,,,Fee Schedule,100% of CMS OPPS Rate,685.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,12.71,14,,,percent of total billed charges,14% of total billed charges,12.71,3263.41,
56606- Bx vulva or perineum/ea add lesion,3431358,CDM,360,RC,56606,HCPCS,Outpatient,,,22.09,11.05,,16.57,75,,,percent of total billed charges,75% of total billed charges,16.57,75,,,percent of total billed charges,75% of total billed charges,7.07,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.09,14,,,percent of total billed charges,14% of total billed charges,3.09,16.57,
57061-MA DESTROY VAG LESIONS,3430142,CDM,510,RC,57061,HCPCS,Outpatient,,,15787.48,7893.74,,11840.61,75,,,percent of total billed charges,75% of total billed charges,11840.61,75,,,percent of total billed charges,75% of total billed charges,2658.26,100,,,Fee Schedule,100% of CMS OPPS Rate,97.45,102,,,Fee Schedule,102% of WV Medicaid Rate,4386.13,165,,,Fee Schedule,165% of CMS OPPS Rate,2755.05,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,7635.49,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,10471.46,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13116.58,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,95.54,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2658.26,100,,,Fee Schedule,100% of CMS OPPS Rate,2755.05,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,2210.25,14,,,percent of total billed charges,14% of total billed charges,95.54,13116.58,
57100 - Bx vaginal mucosa; simple,3431363,CDM,360,RC,57100,HCPCS,Outpatient,,,91.62,45.81,,68.72,75,,,percent of total billed charges,75% of total billed charges,68.72,75,,,percent of total billed charges,75% of total billed charges,661.37,100,,,Fee Schedule,100% of CMS OPPS Rate,46.41,102,,,Fee Schedule,102% of WV Medicaid Rate,1091.26,165,,,Fee Schedule,165% of CMS OPPS Rate,685.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1899.71,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2605.3,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,3263.41,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,45.5,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,661.37,100,,,Fee Schedule,100% of CMS OPPS Rate,685.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,12.83,14,,,percent of total billed charges,14% of total billed charges,12.83,3263.41,
57135-MA REMOVE VAGINA LESION,3430152,CDM,510,RC,57135,HCPCS,Outpatient,,,147.64,73.82,,110.73,75,,,percent of total billed charges,75% of total billed charges,110.73,75,,,percent of total billed charges,75% of total billed charges,2658.26,100,,,Fee Schedule,100% of CMS OPPS Rate,1048.68,102,,,Fee Schedule,102% of WV Medicaid Rate,4386.13,165,,,Fee Schedule,165% of CMS OPPS Rate,2755.05,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,7635.49,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,10471.46,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13116.58,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1028.12,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2658.26,100,,,Fee Schedule,100% of CMS OPPS Rate,2755.05,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,20.67,14,,,percent of total billed charges,14% of total billed charges,20.67,13116.58,
57156 - Insertion of a vaginal radiation afterloading appara,3938956,CDM,510,RC,57156,HCPCS,Outpatient,,,183.97,91.99,,137.98,75,,,percent of total billed charges,75% of total billed charges,137.98,75,,,percent of total billed charges,75% of total billed charges,274.47,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,452.9,165,,,Fee Schedule,165% of CMS OPPS Rate,284.48,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,788.43,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1081.27,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1354.41,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,274.47,100,,,Fee Schedule,100% of CMS OPPS Rate,284.48,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,25.76,14,,,percent of total billed charges,14% of total billed charges,25.76,1354.41,
57156-Ins Vag Brachytx Device,4169512,CDM,360,RC,57156,HCPCS,Outpatient,,,164.26,82.13,,123.2,75,,,percent of total billed charges,75% of total billed charges,123.2,75,,,percent of total billed charges,75% of total billed charges,274.47,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,452.9,165,,,Fee Schedule,165% of CMS OPPS Rate,284.48,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,788.43,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1081.27,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1354.41,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,274.47,100,,,Fee Schedule,100% of CMS OPPS Rate,284.48,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,23,14,,,percent of total billed charges,14% of total billed charges,23,1354.41,
57454- Colposcopy/cervix/biopsy/curettage,3431388,CDM,510,RC,57454,HCPCS,Outpatient,,,1575.53,787.77,,1181.65,75,,,percent of total billed charges,75% of total billed charges,1181.65,75,,,percent of total billed charges,75% of total billed charges,274.47,100,,,Fee Schedule,100% of CMS OPPS Rate,64.15,102,,,Fee Schedule,102% of WV Medicaid Rate,452.9,165,,,Fee Schedule,165% of CMS OPPS Rate,284.48,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,788.43,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1081.27,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1354.41,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,62.89,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,274.47,100,,,Fee Schedule,100% of CMS OPPS Rate,284.48,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,220.57,14,,,percent of total billed charges,14% of total billed charges,62.89,1354.41,
57500- Biopsy/cervix/single/multiple,3431393,CDM,514,RC,57500,HCPCS,Outpatient,,,3389.46,1694.73,,2542.1,75,,,percent of total billed charges,75% of total billed charges,2542.1,75,,,percent of total billed charges,75% of total billed charges,661.37,100,,,Fee Schedule,100% of CMS OPPS Rate,90.09,102,,,Fee Schedule,102% of WV Medicaid Rate,1091.26,165,,,Fee Schedule,165% of CMS OPPS Rate,685.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1899.71,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2605.3,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,3263.41,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,88.32,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,661.37,100,,,Fee Schedule,100% of CMS OPPS Rate,685.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,474.52,14,,,percent of total billed charges,14% of total billed charges,88.32,3263.41,
57505- Endocervical curettage,3431394,CDM,360,RC,57505,HCPCS,Outpatient,,,113.71,56.86,,85.28,75,,,percent of total billed charges,75% of total billed charges,85.28,75,,,percent of total billed charges,75% of total billed charges,661.37,100,,,Fee Schedule,100% of CMS OPPS Rate,90.63,102,,,Fee Schedule,102% of WV Medicaid Rate,1091.26,165,,,Fee Schedule,165% of CMS OPPS Rate,685.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1899.71,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2605.3,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,3263.41,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,88.85,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,661.37,100,,,Fee Schedule,100% of CMS OPPS Rate,685.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,15.92,14,,,percent of total billed charges,14% of total billed charges,15.92,3263.41,
58100- EMB w/o cervical dilation,3431398,CDM,360,RC,58100,HCPCS,Outpatient,,,93.96,46.98,,70.47,75,,,percent of total billed charges,75% of total billed charges,70.47,75,,,percent of total billed charges,75% of total billed charges,167.47,100,,,Fee Schedule,100% of CMS OPPS Rate,45.32,102,,,Fee Schedule,102% of WV Medicaid Rate,276.31,165,,,Fee Schedule,165% of CMS OPPS Rate,173.56,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,481.04,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,659.7,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,826.34,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,44.43,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,167.47,100,,,Fee Schedule,100% of CMS OPPS Rate,173.56,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,13.15,14,,,percent of total billed charges,14% of total billed charges,13.15,826.34,
58110- EMB w/colposcopy,3431399,CDM,510,RC,58110,HCPCS,Outpatient,,,275.6,137.8,,206.7,75,,,percent of total billed charges,75% of total billed charges,206.7,75,,,percent of total billed charges,75% of total billed charges,88.19,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.58,14,,,percent of total billed charges,14% of total billed charges,38.58,206.7,
58300- Insertion/intrauterine device,3431410,CDM,360,RC,58300,HCPCS,Outpatient,,,95.88,47.94,,71.91,75,,,percent of total billed charges,75% of total billed charges,71.91,75,,,percent of total billed charges,75% of total billed charges,30.68,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.42,14,,,percent of total billed charges,14% of total billed charges,13.42,71.91,
AMB IUD Admin Charge:Insert Intrauterine Device 58300,3444234,CDM,510,RC,58300,HCPCS,Outpatient,,,95.88,47.94,,71.91,75,,,percent of total billed charges,75% of total billed charges,71.91,75,,,percent of total billed charges,75% of total billed charges,30.68,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.42,14,,,percent of total billed charges,14% of total billed charges,13.42,71.91,
58301- Remove intrauterine device,3431411,CDM,360,RC,58301,HCPCS,Outpatient,,,1312.71,656.36,,984.53,75,,,percent of total billed charges,75% of total billed charges,984.53,75,,,percent of total billed charges,75% of total billed charges,274.49,100,,,Fee Schedule,100% of CMS OPPS Rate,50.5,102,,,Fee Schedule,102% of WV Medicaid Rate,452.91,165,,,Fee Schedule,165% of CMS OPPS Rate,284.48,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,788.43,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1081.27,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1354.41,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,49.51,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,274.49,100,,,Fee Schedule,100% of CMS OPPS Rate,284.48,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,183.78,14,,,percent of total billed charges,14% of total billed charges,49.51,1354.41,
Clinic NST,3428544,CDM,920,RC,59025,HCPCS,Outpatient,,,890.47,445.24,,667.85,75,,,percent of total billed charges,75% of total billed charges,667.85,75,,,percent of total billed charges,75% of total billed charges,167.47,100,,,Fee Schedule,100% of CMS OPPS Rate,15.57,102,,,Fee Schedule,102% of WV Medicaid Rate,276.31,165,,,Fee Schedule,165% of CMS OPPS Rate,173.56,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,481.04,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,659.7,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,826.34,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,15.26,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,167.47,100,,,Fee Schedule,100% of CMS OPPS Rate,173.56,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,124.67,14,,,percent of total billed charges,14% of total billed charges,15.26,826.34,
"59300 - Episiotomy or vaginal repair, by other than attending",4037736,CDM,983,RC,59300,HCPCS,Outpatient,,,207.66,103.83,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
60300- Thyroid cyst/aspiration and/or inj,3431285,CDM,361,RC,60300,HCPCS,Outpatient,,,3070.13,1535.07,,2302.6,75,,,percent of total billed charges,75% of total billed charges,2302.6,75,,,percent of total billed charges,75% of total billed charges,610.13,100,,,Fee Schedule,100% of CMS OPPS Rate,58.69,102,,,Fee Schedule,102% of WV Medicaid Rate,1006.72,165,,,Fee Schedule,165% of CMS OPPS Rate,632.35,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1752.53,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2403.46,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,3010.58,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,57.54,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,610.13,100,,,Fee Schedule,100% of CMS OPPS Rate,632.35,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,429.82,14,,,percent of total billed charges,14% of total billed charges,57.54,3010.58,
Clinic Lumbar Puncture,3435540,CDM,510,RC,62270,HCPCS,Outpatient,,,2928.85,1464.43,,2196.64,75,,,percent of total billed charges,75% of total billed charges,2196.64,75,,,percent of total billed charges,75% of total billed charges,605.77,100,,,Fee Schedule,100% of CMS OPPS Rate,259.2,102,,,Fee Schedule,102% of WV Medicaid Rate,999.54,165,,,Fee Schedule,165% of CMS OPPS Rate,627.84,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1740.03,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2386.32,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,2989.1,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,254.12,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,605.77,100,,,Fee Schedule,100% of CMS OPPS Rate,627.84,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,410.04,14,,,percent of total billed charges,14% of total billed charges,254.12,2989.1,
64425- Inj/anest/ilioing/hypogastric nerv,3435387,CDM,510,RC,64425,HCPCS,Outpatient,,,135.82,67.91,,101.87,75,,,percent of total billed charges,75% of total billed charges,101.87,75,,,percent of total billed charges,75% of total billed charges,605.77,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,999.54,165,,,Fee Schedule,165% of CMS OPPS Rate,627.84,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1740.03,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2386.32,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,2989.1,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,605.77,100,,,Fee Schedule,100% of CMS OPPS Rate,627.84,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,19.01,14,,,percent of total billed charges,14% of total billed charges,19.01,2989.1,
64450- Inj/anesth/other perph nerv/branch,3435391,CDM,360,RC,64450,HCPCS,Outpatient,,,80.55,40.28,,60.41,75,,,percent of total billed charges,75% of total billed charges,60.41,75,,,percent of total billed charges,75% of total billed charges,605.77,100,,,Fee Schedule,100% of CMS OPPS Rate,38.77,102,,,Fee Schedule,102% of WV Medicaid Rate,999.54,165,,,Fee Schedule,165% of CMS OPPS Rate,627.84,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1740.03,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2386.32,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,2989.1,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,38.01,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,605.77,100,,,Fee Schedule,100% of CMS OPPS Rate,627.84,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,11.28,14,,,percent of total billed charges,14% of total billed charges,11.28,2989.1,
Clinic PNE,3550634,CDM,510,RC,64561,HCPCS,Outpatient,,,32010.38,16005.19,,24007.79,75,,,percent of total billed charges,75% of total billed charges,24007.79,75,,,percent of total billed charges,75% of total billed charges,6208.71,100,,,Fee Schedule,100% of CMS OPPS Rate,3685.66,102,,,Fee Schedule,102% of WV Medicaid Rate,10244.37,165,,,Fee Schedule,165% of CMS OPPS Rate,6434.8,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,17833.68,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,24457.48,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,30635.47,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,3613.39,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,6208.71,100,,,Fee Schedule,100% of CMS OPPS Rate,6434.8,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4481.45,14,,,percent of total billed charges,14% of total billed charges,3613.39,30635.47,
64595- Rev/rmv prph sac/gstr npgr,3621302,CDM,510,RC,64595,HCPCS,Outpatient,,,255.06,127.53,,191.3,75,,,percent of total billed charges,75% of total billed charges,191.3,75,,,percent of total billed charges,75% of total billed charges,3053.35,100,,,Fee Schedule,100% of CMS OPPS Rate,2364.23,102,,,Fee Schedule,102% of WV Medicaid Rate,5038.03,165,,,Fee Schedule,165% of CMS OPPS Rate,3164.54,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8770.35,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,12027.84,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,15066.08,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,2317.87,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,3053.35,100,,,Fee Schedule,100% of CMS OPPS Rate,3164.54,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,35.71,14,,,percent of total billed charges,14% of total billed charges,35.71,15066.08,
64612- Chemodenerv/facial nerv musc/uni,3435409,CDM,510,RC,64612,HCPCS,Outpatient,,,1495.66,747.83,,1121.75,75,,,percent of total billed charges,75% of total billed charges,1121.75,75,,,percent of total billed charges,75% of total billed charges,255.61,100,,,Fee Schedule,100% of CMS OPPS Rate,63.88,102,,,Fee Schedule,102% of WV Medicaid Rate,421.75,165,,,Fee Schedule,165% of CMS OPPS Rate,264.92,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,734.23,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1006.94,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1261.29,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,62.63,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,255.61,100,,,Fee Schedule,100% of CMS OPPS Rate,264.92,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,209.39,14,,,percent of total billed charges,14% of total billed charges,62.63,1261.29,
65220- Removal/FB/corneal/slit lamp,3431305,CDM,510,RC,65220,HCPCS,Outpatient,,,2012.04,1006.02,,1509.03,75,,,percent of total billed charges,75% of total billed charges,1509.03,75,,,percent of total billed charges,75% of total billed charges,354.97,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,585.71,165,,,Fee Schedule,165% of CMS OPPS Rate,367.9,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1019.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1398.33,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1751.55,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,354.97,100,,,Fee Schedule,100% of CMS OPPS Rate,367.9,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,281.69,14,,,percent of total billed charges,14% of total billed charges,281.69,1751.55,
65222- Rmv FB/extern eye/cornea/slit lamp,3431306,CDM,510,RC,65222,HCPCS,Outpatient,,,645.06,322.53,,483.8,75,,,percent of total billed charges,75% of total billed charges,483.8,75,,,percent of total billed charges,75% of total billed charges,109.16,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,180.11,165,,,Fee Schedule,165% of CMS OPPS Rate,113.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,313.55,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,430.01,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,538.63,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,109.16,100,,,Fee Schedule,100% of CMS OPPS Rate,113.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,90.31,14,,,percent of total billed charges,14% of total billed charges,90.31,538.63,
67700- Drainage of eyelid abscess,3431315,CDM,510,RC,67700,HCPCS,Outpatient,,,1471.07,735.54,,1103.3,75,,,percent of total billed charges,75% of total billed charges,1103.3,75,,,percent of total billed charges,75% of total billed charges,248.85,100,,,Fee Schedule,100% of CMS OPPS Rate,106.77,102,,,Fee Schedule,102% of WV Medicaid Rate,410.63,165,,,Fee Schedule,165% of CMS OPPS Rate,257.92,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,714.84,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,980.35,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1227.99,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,104.68,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,248.85,100,,,Fee Schedule,100% of CMS OPPS Rate,257.92,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,205.95,14,,,percent of total billed charges,14% of total billed charges,104.68,1227.99,
67800- Excision of chalazion/single,3431316,CDM,510,RC,67800,HCPCS,Outpatient,,,1471.07,735.54,,1103.3,75,,,percent of total billed charges,75% of total billed charges,1103.3,75,,,percent of total billed charges,75% of total billed charges,248.85,100,,,Fee Schedule,100% of CMS OPPS Rate,61.15,102,,,Fee Schedule,102% of WV Medicaid Rate,410.63,165,,,Fee Schedule,165% of CMS OPPS Rate,257.92,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,714.84,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,980.35,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1227.99,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,59.95,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,248.85,100,,,Fee Schedule,100% of CMS OPPS Rate,257.92,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,205.95,14,,,percent of total billed charges,14% of total billed charges,59.95,1227.99,
"67801 Excision of chalazion; multiple, same lid",3621303,CDM,510,RC,67801,HCPCS,Outpatient,,,5112.59,2556.3,,3834.44,75,,,percent of total billed charges,75% of total billed charges,3834.44,75,,,percent of total billed charges,75% of total billed charges,820.41,100,,,Fee Schedule,100% of CMS OPPS Rate,73.71,102,,,Fee Schedule,102% of WV Medicaid Rate,1353.69,165,,,Fee Schedule,165% of CMS OPPS Rate,850.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,2356.56,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,3231.83,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,4048.2,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,72.26,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,820.41,100,,,Fee Schedule,100% of CMS OPPS Rate,850.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,715.76,14,,,percent of total billed charges,14% of total billed charges,72.26,4048.2,
67805- EXCIS CHALAZION MULT BOTH,3431317,CDM,510,RC,67805,HCPCS,Outpatient,,,1471.07,735.54,,1103.3,75,,,percent of total billed charges,75% of total billed charges,1103.3,75,,,percent of total billed charges,75% of total billed charges,248.85,100,,,Fee Schedule,100% of CMS OPPS Rate,95,102,,,Fee Schedule,102% of WV Medicaid Rate,410.63,165,,,Fee Schedule,165% of CMS OPPS Rate,257.92,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,714.84,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,980.35,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1227.99,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,93.14,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,248.85,100,,,Fee Schedule,100% of CMS OPPS Rate,257.92,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,205.95,14,,,percent of total billed charges,14% of total billed charges,93.14,1227.99,
67810- Incisional biopsy/eyelid,3586925,CDM,983,RC,67810,HCPCS,Outpatient,,,281.89,140.95,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
67820- Revise eyelashes,3431319,CDM,510,RC,67820,HCPCS,Outpatient,,,645.06,322.53,,483.8,75,,,percent of total billed charges,75% of total billed charges,483.8,75,,,percent of total billed charges,75% of total billed charges,109.16,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,180.11,165,,,Fee Schedule,165% of CMS OPPS Rate,113.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,313.55,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,430.01,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,538.63,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,109.16,100,,,Fee Schedule,100% of CMS OPPS Rate,113.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,90.31,14,,,percent of total billed charges,14% of total billed charges,90.31,538.63,
67840-EYE RMV EYELID LESION -NOT CHAL,3430499,CDM,510,RC,67840,HCPCS,Outpatient,,,5112.59,2556.3,,3834.44,75,,,percent of total billed charges,75% of total billed charges,3834.44,75,,,percent of total billed charges,75% of total billed charges,820.41,100,,,Fee Schedule,100% of CMS OPPS Rate,167.07,102,,,Fee Schedule,102% of WV Medicaid Rate,1353.69,165,,,Fee Schedule,165% of CMS OPPS Rate,850.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,2356.56,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,3231.83,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,4048.2,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,163.79,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,820.41,100,,,Fee Schedule,100% of CMS OPPS Rate,850.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,715.76,14,,,percent of total billed charges,14% of total billed charges,163.79,4048.2,
67840-OCC Exc eyelid lesion/excpt chalazion,3536978,CDM,983,RC,67840,HCPCS,Outpatient,,,302.45,151.23,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
67850- Destruction/lid lesion/up to 1 cm,3431321,CDM,510,RC,67850,HCPCS,Outpatient,,,5112.59,2556.3,,3834.44,75,,,percent of total billed charges,75% of total billed charges,3834.44,75,,,percent of total billed charges,75% of total billed charges,820.41,100,,,Fee Schedule,100% of CMS OPPS Rate,124.22,102,,,Fee Schedule,102% of WV Medicaid Rate,1353.69,165,,,Fee Schedule,165% of CMS OPPS Rate,850.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,2356.56,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,3231.83,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,4048.2,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,121.78,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,820.41,100,,,Fee Schedule,100% of CMS OPPS Rate,850.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,715.76,14,,,percent of total billed charges,14% of total billed charges,121.78,4048.2,
67875- Temp eyelid closure/suture,3431322,CDM,510,RC,67875,HCPCS,Outpatient,,,5112.59,2556.3,,3834.44,75,,,percent of total billed charges,75% of total billed charges,3834.44,75,,,percent of total billed charges,75% of total billed charges,820.41,100,,,Fee Schedule,100% of CMS OPPS Rate,330.54,102,,,Fee Schedule,102% of WV Medicaid Rate,1353.69,165,,,Fee Schedule,165% of CMS OPPS Rate,850.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,2356.56,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,3231.83,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,4048.2,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,324.06,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,820.41,100,,,Fee Schedule,100% of CMS OPPS Rate,850.3,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,715.76,14,,,percent of total billed charges,14% of total billed charges,324.06,4048.2,
67880- Revision of eyelid,3431323,CDM,510,RC,67880,HCPCS,Outpatient,,,11800.34,5900.17,,8850.26,75,,,percent of total billed charges,75% of total billed charges,8850.26,75,,,percent of total billed charges,75% of total billed charges,1987.7,100,,,Fee Schedule,100% of CMS OPPS Rate,688.56,102,,,Fee Schedule,102% of WV Medicaid Rate,3279.73,165,,,Fee Schedule,165% of CMS OPPS Rate,2060.09,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,5709.44,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,7830.05,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,9807.93,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,675.06,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1987.7,100,,,Fee Schedule,100% of CMS OPPS Rate,2060.09,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1652.05,14,,,percent of total billed charges,14% of total billed charges,675.06,9807.93,
67903 -OCC Blepharoptosis/levator resct/int,3548670,CDM,510,RC,67903,HCPCS,Outpatient,,,304.79,152.4,,228.59,75,,,percent of total billed charges,75% of total billed charges,228.59,75,,,percent of total billed charges,75% of total billed charges,1987.7,100,,,Fee Schedule,100% of CMS OPPS Rate,688.56,102,,,Fee Schedule,102% of WV Medicaid Rate,3279.73,165,,,Fee Schedule,165% of CMS OPPS Rate,2060.09,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,5709.44,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,7830.05,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,9807.93,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,675.06,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1987.7,100,,,Fee Schedule,100% of CMS OPPS Rate,2060.09,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,42.67,14,,,percent of total billed charges,14% of total billed charges,42.67,9807.93,
67909- Revise eyelid defect,3431327,CDM,510,RC,67909,HCPCS,Outpatient,,,11800.34,5900.17,,8850.26,75,,,percent of total billed charges,75% of total billed charges,8850.26,75,,,percent of total billed charges,75% of total billed charges,1987.7,100,,,Fee Schedule,100% of CMS OPPS Rate,688.56,102,,,Fee Schedule,102% of WV Medicaid Rate,3279.73,165,,,Fee Schedule,165% of CMS OPPS Rate,2060.09,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,5709.44,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,7830.05,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,9807.93,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,675.06,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1987.7,100,,,Fee Schedule,100% of CMS OPPS Rate,2060.09,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1652.05,14,,,percent of total billed charges,14% of total billed charges,675.06,9807.93,
67935- Eyelid/recent wound sut/full thick,3431332,CDM,510,RC,67935,HCPCS,Outpatient,,,11800.34,5900.17,,8850.26,75,,,percent of total billed charges,75% of total billed charges,8850.26,75,,,percent of total billed charges,75% of total billed charges,1987.7,100,,,Fee Schedule,100% of CMS OPPS Rate,688.56,102,,,Fee Schedule,102% of WV Medicaid Rate,3279.73,165,,,Fee Schedule,165% of CMS OPPS Rate,2060.09,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,5709.44,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,7830.05,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,9807.93,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,675.06,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1987.7,100,,,Fee Schedule,100% of CMS OPPS Rate,2060.09,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1652.05,14,,,percent of total billed charges,14% of total billed charges,675.06,9807.93,
67938- Removal of embedded FB/eyelid,3431333,CDM,510,RC,67938,HCPCS,Outpatient,,,1471.07,735.54,,1103.3,75,,,percent of total billed charges,75% of total billed charges,1103.3,75,,,percent of total billed charges,75% of total billed charges,248.85,100,,,Fee Schedule,100% of CMS OPPS Rate,106.77,102,,,Fee Schedule,102% of WV Medicaid Rate,410.63,165,,,Fee Schedule,165% of CMS OPPS Rate,257.92,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,714.84,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,980.35,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1227.99,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,104.68,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,248.85,100,,,Fee Schedule,100% of CMS OPPS Rate,257.92,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,205.95,14,,,percent of total billed charges,14% of total billed charges,104.68,1227.99,
67961- Exc/rpr eyelid/to 1/4 lid margin,3431335,CDM,510,RC,67961,HCPCS,Outpatient,,,11800.34,5900.17,,8850.26,75,,,percent of total billed charges,75% of total billed charges,8850.26,75,,,percent of total billed charges,75% of total billed charges,1987.7,100,,,Fee Schedule,100% of CMS OPPS Rate,688.56,102,,,Fee Schedule,102% of WV Medicaid Rate,3279.73,165,,,Fee Schedule,165% of CMS OPPS Rate,2060.09,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,5709.44,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,7830.05,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,9807.93,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,675.06,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1987.7,100,,,Fee Schedule,100% of CMS OPPS Rate,2060.09,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1652.05,14,,,percent of total billed charges,14% of total billed charges,675.06,9807.93,
68761- Close lacrimal punctum/plug/each,3431340,CDM,510,RC,68761,HCPCS,Outpatient,,,1471.07,735.54,,1103.3,75,,,percent of total billed charges,75% of total billed charges,1103.3,75,,,percent of total billed charges,75% of total billed charges,248.85,100,,,Fee Schedule,100% of CMS OPPS Rate,77.53,102,,,Fee Schedule,102% of WV Medicaid Rate,410.63,165,,,Fee Schedule,165% of CMS OPPS Rate,257.92,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,714.84,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,980.35,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1227.99,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,76.01,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,248.85,100,,,Fee Schedule,100% of CMS OPPS Rate,257.92,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,205.95,14,,,percent of total billed charges,14% of total billed charges,76.01,1227.99,
68801- Dilation of lacrimal punctum,3431341,CDM,510,RC,68801,HCPCS,Outpatient,,,2012.04,1006.02,,1509.03,75,,,percent of total billed charges,75% of total billed charges,1509.03,75,,,percent of total billed charges,75% of total billed charges,354.97,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,585.71,165,,,Fee Schedule,165% of CMS OPPS Rate,367.9,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1019.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1398.33,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1751.55,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,354.97,100,,,Fee Schedule,100% of CMS OPPS Rate,367.9,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,281.69,14,,,percent of total billed charges,14% of total billed charges,281.69,1751.55,
"68811 - Probing of nasolacrimal duct, with or without irrigation; requiring general anesthesia",3699550,CDM,510,RC,68811,HCPCS,Outpatient,,,11800.34,5900.17,,8850.26,75,,,percent of total billed charges,75% of total billed charges,8850.26,75,,,percent of total billed charges,75% of total billed charges,1987.7,100,,,Fee Schedule,100% of CMS OPPS Rate,688.56,102,,,Fee Schedule,102% of WV Medicaid Rate,3279.73,165,,,Fee Schedule,165% of CMS OPPS Rate,2060.09,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,5709.44,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,7830.05,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,9807.93,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,675.06,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1987.7,100,,,Fee Schedule,100% of CMS OPPS Rate,2060.09,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1652.05,14,,,percent of total billed charges,14% of total billed charges,675.06,9807.93,
68815- Probe/nasolacrimal/tube/stent,3431342,CDM,510,RC,68815,HCPCS,Outpatient,,,11800.4,5900.2,,8850.3,75,,,percent of total billed charges,75% of total billed charges,8850.3,75,,,percent of total billed charges,75% of total billed charges,1987.7,100,,,Fee Schedule,100% of CMS OPPS Rate,688.56,102,,,Fee Schedule,102% of WV Medicaid Rate,3279.73,165,,,Fee Schedule,165% of CMS OPPS Rate,2060.09,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,5709.44,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,7830.05,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,9807.93,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,675.06,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1987.7,100,,,Fee Schedule,100% of CMS OPPS Rate,2060.09,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1652.06,14,,,percent of total billed charges,14% of total billed charges,675.06,9807.93,
68840- Probe lacrimal canaliculi,3431343,CDM,510,RC,68840,HCPCS,Outpatient,,,1471.07,735.54,,1103.3,75,,,percent of total billed charges,75% of total billed charges,1103.3,75,,,percent of total billed charges,75% of total billed charges,248.85,100,,,Fee Schedule,100% of CMS OPPS Rate,68.26,102,,,Fee Schedule,102% of WV Medicaid Rate,410.63,165,,,Fee Schedule,165% of CMS OPPS Rate,257.92,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,714.84,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,980.35,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1227.99,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,66.92,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,248.85,100,,,Fee Schedule,100% of CMS OPPS Rate,257.92,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,205.95,14,,,percent of total billed charges,14% of total billed charges,66.92,1227.99,
69100- Biopsy external ear,3430622,CDM,510,RC,69100,HCPCS,Outpatient,,,1233.47,616.74,,925.1,75,,,percent of total billed charges,75% of total billed charges,925.1,75,,,percent of total billed charges,75% of total billed charges,195.39,100,,,Fee Schedule,100% of CMS OPPS Rate,54.05,102,,,Fee Schedule,102% of WV Medicaid Rate,322.39,165,,,Fee Schedule,165% of CMS OPPS Rate,202.5,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,561.23,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,769.7,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,964.12,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,52.99,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,195.39,100,,,Fee Schedule,100% of CMS OPPS Rate,202.5,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,172.69,14,,,percent of total billed charges,14% of total billed charges,52.99,964.12,
WW Chest single view AP or PA,3373170,CDM,972,RC,71045,HCPCS,Outpatient,,,48.89,24.45,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
WW Chest PA and Lat:WW DR Exam,3373168,CDM,972,RC,71046,HCPCS,Outpatient,,,54.81,27.41,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
WW Hand Rt AP Lat & Oblique,3373218,CDM,972,RC,73130,HCPCS,Outpatient,,,66.64,33.32,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
WW Knee Rt Series,3373252,CDM,972,RC,73564,HCPCS,Outpatient,,,84.01,42.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
CT Abdomen Pelvis ENH no oral,3351172,CDM,350,RC,74177,HCPCS,Outpatient,,,1816.78,908.39,,1362.59,75,,,percent of total billed charges,75% of total billed charges,1362.59,75,,,percent of total billed charges,75% of total billed charges,346.38,100,,,Fee Schedule,100% of CMS OPPS Rate,210.4,100,,,Fee Schedule,100% of WV Medicaid Rate,571.51,165,,,Fee Schedule,165% of CMS OPPS Rate,358.99,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,994.94,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1364.48,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1709.15,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,210.4,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,346.38,100,,,Fee Schedule,100% of CMS OPPS Rate,358.99,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,254.35,14,,,percent of total billed charges,14% of total billed charges,210.4,1709.15,
"74740 - PB Tech - Hysterosalpingography, radiological supervision and interpretation",3640902,CDM,510,RC,74740,HCPCS,Outpatient,,,189.82,94.91,,142.37,75,,,percent of total billed charges,75% of total billed charges,142.37,75,,,percent of total billed charges,75% of total billed charges,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,63.66,100,,,Fee Schedule,100% of WV Medicaid Rate,362.25,165,,,Fee Schedule,165% of CMS OPPS Rate,227.54,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,630.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,864.84,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1083.3,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,63.66,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,227.54,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,26.57,14,,,percent of total billed charges,14% of total billed charges,26.57,1083.3,
75565- Cardiac MRI for velocity flow mapping,3569427,CDM,510,RC,75565,HCPCS,Outpatient,,,87.65,43.83,,65.74,75,,,percent of total billed charges,75% of total billed charges,65.74,75,,,percent of total billed charges,75% of total billed charges,28.05,32,,,percent of total billed charges,32% of total billed charges,31.71,100,,,Fee Schedule,100% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.71,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.27,14,,,percent of total billed charges,14% of total billed charges,12.27,65.74,
"75605- Aortography/thor, serialogrph,radio sup& intp",3569425,CDM,510,RC,75605,HCPCS,Outpatient,,,161.71,80.86,,121.28,75,,,percent of total billed charges,75% of total billed charges,121.28,75,,,percent of total billed charges,75% of total billed charges,4832.22,100,,,Fee Schedule,100% of CMS OPPS Rate,81.61,100,,,Fee Schedule,100% of WV Medicaid Rate,7973.18,165,,,Fee Schedule,165% of CMS OPPS Rate,5008.19,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,13879.91,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,19035.19,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,23843.51,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,81.61,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,4832.22,100,,,Fee Schedule,100% of CMS OPPS Rate,5008.19,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,22.64,14,,,percent of total billed charges,14% of total billed charges,22.64,23843.51,
"75630 - PF - Aortography, abdominal plus bilateral iliofemoral lower extremity, catheter, by serialo",3640904,CDM,510,RC,75630,HCPCS,Outpatient,,,16096.15,8048.08,,12072.11,75,,,percent of total billed charges,75% of total billed charges,12072.11,75,,,percent of total billed charges,75% of total billed charges,2800.72,100,,,Fee Schedule,100% of CMS OPPS Rate,108.4,100,,,Fee Schedule,100% of WV Medicaid Rate,4621.2,165,,,Fee Schedule,165% of CMS OPPS Rate,2902.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8044.7,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11032.67,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13819.54,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,108.4,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2800.72,100,,,Fee Schedule,100% of CMS OPPS Rate,2902.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,2253.46,14,,,percent of total billed charges,14% of total billed charges,108.4,13819.54,
Peripheral Angio Aortagram w Runoff,3427191,CDM,320,RC,75630,HCPCS,Outpatient,,,16096.15,8048.08,,12072.11,75,,,percent of total billed charges,75% of total billed charges,12072.11,75,,,percent of total billed charges,75% of total billed charges,2800.72,100,,,Fee Schedule,100% of CMS OPPS Rate,108.4,100,,,Fee Schedule,100% of WV Medicaid Rate,4621.2,165,,,Fee Schedule,165% of CMS OPPS Rate,2902.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8044.7,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11032.67,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13819.54,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,108.4,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2800.72,100,,,Fee Schedule,100% of CMS OPPS Rate,2902.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,2253.46,14,,,percent of total billed charges,14% of total billed charges,108.4,13819.54,
"75710 - Angiography, extremity, unilateral, radiological supervision and interpretation",3640905,CDM,510,RC,75710,HCPCS,Outpatient,,,16096.15,8048.08,,12072.11,75,,,percent of total billed charges,75% of total billed charges,12072.11,75,,,percent of total billed charges,75% of total billed charges,2800.72,100,,,Fee Schedule,100% of CMS OPPS Rate,103.48,100,,,Fee Schedule,100% of WV Medicaid Rate,4621.2,165,,,Fee Schedule,165% of CMS OPPS Rate,2902.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8044.7,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11032.67,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13819.54,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,103.48,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2800.72,100,,,Fee Schedule,100% of CMS OPPS Rate,2902.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,2253.46,14,,,percent of total billed charges,14% of total billed charges,103.48,13819.54,
Peripheral Angio Lower Extremity LT,3427218,CDM,320,RC,75710,HCPCS,Outpatient,,,16096.15,8048.08,,12072.11,75,,,percent of total billed charges,75% of total billed charges,12072.11,75,,,percent of total billed charges,75% of total billed charges,2800.72,100,,,Fee Schedule,100% of CMS OPPS Rate,103.48,100,,,Fee Schedule,100% of WV Medicaid Rate,4621.2,165,,,Fee Schedule,165% of CMS OPPS Rate,2902.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8044.7,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11032.67,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13819.54,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,103.48,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2800.72,100,,,Fee Schedule,100% of CMS OPPS Rate,2902.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,2253.46,14,,,percent of total billed charges,14% of total billed charges,103.48,13819.54,
Peripheral Angio Lower Extremity RT,3427219,CDM,320,RC,75710,HCPCS,Outpatient,,,16096.15,8048.08,,12072.11,75,,,percent of total billed charges,75% of total billed charges,12072.11,75,,,percent of total billed charges,75% of total billed charges,2800.72,100,,,Fee Schedule,100% of CMS OPPS Rate,103.48,100,,,Fee Schedule,100% of WV Medicaid Rate,4621.2,165,,,Fee Schedule,165% of CMS OPPS Rate,2902.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8044.7,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11032.67,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13819.54,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,103.48,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2800.72,100,,,Fee Schedule,100% of CMS OPPS Rate,2902.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,2253.46,14,,,percent of total billed charges,14% of total billed charges,103.48,13819.54,
Peripheral Angio Tibal Peroneal,3427225,CDM,320,RC,75710,HCPCS,Outpatient,,,16096.15,8048.08,,12072.11,75,,,percent of total billed charges,75% of total billed charges,12072.11,75,,,percent of total billed charges,75% of total billed charges,2800.72,100,,,Fee Schedule,100% of CMS OPPS Rate,103.48,100,,,Fee Schedule,100% of WV Medicaid Rate,4621.2,165,,,Fee Schedule,165% of CMS OPPS Rate,2902.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8044.7,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11032.67,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13819.54,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,103.48,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2800.72,100,,,Fee Schedule,100% of CMS OPPS Rate,2902.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,2253.46,14,,,percent of total billed charges,14% of total billed charges,103.48,13819.54,
"75822 - Venography, extremity, bilateral, radiological supervision and interpretation",3761052,CDM,320,RC,75822,HCPCS,Outpatient,,,155.86,77.93,,116.9,75,,,percent of total billed charges,75% of total billed charges,116.9,75,,,percent of total billed charges,75% of total billed charges,1398.82,100,,,Fee Schedule,100% of CMS OPPS Rate,90.21,100,,,Fee Schedule,100% of WV Medicaid Rate,2308.05,165,,,Fee Schedule,165% of CMS OPPS Rate,1449.76,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4017.93,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,5510.28,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6902.18,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,90.21,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1398.82,100,,,Fee Schedule,100% of CMS OPPS Rate,1449.76,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,21.82,14,,,percent of total billed charges,14% of total billed charges,21.82,6902.18,
75825 - Venography caval inferior w/ serial,4241822,CDM,510,RC,75825,HCPCS,Outpatient,,,93.86,46.93,,70.4,75,,,percent of total billed charges,75% of total billed charges,70.4,75,,,percent of total billed charges,75% of total billed charges,2800.72,100,,,Fee Schedule,100% of CMS OPPS Rate,76.94,100,,,Fee Schedule,100% of WV Medicaid Rate,4621.2,165,,,Fee Schedule,165% of CMS OPPS Rate,2902.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,8044.7,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,11032.67,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13819.54,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,76.94,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2800.72,100,,,Fee Schedule,100% of CMS OPPS Rate,2902.71,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,13.14,14,,,percent of total billed charges,14% of total billed charges,13.14,13819.54,
75894 XR Transcatheter Embolization Any Meth RS&I,3436057,CDM,761,RC,75894,HCPCS,Outpatient,,,5431,2715.5,,4073.25,75,,,percent of total billed charges,75% of total billed charges,4073.25,75,,,percent of total billed charges,75% of total billed charges,1737.92,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,760.34,14,,,percent of total billed charges,14% of total billed charges,760.34,4073.25,
75957-ENDOVASCULAR TAA REPAIR INTERP,3430924,CDM,510,RC,75957,HCPCS,Outpatient,,,777.51,388.76,,583.13,75,,,percent of total billed charges,75% of total billed charges,583.13,75,,,percent of total billed charges,75% of total billed charges,777.51,100,,,Fee Schedule,Pays at line item charges based on APC Setting,,,,,Other,Not Separately reimbursable,777.51,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,777.51,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,777.51,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,777.51,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,777.51,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,777.51,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,777.51,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,108.85,14,,,percent of total billed charges,14% of total billed charges,108.85,777.51,
SCMP US Guided Fine Needle Asp. Thyroid,3370908,CDM,972,RC,76536,HCPCS,Outpatient,,,534.4,267.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
SCMP US Thyroid,3370915,CDM,402,RC,76536,HCPCS,Outpatient,,,571.2,285.6,,428.4,75,,,percent of total billed charges,75% of total billed charges,428.4,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,73.48,100,,,Fee Schedule,100% of WV Medicaid Rate,165.8,165,,,Fee Schedule,165% of CMS OPPS Rate,104.14,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.83,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,73.48,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.14,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,79.97,14,,,percent of total billed charges,14% of total billed charges,73.48,495.81,
SCSN US Exam,4345735,CDM,402,RC,76536,HCPCS,Outpatient,,,534.4,267.2,,400.8,75,,,percent of total billed charges,75% of total billed charges,400.8,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,73.48,100,,,Fee Schedule,100% of WV Medicaid Rate,165.8,165,,,Fee Schedule,165% of CMS OPPS Rate,104.14,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.83,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,73.48,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.14,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,74.82,14,,,percent of total billed charges,14% of total billed charges,73.48,495.81,
SCSN US Exam,4345741,CDM,402,RC,76536,HCPCS,Outpatient,,,534.4,267.2,,400.8,75,,,percent of total billed charges,75% of total billed charges,400.8,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,73.48,100,,,Fee Schedule,100% of WV Medicaid Rate,165.8,165,,,Fee Schedule,165% of CMS OPPS Rate,104.14,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.83,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,73.48,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.14,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,74.82,14,,,percent of total billed charges,14% of total billed charges,73.48,495.81,
US Neck Including Thyroid,596513,CDM,402,RC,76536,HCPCS,Outpatient,,,571.2,285.6,,428.4,75,,,percent of total billed charges,75% of total billed charges,428.4,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,73.48,100,,,Fee Schedule,100% of WV Medicaid Rate,165.8,165,,,Fee Schedule,165% of CMS OPPS Rate,104.14,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.83,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,73.48,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.14,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,79.97,14,,,percent of total billed charges,14% of total billed charges,73.48,495.81,
76641- US  breast complete,3430614,CDM,402,RC,76641,HCPCS,Outpatient,,,163.76,81.88,,122.82,75,,,percent of total billed charges,75% of total billed charges,122.82,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,68.33,100,,,Fee Schedule,100% of WV Medicaid Rate,165.8,165,,,Fee Schedule,165% of CMS OPPS Rate,104.14,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.83,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,68.33,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.14,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,22.93,14,,,percent of total billed charges,14% of total billed charges,22.93,495.81,
Read,3370897,CDM,402,RC,76641,HCPCS,Outpatient,,,537.19,268.6,,402.89,75,,,percent of total billed charges,75% of total billed charges,402.89,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,68.33,100,,,Fee Schedule,100% of WV Medicaid Rate,165.8,165,,,Fee Schedule,165% of CMS OPPS Rate,104.14,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.83,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,68.33,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.14,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,75.21,14,,,percent of total billed charges,14% of total billed charges,68.33,495.81,
SCMP US Breast L,3370898,CDM,972,RC,76641,HCPCS,Outpatient,,,537.19,268.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
SCMP US Breast R,3370900,CDM,972,RC,76641,HCPCS,Outpatient,,,537.19,268.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
76642- US  breast limited,3430615,CDM,402,RC,76642,HCPCS,Outpatient,,,125.07,62.54,,93.8,75,,,percent of total billed charges,75% of total billed charges,93.8,75,,,percent of total billed charges,75% of total billed charges,81.68,100,,,Fee Schedule,100% of CMS OPPS Rate,56.29,100,,,Fee Schedule,100% of WV Medicaid Rate,134.77,165,,,Fee Schedule,165% of CMS OPPS Rate,84.65,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,234.61,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,321.76,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,403.03,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,56.29,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,81.68,100,,,Fee Schedule,100% of CMS OPPS Rate,84.65,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,17.51,14,,,percent of total billed charges,14% of total billed charges,17.51,403.03,
SCSN US Breast Limite Bilat Interp,3575276,CDM,972,RC,76642,HCPCS,Outpatient,,,125.07,62.54,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
SCSN US Breast Limited Bilat,3569759,CDM,401,RC,76642,HCPCS,Outpatient,,,250.14,125.07,,187.61,75,,,percent of total billed charges,75% of total billed charges,187.61,75,,,percent of total billed charges,75% of total billed charges,81.68,100,,,Fee Schedule,100% of CMS OPPS Rate,56.29,100,,,Fee Schedule,100% of WV Medicaid Rate,134.77,165,,,Fee Schedule,165% of CMS OPPS Rate,84.65,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,234.61,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,321.76,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,403.03,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,56.29,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,81.68,100,,,Fee Schedule,100% of CMS OPPS Rate,84.65,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,35.02,14,,,percent of total billed charges,14% of total billed charges,35.02,403.03,
SCSN US Breast Limited LT,3569761,CDM,401,RC,76642,HCPCS,Outpatient,,,125.07,62.54,,93.8,75,,,percent of total billed charges,75% of total billed charges,93.8,75,,,percent of total billed charges,75% of total billed charges,81.68,100,,,Fee Schedule,100% of CMS OPPS Rate,56.29,100,,,Fee Schedule,100% of WV Medicaid Rate,134.77,165,,,Fee Schedule,165% of CMS OPPS Rate,84.65,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,234.61,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,321.76,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,403.03,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,56.29,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,81.68,100,,,Fee Schedule,100% of CMS OPPS Rate,84.65,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,17.51,14,,,percent of total billed charges,14% of total billed charges,17.51,403.03,
SCSN US Breast Limited RT,3569763,CDM,401,RC,76642,HCPCS,Outpatient,,,125.07,62.54,,93.8,75,,,percent of total billed charges,75% of total billed charges,93.8,75,,,percent of total billed charges,75% of total billed charges,81.68,100,,,Fee Schedule,100% of CMS OPPS Rate,56.29,100,,,Fee Schedule,100% of WV Medicaid Rate,134.77,165,,,Fee Schedule,165% of CMS OPPS Rate,84.65,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,234.61,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,321.76,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,403.03,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,56.29,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,81.68,100,,,Fee Schedule,100% of CMS OPPS Rate,84.65,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,17.51,14,,,percent of total billed charges,14% of total billed charges,17.51,403.03,
SCSN US Breast Limited RT Interp,3575280,CDM,510,RC,76642,HCPCS,Outpatient,,,125.07,62.54,,93.8,75,,,percent of total billed charges,75% of total billed charges,93.8,75,,,percent of total billed charges,75% of total billed charges,81.68,100,,,Fee Schedule,100% of CMS OPPS Rate,56.29,100,,,Fee Schedule,100% of WV Medicaid Rate,134.77,165,,,Fee Schedule,165% of CMS OPPS Rate,84.65,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,234.61,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,321.76,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,403.03,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,56.29,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,81.68,100,,,Fee Schedule,100% of CMS OPPS Rate,84.65,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,17.51,14,,,percent of total billed charges,14% of total billed charges,17.51,403.03,
SCSN US Breast w Axilla Bilat,3569765,CDM,401,RC,76642,HCPCS,Outpatient,,,250.14,125.07,,187.61,75,,,percent of total billed charges,75% of total billed charges,187.61,75,,,percent of total billed charges,75% of total billed charges,81.68,100,,,Fee Schedule,100% of CMS OPPS Rate,56.29,100,,,Fee Schedule,100% of WV Medicaid Rate,134.77,165,,,Fee Schedule,165% of CMS OPPS Rate,84.65,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,234.61,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,321.76,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,403.03,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,56.29,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,81.68,100,,,Fee Schedule,100% of CMS OPPS Rate,84.65,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,35.02,14,,,percent of total billed charges,14% of total billed charges,35.02,403.03,
SCSN US Breast w axilla BILAT PR,3575282,CDM,972,RC,76642,HCPCS,Outpatient,,,125.07,62.54,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
SCSN US Breast w Axilla LT,3575284,CDM,510,RC,76642,HCPCS,Outpatient,,,125.07,62.54,,93.8,75,,,percent of total billed charges,75% of total billed charges,93.8,75,,,percent of total billed charges,75% of total billed charges,81.68,100,,,Fee Schedule,100% of CMS OPPS Rate,56.29,100,,,Fee Schedule,100% of WV Medicaid Rate,134.77,165,,,Fee Schedule,165% of CMS OPPS Rate,84.65,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,234.61,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,321.76,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,403.03,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,56.29,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,81.68,100,,,Fee Schedule,100% of CMS OPPS Rate,84.65,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,17.51,14,,,percent of total billed charges,14% of total billed charges,17.51,403.03,
SCSN US Breast w Axilla LT,3575286,CDM,510,RC,76642,HCPCS,Outpatient,,,125.07,62.54,,93.8,75,,,percent of total billed charges,75% of total billed charges,93.8,75,,,percent of total billed charges,75% of total billed charges,81.68,100,,,Fee Schedule,100% of CMS OPPS Rate,56.29,100,,,Fee Schedule,100% of WV Medicaid Rate,134.77,165,,,Fee Schedule,165% of CMS OPPS Rate,84.65,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,234.61,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,321.76,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,403.03,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,56.29,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,81.68,100,,,Fee Schedule,100% of CMS OPPS Rate,84.65,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,17.51,14,,,percent of total billed charges,14% of total billed charges,17.51,403.03,
SCSN US Breast w Axilla LT,3569767,CDM,401,RC,76642,HCPCS,Outpatient,,,125.07,62.54,,93.8,75,,,percent of total billed charges,75% of total billed charges,93.8,75,,,percent of total billed charges,75% of total billed charges,81.68,100,,,Fee Schedule,100% of CMS OPPS Rate,56.29,100,,,Fee Schedule,100% of WV Medicaid Rate,134.77,165,,,Fee Schedule,165% of CMS OPPS Rate,84.65,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,234.61,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,321.76,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,403.03,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,56.29,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,81.68,100,,,Fee Schedule,100% of CMS OPPS Rate,84.65,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,17.51,14,,,percent of total billed charges,14% of total billed charges,17.51,403.03,
SCSN US Breast w Axilla RT,3569769,CDM,401,RC,76642,HCPCS,Outpatient,,,125.07,62.54,,93.8,75,,,percent of total billed charges,75% of total billed charges,93.8,75,,,percent of total billed charges,75% of total billed charges,81.68,100,,,Fee Schedule,100% of CMS OPPS Rate,56.29,100,,,Fee Schedule,100% of WV Medicaid Rate,134.77,165,,,Fee Schedule,165% of CMS OPPS Rate,84.65,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,234.61,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,321.76,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,403.03,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,56.29,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,81.68,100,,,Fee Schedule,100% of CMS OPPS Rate,84.65,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,17.51,14,,,percent of total billed charges,14% of total billed charges,17.51,403.03,
SCSN US Exam,3575278,CDM,972,RC,76642,HCPCS,Outpatient,,,125.07,62.54,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
US Breast Left Limited,3318564,CDM,402,RC,76642,HCPCS,Outpatient,,,399.08,199.54,,299.31,75,,,percent of total billed charges,75% of total billed charges,299.31,75,,,percent of total billed charges,75% of total billed charges,81.68,100,,,Fee Schedule,100% of CMS OPPS Rate,56.29,100,,,Fee Schedule,100% of WV Medicaid Rate,134.77,165,,,Fee Schedule,165% of CMS OPPS Rate,84.65,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,234.61,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,321.76,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,403.03,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,56.29,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,81.68,100,,,Fee Schedule,100% of CMS OPPS Rate,84.65,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,55.87,14,,,percent of total billed charges,14% of total billed charges,55.87,403.03,
US Breast Right Limited,3318566,CDM,402,RC,76642,HCPCS,Outpatient,,,399.08,199.54,,299.31,75,,,percent of total billed charges,75% of total billed charges,299.31,75,,,percent of total billed charges,75% of total billed charges,81.68,100,,,Fee Schedule,100% of CMS OPPS Rate,56.29,100,,,Fee Schedule,100% of WV Medicaid Rate,134.77,165,,,Fee Schedule,165% of CMS OPPS Rate,84.65,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,234.61,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,321.76,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,403.03,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,56.29,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,81.68,100,,,Fee Schedule,100% of CMS OPPS Rate,84.65,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,55.87,14,,,percent of total billed charges,14% of total billed charges,55.87,403.03,
76700- US abdommen complete,3430616,CDM,402,RC,76700,HCPCS,Outpatient,,,189.03,94.52,,141.77,75,,,percent of total billed charges,75% of total billed charges,141.77,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,77.67,100,,,Fee Schedule,100% of WV Medicaid Rate,165.79,165,,,Fee Schedule,165% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.82,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,77.67,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,26.46,14,,,percent of total billed charges,14% of total billed charges,26.46,495.81,
SCSN US Abdomen Complete PR:SCSN US Exam,3575254,CDM,510,RC,76700,HCPCS,Outpatient,,,189.03,94.52,,141.77,75,,,percent of total billed charges,75% of total billed charges,141.77,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,77.67,100,,,Fee Schedule,100% of WV Medicaid Rate,165.79,165,,,Fee Schedule,165% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.82,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,77.67,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,26.46,14,,,percent of total billed charges,14% of total billed charges,26.46,495.81,
SCSN US Abdomen Complete:SCSN US Exam,3555174,CDM,402,RC,76700,HCPCS,Outpatient,,,189.03,94.52,,141.77,75,,,percent of total billed charges,75% of total billed charges,141.77,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,77.67,100,,,Fee Schedule,100% of WV Medicaid Rate,165.79,165,,,Fee Schedule,165% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.82,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,77.67,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,26.46,14,,,percent of total billed charges,14% of total billed charges,26.46,495.81,
US Abdomen Complete,596620,CDM,402,RC,76700,HCPCS,Outpatient,,,571.2,285.6,,428.4,75,,,percent of total billed charges,75% of total billed charges,428.4,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,77.67,100,,,Fee Schedule,100% of WV Medicaid Rate,165.79,165,,,Fee Schedule,165% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.82,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,77.67,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,79.97,14,,,percent of total billed charges,14% of total billed charges,77.67,495.81,
76705 - (TC) Echo Exam of Abdomen -Limited,3897025,CDM,960,RC,76705,HCPCS,Outpatient,,,142.44,71.22,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
"76705 Ultrasound, abdominal, real time with image documentation; limited (eg, single organ, qua",3715135,CDM,510,RC,76705,HCPCS,Outpatient,,,142.44,71.22,,106.83,75,,,percent of total billed charges,75% of total billed charges,106.83,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,58.25,100,,,Fee Schedule,100% of WV Medicaid Rate,165.79,165,,,Fee Schedule,165% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.82,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,58.25,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,19.94,14,,,percent of total billed charges,14% of total billed charges,19.94,495.81,
SCMP US Abdomen,3370896,CDM,972,RC,76705,HCPCS,Outpatient,,,534.4,267.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
SCSN US Exam,3575310,CDM,402,RC,76705,HCPCS,Outpatient,,,142.43,71.22,,106.82,75,,,percent of total billed charges,75% of total billed charges,106.82,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,58.25,100,,,Fee Schedule,100% of WV Medicaid Rate,165.79,165,,,Fee Schedule,165% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.82,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,58.25,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,19.94,14,,,percent of total billed charges,14% of total billed charges,19.94,495.81,
SCSN US RUQ/GB Ultrasound,3370960,CDM,402,RC,76705,HCPCS,Outpatient,,,142.43,71.22,,106.82,75,,,percent of total billed charges,75% of total billed charges,106.82,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,58.25,100,,,Fee Schedule,100% of WV Medicaid Rate,165.79,165,,,Fee Schedule,165% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.82,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,58.25,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,19.94,14,,,percent of total billed charges,14% of total billed charges,19.94,495.81,
URMC US Abdomen,3358605,CDM,402,RC,76705,HCPCS,Outpatient,,,1633.23,816.62,,1224.92,75,,,percent of total billed charges,75% of total billed charges,1224.92,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,58.25,100,,,Fee Schedule,100% of WV Medicaid Rate,165.79,165,,,Fee Schedule,165% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.82,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,58.25,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,228.65,14,,,percent of total billed charges,14% of total billed charges,58.25,1224.92,
76770- US abdomen back wall complete,3430617,CDM,402,RC,76770,HCPCS,Outpatient,,,176.39,88.2,,132.29,75,,,percent of total billed charges,75% of total billed charges,132.29,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,72.02,100,,,Fee Schedule,100% of WV Medicaid Rate,165.79,165,,,Fee Schedule,165% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.82,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,72.02,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,24.69,14,,,percent of total billed charges,14% of total billed charges,24.69,495.81,
SCMP US Aorta/ Retro,3563000,CDM,972,RC,76770,HCPCS,Outpatient,,,571.2,285.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
SCMP US Exam,3575228,CDM,402,RC,76770,HCPCS,Outpatient,,,176.39,88.2,,132.29,75,,,percent of total billed charges,75% of total billed charges,132.29,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,72.02,100,,,Fee Schedule,100% of WV Medicaid Rate,165.79,165,,,Fee Schedule,165% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.82,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,72.02,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,24.69,14,,,percent of total billed charges,14% of total billed charges,24.69,495.81,
SCSN US Aorta/ Retro Complete,3575258,CDM,320,RC,76770,HCPCS,Outpatient,,,176.39,88.2,,132.29,75,,,percent of total billed charges,75% of total billed charges,132.29,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,72.02,100,,,Fee Schedule,100% of WV Medicaid Rate,165.79,165,,,Fee Schedule,165% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.82,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,72.02,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,24.69,14,,,percent of total billed charges,14% of total billed charges,24.69,495.81,
SCSN US Aorta/ Retro Complete,3370930,CDM,402,RC,76770,HCPCS,Outpatient,,,176.39,88.2,,132.29,75,,,percent of total billed charges,75% of total billed charges,132.29,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,72.02,100,,,Fee Schedule,100% of WV Medicaid Rate,165.79,165,,,Fee Schedule,165% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.82,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,72.02,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,24.69,14,,,percent of total billed charges,14% of total billed charges,24.69,495.81,
SCSN US Renal BILAT,3569771,CDM,402,RC,76770,HCPCS,Outpatient,,,176.39,88.2,,132.29,75,,,percent of total billed charges,75% of total billed charges,132.29,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,72.02,100,,,Fee Schedule,100% of WV Medicaid Rate,165.79,165,,,Fee Schedule,165% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.82,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,72.02,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,24.69,14,,,percent of total billed charges,14% of total billed charges,24.69,495.81,
SCSN US Renal Bilat Interp,3575304,CDM,402,RC,76770,HCPCS,Outpatient,,,176.39,88.2,,132.29,75,,,percent of total billed charges,75% of total billed charges,132.29,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,72.02,100,,,Fee Schedule,100% of WV Medicaid Rate,165.79,165,,,Fee Schedule,165% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.82,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,72.02,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,24.69,14,,,percent of total billed charges,14% of total billed charges,24.69,495.81,
76775- Us exam abdo back wall lim,3430507,CDM,402,RC,76775,HCPCS,Outpatient,,,576.75,288.38,,432.56,75,,,percent of total billed charges,75% of total billed charges,432.56,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,38.84,100,,,Fee Schedule,100% of WV Medicaid Rate,165.8,165,,,Fee Schedule,165% of CMS OPPS Rate,104.14,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.83,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,38.84,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.14,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,80.75,14,,,percent of total billed charges,14% of total billed charges,38.84,495.81,
CL Renal Artery Ultrasound LT,3427573,CDM,402,RC,76775,HCPCS,Outpatient,,,576.75,288.38,,432.56,75,,,percent of total billed charges,75% of total billed charges,432.56,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,38.84,100,,,Fee Schedule,100% of WV Medicaid Rate,165.8,165,,,Fee Schedule,165% of CMS OPPS Rate,104.14,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.83,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,38.84,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.14,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,80.75,14,,,percent of total billed charges,14% of total billed charges,38.84,495.81,
CL Renal Artery Ultrasound RT,3427574,CDM,402,RC,76775,HCPCS,Outpatient,,,576.75,288.38,,432.56,75,,,percent of total billed charges,75% of total billed charges,432.56,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,38.84,100,,,Fee Schedule,100% of WV Medicaid Rate,165.8,165,,,Fee Schedule,165% of CMS OPPS Rate,104.14,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.83,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,38.84,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.14,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,80.75,14,,,percent of total billed charges,14% of total billed charges,38.84,495.81,
SCSN US Aorta Stent,3575256,CDM,972,RC,76775,HCPCS,Outpatient,,,576.75,288.38,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
SCSN US Aorta Stent,3370926,CDM,402,RC,76775,HCPCS,Outpatient,,,576.75,288.38,,432.56,75,,,percent of total billed charges,75% of total billed charges,432.56,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,38.84,100,,,Fee Schedule,100% of WV Medicaid Rate,165.8,165,,,Fee Schedule,165% of CMS OPPS Rate,104.14,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.83,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,38.84,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.14,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,80.75,14,,,percent of total billed charges,14% of total billed charges,38.84,495.81,
SCSN US Exam,3575302,CDM,402,RC,76775,HCPCS,Outpatient,,,576.75,288.38,,432.56,75,,,percent of total billed charges,75% of total billed charges,432.56,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,38.84,100,,,Fee Schedule,100% of WV Medicaid Rate,165.8,165,,,Fee Schedule,165% of CMS OPPS Rate,104.14,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.83,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,38.84,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.14,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,80.75,14,,,percent of total billed charges,14% of total billed charges,38.84,495.81,
SCSN US Renal Artery,3370956,CDM,402,RC,76775,HCPCS,Outpatient,,,576.75,288.38,,432.56,75,,,percent of total billed charges,75% of total billed charges,432.56,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,38.84,100,,,Fee Schedule,100% of WV Medicaid Rate,165.8,165,,,Fee Schedule,165% of CMS OPPS Rate,104.14,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.83,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,38.84,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.14,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,80.75,14,,,percent of total billed charges,14% of total billed charges,38.84,495.81,
SCSN US Renal LT,3569773,CDM,402,RC,76775,HCPCS,Outpatient,,,576.75,288.38,,432.56,75,,,percent of total billed charges,75% of total billed charges,432.56,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,38.84,100,,,Fee Schedule,100% of WV Medicaid Rate,165.8,165,,,Fee Schedule,165% of CMS OPPS Rate,104.14,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.83,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,38.84,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.14,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,80.75,14,,,percent of total billed charges,14% of total billed charges,38.84,495.81,
SCSN US Renal LT Interp,3575306,CDM,402,RC,76775,HCPCS,Outpatient,,,576.75,288.38,,432.56,75,,,percent of total billed charges,75% of total billed charges,432.56,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,38.84,100,,,Fee Schedule,100% of WV Medicaid Rate,165.8,165,,,Fee Schedule,165% of CMS OPPS Rate,104.14,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.83,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,38.84,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.14,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,80.75,14,,,percent of total billed charges,14% of total billed charges,38.84,495.81,
SCSN US Renal LT Interp,3575308,CDM,402,RC,76775,HCPCS,Outpatient,,,576.75,288.38,,432.56,75,,,percent of total billed charges,75% of total billed charges,432.56,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,38.84,100,,,Fee Schedule,100% of WV Medicaid Rate,165.8,165,,,Fee Schedule,165% of CMS OPPS Rate,104.14,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.83,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,38.84,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.14,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,80.75,14,,,percent of total billed charges,14% of total billed charges,38.84,495.81,
SCSN US Renal RT,3569775,CDM,402,RC,76775,HCPCS,Outpatient,,,576.75,288.38,,432.56,75,,,percent of total billed charges,75% of total billed charges,432.56,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,38.84,100,,,Fee Schedule,100% of WV Medicaid Rate,165.8,165,,,Fee Schedule,165% of CMS OPPS Rate,104.14,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.83,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,38.84,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.14,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,80.75,14,,,percent of total billed charges,14% of total billed charges,38.84,495.81,
URMC US Kidney,3370978,CDM,402,RC,76775,HCPCS,Outpatient,,,576.75,288.38,,432.56,75,,,percent of total billed charges,75% of total billed charges,432.56,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,38.84,100,,,Fee Schedule,100% of WV Medicaid Rate,165.8,165,,,Fee Schedule,165% of CMS OPPS Rate,104.14,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.83,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,38.84,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.14,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,80.75,14,,,percent of total billed charges,14% of total billed charges,38.84,495.81,
76801 Ob us < 14 wks single fetus,3428328,CDM,983,RC,76801,HCPCS,Outpatient,,,158.96,79.48,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
76802 Ob us < 14 wks addl fetus,3428329,CDM,983,RC,76802,HCPCS,Outpatient,,,47.67,23.84,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
76805 Ob us >/= 14 wks sngl fetus,3428330,CDM,983,RC,76805,HCPCS,Outpatient,,,197.69,98.85,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
76810 Ob us >/= 14 wks addl fetus,3428331,CDM,983,RC,76810,HCPCS,Outpatient,,,93.41,46.71,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
"76811 OB US, DETAILED SINGL FETUS",3430508,CDM,960,RC,76811,HCPCS,Outpatient,,,198.65,99.33,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
76815 Ob us limited fetus(s),3428332,CDM,983,RC,76815,HCPCS,Outpatient,,,113.52,56.76,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
76818- Fetal biophys profile/non-stress,3431737,CDM,402,RC,76818,HCPCS,Outpatient,,,153.02,76.51,,114.77,75,,,percent of total billed charges,75% of total billed charges,114.77,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,76.2,100,,,Fee Schedule,100% of WV Medicaid Rate,165.79,165,,,Fee Schedule,165% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.82,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,76.2,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,21.42,14,,,percent of total billed charges,14% of total billed charges,21.42,495.81,
76819- Fetal biophy profile w/o non-stres,3431738,CDM,402,RC,76819,HCPCS,Outpatient,,,110.88,55.44,,83.16,75,,,percent of total billed charges,75% of total billed charges,83.16,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,55.8,100,,,Fee Schedule,100% of WV Medicaid Rate,165.79,165,,,Fee Schedule,165% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.82,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,55.8,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,15.52,14,,,percent of total billed charges,14% of total billed charges,15.52,495.81,
76820 Umbilical artery echo,3428335,CDM,983,RC,76820,HCPCS,Outpatient,,,47.97,23.99,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
76821 Middle cerebral artery echo,3430509,CDM,960,RC,76821,HCPCS,Outpatient,,,131.4,65.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
76825 Echo exam of fetal heart,3430510,CDM,960,RC,76825,HCPCS,Outpatient,,,441.85,220.93,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
76826 Echo exam of fetal heart,3430511,CDM,960,RC,76826,HCPCS,Outpatient,,,284.1,142.05,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
76827 Echo exam of fetal heart,3430512,CDM,960,RC,76827,HCPCS,Outpatient,,,102.97,51.49,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
76828 Echo exam of fetal heart,3430513,CDM,960,RC,76828,HCPCS,Outpatient,,,54.81,27.41,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
"76830- US Transvaginal, non-ob",3430618,CDM,402,RC,76830,HCPCS,Outpatient,,,207.98,103.99,,155.99,75,,,percent of total billed charges,75% of total billed charges,155.99,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,78.9,100,,,Fee Schedule,100% of WV Medicaid Rate,165.79,165,,,Fee Schedule,165% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.82,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,78.9,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,29.12,14,,,percent of total billed charges,14% of total billed charges,29.12,495.81,
"76831 - PB Tech - Saline infusion sonohysterography (SIS), including color flow Doppler, when perfor",3640910,CDM,510,RC,76831,HCPCS,Outpatient,,,1458.24,729.12,,1093.68,75,,,percent of total billed charges,75% of total billed charges,1093.68,75,,,percent of total billed charges,75% of total billed charges,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,76.94,100,,,Fee Schedule,100% of WV Medicaid Rate,362.24,165,,,Fee Schedule,165% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,630.61,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,864.84,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1083.29,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,76.94,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,204.15,14,,,percent of total billed charges,14% of total billed charges,76.94,1093.68,
76856- US pelvic complete,3430619,CDM,402,RC,76856,HCPCS,Outpatient,,,174.83,87.42,,131.12,75,,,percent of total billed charges,75% of total billed charges,131.12,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,70.05,100,,,Fee Schedule,100% of WV Medicaid Rate,165.79,165,,,Fee Schedule,165% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.82,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,70.05,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,24.48,14,,,percent of total billed charges,14% of total billed charges,24.48,495.81,
76857 Us exam pelvic limited,3428336,CDM,402,RC,76857,HCPCS,Outpatient,,,54.67,27.34,,41,75,,,percent of total billed charges,75% of total billed charges,41,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,31.95,100,,,Fee Schedule,100% of WV Medicaid Rate,165.79,165,,,Fee Schedule,165% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.82,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,31.95,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,7.65,14,,,percent of total billed charges,14% of total billed charges,7.65,495.81,
"URMC US NON OB Pelvic, Limited PR:URMC US Exam",3575336,CDM,402,RC,76857,HCPCS,Outpatient,,,1633.23,816.62,,1224.92,75,,,percent of total billed charges,75% of total billed charges,1224.92,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,31.95,100,,,Fee Schedule,100% of WV Medicaid Rate,165.79,165,,,Fee Schedule,165% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.82,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,31.95,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,228.65,14,,,percent of total billed charges,14% of total billed charges,31.95,1224.92,
76870- Us exam scrotum,3430514,CDM,402,RC,76870,HCPCS,Outpatient,,,576.75,288.38,,432.56,75,,,percent of total billed charges,75% of total billed charges,432.56,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,66.86,100,,,Fee Schedule,100% of WV Medicaid Rate,165.8,165,,,Fee Schedule,165% of CMS OPPS Rate,104.14,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.83,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,66.86,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.14,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,80.75,14,,,percent of total billed charges,14% of total billed charges,66.86,495.81,
URMC US Kidney,3584947,CDM,402,RC,76870,HCPCS,Outpatient,,,576.75,288.38,,432.56,75,,,percent of total billed charges,75% of total billed charges,432.56,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,66.86,100,,,Fee Schedule,100% of WV Medicaid Rate,165.8,165,,,Fee Schedule,165% of CMS OPPS Rate,104.14,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.83,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,66.86,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.14,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,80.75,14,,,percent of total billed charges,14% of total billed charges,66.86,495.81,
URMC US Scrotum,3370986,CDM,402,RC,76870,HCPCS,Outpatient,,,576.75,288.38,,432.56,75,,,percent of total billed charges,75% of total billed charges,432.56,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,66.86,100,,,Fee Schedule,100% of WV Medicaid Rate,165.8,165,,,Fee Schedule,165% of CMS OPPS Rate,104.14,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.83,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,66.86,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.14,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,80.75,14,,,percent of total billed charges,14% of total billed charges,66.86,495.81,
"76872 Ultrasound, transrectal",3430515,CDM,402,RC,76872,HCPCS,Outpatient,,,576.75,288.38,,432.56,75,,,percent of total billed charges,75% of total billed charges,432.56,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,90.39,100,,,Fee Schedule,100% of WV Medicaid Rate,165.79,165,,,Fee Schedule,165% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.82,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,90.39,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,80.75,14,,,percent of total billed charges,14% of total billed charges,80.75,495.81,
URMC US Prostate w/o Biopsy PR,3575342,CDM,402,RC,76872,HCPCS,Outpatient,,,576.75,288.38,,432.56,75,,,percent of total billed charges,75% of total billed charges,432.56,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,90.39,100,,,Fee Schedule,100% of WV Medicaid Rate,165.79,165,,,Fee Schedule,165% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.82,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,90.39,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,80.75,14,,,percent of total billed charges,14% of total billed charges,80.75,495.81,
SCSN US Exam,3575300,CDM,510,RC,76881,HCPCS,Outpatient,,,67.45,33.73,,50.59,75,,,percent of total billed charges,75% of total billed charges,50.59,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,39.33,100,,,Fee Schedule,100% of WV Medicaid Rate,165.79,165,,,Fee Schedule,165% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.82,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,39.33,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,9.44,14,,,percent of total billed charges,14% of total billed charges,9.44,495.81,
76882 US Extrem limited/nonvasc anatomic struct,3428337,CDM,983,RC,76882,HCPCS,Outpatient,,,74.03,37.02,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
76937-MA US GUIDE VASCULAR ACCESS,3430516,CDM,402,RC,76937,HCPCS,Outpatient,,,60.8,30.4,,45.6,75,,,percent of total billed charges,75% of total billed charges,45.6,75,,,percent of total billed charges,75% of total billed charges,19.46,32,,,percent of total billed charges,32% of total billed charges,25.81,100,,,Fee Schedule,100% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.81,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.51,14,,,percent of total billed charges,14% of total billed charges,8.51,45.6,
"76942 - Ultrasonic guidance for needle placement (eg, biopsy, aspiration, injection, localization de",3676896,CDM,402,RC,76942,HCPCS,Outpatient,,,610.56,305.28,,457.92,75,,,percent of total billed charges,75% of total billed charges,457.92,75,,,percent of total billed charges,75% of total billed charges,195.38,32,,,percent of total billed charges,32% of total billed charges,39.08,100,,,Fee Schedule,100% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.08,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,85.48,14,,,percent of total billed charges,14% of total billed charges,39.08,457.92,
"76942 (TC) - Ultrasonic guidance for needle placement (eg, biopsy, aspiration, injection, localizati",3676898,CDM,402,RC,76942,HCPCS,Outpatient,,,65.07,32.54,,48.8,75,,,percent of total billed charges,75% of total billed charges,48.8,75,,,percent of total billed charges,75% of total billed charges,20.82,32,,,percent of total billed charges,32% of total billed charges,39.08,100,,,Fee Schedule,100% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.08,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.11,14,,,percent of total billed charges,14% of total billed charges,9.11,48.8,
"76942- Ultrasonic guidance for needle placement (eg, biopsy, aspiration, injection, localizati",3676897,CDM,402,RC,76942,HCPCS,Outpatient,,,65.07,32.54,,48.8,75,,,percent of total billed charges,75% of total billed charges,48.8,75,,,percent of total billed charges,75% of total billed charges,20.82,32,,,percent of total billed charges,32% of total billed charges,39.08,100,,,Fee Schedule,100% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.08,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.11,14,,,percent of total billed charges,14% of total billed charges,9.11,48.8,
SCSN US Breast Cyst Aspiration,3370938,CDM,402,RC,76942,HCPCS,Outpatient,,,610.56,305.28,,457.92,75,,,percent of total billed charges,75% of total billed charges,457.92,75,,,percent of total billed charges,75% of total billed charges,195.38,32,,,percent of total billed charges,32% of total billed charges,39.08,100,,,Fee Schedule,100% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.08,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,85.48,14,,,percent of total billed charges,14% of total billed charges,39.08,457.92,
SCSN US Exam,4345731,CDM,402,RC,76942,HCPCS,Outpatient,,,610.56,305.28,,457.92,75,,,percent of total billed charges,75% of total billed charges,457.92,75,,,percent of total billed charges,75% of total billed charges,195.38,32,,,percent of total billed charges,32% of total billed charges,39.08,100,,,Fee Schedule,100% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.08,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,85.48,14,,,percent of total billed charges,14% of total billed charges,39.08,457.92,
SCSN US Exam,4345733,CDM,402,RC,76942,HCPCS,Outpatient,,,610.56,305.28,,457.92,75,,,percent of total billed charges,75% of total billed charges,457.92,75,,,percent of total billed charges,75% of total billed charges,195.38,32,,,percent of total billed charges,32% of total billed charges,39.08,100,,,Fee Schedule,100% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.08,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,85.48,14,,,percent of total billed charges,14% of total billed charges,39.08,457.92,
SCSN US Exam,3370948,CDM,402,RC,76942,HCPCS,Outpatient,,,610.56,305.28,,457.92,75,,,percent of total billed charges,75% of total billed charges,457.92,75,,,percent of total billed charges,75% of total billed charges,195.38,32,,,percent of total billed charges,32% of total billed charges,39.08,100,,,Fee Schedule,100% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.08,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,85.48,14,,,percent of total billed charges,14% of total billed charges,39.08,457.92,
SCSN US Exam,3575274,CDM,402,RC,76942,HCPCS,Outpatient,,,610.56,305.28,,457.92,75,,,percent of total billed charges,75% of total billed charges,457.92,75,,,percent of total billed charges,75% of total billed charges,195.38,32,,,percent of total billed charges,32% of total billed charges,39.08,100,,,Fee Schedule,100% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.08,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,85.48,14,,,percent of total billed charges,14% of total billed charges,39.08,457.92,
SCSN US Exam,3575292,CDM,402,RC,76942,HCPCS,Outpatient,,,610.56,305.28,,457.92,75,,,percent of total billed charges,75% of total billed charges,457.92,75,,,percent of total billed charges,75% of total billed charges,195.38,32,,,percent of total billed charges,32% of total billed charges,39.08,100,,,Fee Schedule,100% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.08,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,85.48,14,,,percent of total billed charges,14% of total billed charges,39.08,457.92,
SCSN US Exam,3575294,CDM,402,RC,76942,HCPCS,Outpatient,,,610.56,305.28,,457.92,75,,,percent of total billed charges,75% of total billed charges,457.92,75,,,percent of total billed charges,75% of total billed charges,195.38,32,,,percent of total billed charges,32% of total billed charges,39.08,100,,,Fee Schedule,100% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.08,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,85.48,14,,,percent of total billed charges,14% of total billed charges,39.08,457.92,
SCSN US Exam,3575314,CDM,402,RC,76942,HCPCS,Outpatient,,,610.56,305.28,,457.92,75,,,percent of total billed charges,75% of total billed charges,457.92,75,,,percent of total billed charges,75% of total billed charges,195.38,32,,,percent of total billed charges,32% of total billed charges,39.08,100,,,Fee Schedule,100% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.08,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,85.48,14,,,percent of total billed charges,14% of total billed charges,39.08,457.92,
SCSN US Exam,3749006,CDM,402,RC,76942,HCPCS,Outpatient,,,610.56,305.28,,457.92,75,,,percent of total billed charges,75% of total billed charges,457.92,75,,,percent of total billed charges,75% of total billed charges,195.38,32,,,percent of total billed charges,32% of total billed charges,39.08,100,,,Fee Schedule,100% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.08,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,85.48,14,,,percent of total billed charges,14% of total billed charges,39.08,457.92,
SCSN US Exam,3749008,CDM,402,RC,76942,HCPCS,Outpatient,,,610.56,305.28,,457.92,75,,,percent of total billed charges,75% of total billed charges,457.92,75,,,percent of total billed charges,75% of total billed charges,195.38,32,,,percent of total billed charges,32% of total billed charges,39.08,100,,,Fee Schedule,100% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.08,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,85.48,14,,,percent of total billed charges,14% of total billed charges,39.08,457.92,
URMC US Prostate w/ Biopsy:URMC US Exam,3575340,CDM,402,RC,76942,HCPCS,Outpatient,,,610.56,305.28,,457.92,75,,,percent of total billed charges,75% of total billed charges,457.92,75,,,percent of total billed charges,75% of total billed charges,195.38,32,,,percent of total billed charges,32% of total billed charges,39.08,100,,,Fee Schedule,100% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.08,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,85.48,14,,,percent of total billed charges,14% of total billed charges,39.08,457.92,
US Guidance Aspiration Bx or Injection,596562,CDM,402,RC,76942,HCPCS,Outpatient,,,984.74,492.37,,738.56,75,,,percent of total billed charges,75% of total billed charges,738.56,75,,,percent of total billed charges,75% of total billed charges,315.12,32,,,percent of total billed charges,32% of total billed charges,39.08,100,,,Fee Schedule,100% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.08,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,137.86,14,,,percent of total billed charges,14% of total billed charges,39.08,738.56,
76946- Echo guide for amniocentesis,3430620,CDM,510,RC,76946,HCPCS,Outpatient,,,33.47,16.74,,25.1,75,,,percent of total billed charges,75% of total billed charges,25.1,75,,,percent of total billed charges,75% of total billed charges,10.71,32,,,percent of total billed charges,32% of total billed charges,21.38,100,,,Fee Schedule,100% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.38,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.69,14,,,percent of total billed charges,14% of total billed charges,4.69,25.1,
"77001 Fluoroscopic guidance for central venous access device placement, replacement (catheter only o",3620980,CDM,510,RC,77001,HCPCS,Outpatient,,,200.89,100.45,,150.67,75,,,percent of total billed charges,75% of total billed charges,150.67,75,,,percent of total billed charges,75% of total billed charges,64.28,32,,,percent of total billed charges,32% of total billed charges,66.61,100,,,Fee Schedule,100% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.61,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.12,14,,,percent of total billed charges,14% of total billed charges,28.12,150.67,
SCSN US Assist with Venefit PR:SCSN US Exam,3575272,CDM,510,RC,77001,HCPCS,Outpatient,,,200.89,100.45,,150.67,75,,,percent of total billed charges,75% of total billed charges,150.67,75,,,percent of total billed charges,75% of total billed charges,64.28,32,,,percent of total billed charges,32% of total billed charges,66.61,100,,,Fee Schedule,100% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.61,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.12,14,,,percent of total billed charges,14% of total billed charges,28.12,150.67,
SCSN US Assist with Venefit:SCSN US Exam,3370936,CDM,510,RC,77001,HCPCS,Outpatient,,,200.89,100.45,,150.67,75,,,percent of total billed charges,75% of total billed charges,150.67,75,,,percent of total billed charges,75% of total billed charges,64.28,32,,,percent of total billed charges,32% of total billed charges,66.61,100,,,Fee Schedule,100% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.61,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.12,14,,,percent of total billed charges,14% of total billed charges,28.12,150.67,
77061 (TC) - Diagnostic digital breast tomosynthesis; unilateral,4037468,CDM,401,RC,77061,HCPCS,Outpatient,,,135.84,67.92,,101.88,75,,,percent of total billed charges,75% of total billed charges,101.88,75,,,percent of total billed charges,75% of total billed charges,43.47,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.02,14,,,percent of total billed charges,14% of total billed charges,19.02,101.88,
MA Mammogram Rt Unilat Diagnostic,603851,CDM,401,RC,77065,HCPCS,Outpatient,,,655.33,327.67,,491.5,75,,,percent of total billed charges,75% of total billed charges,491.5,75,,,percent of total billed charges,75% of total billed charges,76.49,100,,,Fee Schedule,100% of CMS OPPS Rate,82.59,100,,,Fee Schedule,100% of WV Medicaid Rate,126.21,165,,,Fee Schedule,165% of CMS OPPS Rate,111.32,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,271.19,354.54,,,Fee Schedule,354.54% of CMS OPPS Fee Schedule Rate,327.91,428.7,,,Fee Schedule,428.7% of CMS OPPS Fee Schedule Rate,344.82,450.81,,,Fee Schedule,450.81% of CMS OPPS Fee Schedule Rate,82.59,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,76.49,100,,,Fee Schedule,100% of CMS OPPS Rate,111.32,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,91.75,14,,,percent of total billed charges,14% of total billed charges,76.49,491.5,
"77080- Dual-energy X-ray absorptiometry (DXA), bone density study, 1 or more sites; axial skelet",3623708,CDM,510,RC,77080,HCPCS,Outpatient,,,65.07,32.54,,48.8,75,,,percent of total billed charges,75% of total billed charges,48.8,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,24.09,100,,,Fee Schedule,100% of WV Medicaid Rate,165.79,165,,,Fee Schedule,165% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.82,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,24.09,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,9.11,14,,,percent of total billed charges,14% of total billed charges,9.11,495.81,
77261-Radiation Therapy Planning Simple,4169504,CDM,333,RC,77261,HCPCS,Outpatient,,,164.33,82.17,,123.25,75,,,percent of total billed charges,75% of total billed charges,123.25,75,,,percent of total billed charges,75% of total billed charges,52.59,32,,,percent of total billed charges,32% of total billed charges,49.16,100,,,Fee Schedule,100% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.16,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.01,14,,,percent of total billed charges,14% of total billed charges,23.01,123.25,
77280-SET RADIATION THERAPY FIELD SIMPLE,3435794,CDM,333,RC,77280,HCPCS,Outpatient,,,541.19,270.6,,405.89,75,,,percent of total billed charges,75% of total billed charges,405.89,75,,,percent of total billed charges,75% of total billed charges,125.39,100,,,Fee Schedule,100% of CMS OPPS Rate,170.83,100,,,Fee Schedule,100% of WV Medicaid Rate,206.89,165,,,Fee Schedule,165% of CMS OPPS Rate,129.96,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,360.18,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,493.97,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,618.74,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,170.83,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,125.39,100,,,Fee Schedule,100% of CMS OPPS Rate,129.96,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,75.77,14,,,percent of total billed charges,14% of total billed charges,75.77,618.74,
77285-SET RAD THERAPY FIELD INTERMEDIATE,3537566,CDM,333,RC,77285,HCPCS,Outpatient,,,1216.88,608.44,,912.66,75,,,percent of total billed charges,75% of total billed charges,912.66,75,,,percent of total billed charges,75% of total billed charges,337.24,100,,,Fee Schedule,100% of CMS OPPS Rate,281.69,100,,,Fee Schedule,100% of WV Medicaid Rate,556.45,165,,,Fee Schedule,165% of CMS OPPS Rate,349.52,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,968.72,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1328.52,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1664.11,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,281.69,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,337.24,100,,,Fee Schedule,100% of CMS OPPS Rate,349.52,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,170.36,14,,,percent of total billed charges,14% of total billed charges,170.36,1664.11,
77290-SET RADIATION THERAPY FIELD COMPLEX,3400445,CDM,333,RC,77290,HCPCS,Outpatient,,,881.03,440.52,,660.77,75,,,percent of total billed charges,75% of total billed charges,660.77,75,,,percent of total billed charges,75% of total billed charges,337.24,100,,,Fee Schedule,100% of CMS OPPS Rate,292.26,100,,,Fee Schedule,100% of WV Medicaid Rate,556.45,165,,,Fee Schedule,165% of CMS OPPS Rate,349.52,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,968.72,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1328.52,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1664.11,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,292.26,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,337.24,100,,,Fee Schedule,100% of CMS OPPS Rate,349.52,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,123.34,14,,,percent of total billed charges,14% of total billed charges,123.34,1664.11,
77293-RESPIRATOR MOTION MGMT SIMUL,3400446,CDM,333,RC,77293,HCPCS,Outpatient,,,734.79,367.4,,551.09,75,,,percent of total billed charges,75% of total billed charges,551.09,75,,,percent of total billed charges,75% of total billed charges,235.13,32,,,percent of total billed charges,32% of total billed charges,269.14,100,,,Fee Schedule,100% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,269.14,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,102.87,14,,,percent of total billed charges,14% of total billed charges,102.87,551.09,
77299-RADIATION THERAPY PLANNING,3400447,CDM,333,RC,77299,HCPCS,Outpatient,,,459.45,229.73,,344.59,75,,,percent of total billed charges,75% of total billed charges,344.59,75,,,percent of total billed charges,75% of total billed charges,125.39,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,206.89,165,,,Fee Schedule,165% of CMS OPPS Rate,129.96,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,360.18,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,493.97,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,618.74,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,125.39,100,,,Fee Schedule,100% of CMS OPPS Rate,129.96,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,64.32,14,,,percent of total billed charges,14% of total billed charges,64.32,618.74,
77300-RADIATION THERAPY DOSE PLAN,3400448,CDM,333,RC,77300,HCPCS,Outpatient,,,76.11,38.06,,57.08,75,,,percent of total billed charges,75% of total billed charges,57.08,75,,,percent of total billed charges,75% of total billed charges,125.39,100,,,Fee Schedule,100% of CMS OPPS Rate,42.77,100,,,Fee Schedule,100% of WV Medicaid Rate,206.89,165,,,Fee Schedule,165% of CMS OPPS Rate,129.96,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,360.18,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,493.97,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,618.74,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,42.77,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,125.39,100,,,Fee Schedule,100% of CMS OPPS Rate,129.96,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,10.66,14,,,percent of total billed charges,14% of total billed charges,10.66,618.74,
77301-RADIOTHERAPY DOSE PLAN IMRT,3400449,CDM,333,RC,77301,HCPCS,Outpatient,,,3296.85,1648.43,,2472.64,75,,,percent of total billed charges,75% of total billed charges,2472.64,75,,,percent of total billed charges,75% of total billed charges,1260.44,100,,,Fee Schedule,100% of CMS OPPS Rate,1168.78,100,,,Fee Schedule,100% of WV Medicaid Rate,2079.73,165,,,Fee Schedule,165% of CMS OPPS Rate,1306.33,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,3620.47,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,4965.18,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,6219.4,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1168.78,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1260.44,100,,,Fee Schedule,100% of CMS OPPS Rate,1306.33,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,461.56,14,,,percent of total billed charges,14% of total billed charges,461.56,6219.4,
77307-TELETHX ISODOSE PLAN CPLX,3400450,CDM,333,RC,77307,HCPCS,Outpatient,,,1764.15,882.08,,1323.11,75,,,percent of total billed charges,75% of total billed charges,1323.11,75,,,percent of total billed charges,75% of total billed charges,337.24,100,,,Fee Schedule,100% of CMS OPPS Rate,186.81,100,,,Fee Schedule,100% of WV Medicaid Rate,556.45,165,,,Fee Schedule,165% of CMS OPPS Rate,349.52,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,968.72,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1328.52,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1664.11,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,186.81,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,337.24,100,,,Fee Schedule,100% of CMS OPPS Rate,349.52,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,246.98,14,,,percent of total billed charges,14% of total billed charges,186.81,1664.11,
77317-(TC)-BRACHYTX ISODOSE INTERMED,3537569,CDM,333,RC,77317,HCPCS,Outpatient,,,437.15,218.58,,327.86,75,,,percent of total billed charges,75% of total billed charges,327.86,75,,,percent of total billed charges,75% of total billed charges,337.24,100,,,Fee Schedule,100% of CMS OPPS Rate,205.98,100,,,Fee Schedule,100% of WV Medicaid Rate,556.45,165,,,Fee Schedule,165% of CMS OPPS Rate,349.52,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,968.72,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1328.52,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1664.11,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,205.98,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,337.24,100,,,Fee Schedule,100% of CMS OPPS Rate,349.52,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,61.2,14,,,percent of total billed charges,14% of total billed charges,61.2,1664.11,
77318-(TC)-BRACHYTX ISODOSE COMPLEX,3537570,CDM,333,RC,77318,HCPCS,Outpatient,,,590.27,295.14,,442.7,75,,,percent of total billed charges,75% of total billed charges,442.7,75,,,percent of total billed charges,75% of total billed charges,337.24,100,,,Fee Schedule,100% of CMS OPPS Rate,292.99,100,,,Fee Schedule,100% of WV Medicaid Rate,556.45,165,,,Fee Schedule,165% of CMS OPPS Rate,349.52,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,968.72,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1328.52,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1664.11,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,292.99,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,337.24,100,,,Fee Schedule,100% of CMS OPPS Rate,349.52,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,82.64,14,,,percent of total billed charges,14% of total billed charges,82.64,1664.11,
77321-SPECIAL TELETX PORT PLAN,3400451,CDM,333,RC,77321,HCPCS,Outpatient,,,101.38,50.69,,76.04,75,,,percent of total billed charges,75% of total billed charges,76.04,75,,,percent of total billed charges,75% of total billed charges,337.24,100,,,Fee Schedule,100% of CMS OPPS Rate,61.45,100,,,Fee Schedule,100% of WV Medicaid Rate,556.45,165,,,Fee Schedule,165% of CMS OPPS Rate,349.52,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,968.72,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1328.52,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1664.11,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,61.45,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,337.24,100,,,Fee Schedule,100% of CMS OPPS Rate,349.52,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,14.19,14,,,percent of total billed charges,14% of total billed charges,14.19,1664.11,
77331-SPECIAL RADIATION DOSIMETRY,3400452,CDM,333,RC,77331,HCPCS,Outpatient,,,43.75,21.88,,32.81,75,,,percent of total billed charges,75% of total billed charges,32.81,75,,,percent of total billed charges,75% of total billed charges,125.39,100,,,Fee Schedule,100% of CMS OPPS Rate,43.26,100,,,Fee Schedule,100% of WV Medicaid Rate,206.89,165,,,Fee Schedule,165% of CMS OPPS Rate,129.96,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,360.18,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,493.97,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,618.74,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,43.26,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,125.39,100,,,Fee Schedule,100% of CMS OPPS Rate,129.96,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,6.13,14,,,percent of total billed charges,14% of total billed charges,6.13,618.74,
77332-RADIATION TREATMENT AID(S) SIMPLE,3400453,CDM,333,RC,77332,HCPCS,Outpatient,,,34.27,17.14,,25.7,75,,,percent of total billed charges,75% of total billed charges,25.7,75,,,percent of total billed charges,75% of total billed charges,125.39,100,,,Fee Schedule,100% of CMS OPPS Rate,25.81,100,,,Fee Schedule,100% of WV Medicaid Rate,206.89,165,,,Fee Schedule,165% of CMS OPPS Rate,129.96,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,360.18,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,493.97,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,618.74,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,25.81,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,125.39,100,,,Fee Schedule,100% of CMS OPPS Rate,129.96,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4.8,14,,,percent of total billed charges,14% of total billed charges,4.8,618.74,
77333-RADIATION TREAT AID(S) INTERMEDIATE,3400454,CDM,333,RC,77333,HCPCS,Outpatient,,,459.45,229.73,,344.59,75,,,percent of total billed charges,75% of total billed charges,344.59,75,,,percent of total billed charges,75% of total billed charges,125.39,100,,,Fee Schedule,100% of CMS OPPS Rate,89.72,100,,,Fee Schedule,100% of WV Medicaid Rate,206.89,165,,,Fee Schedule,165% of CMS OPPS Rate,129.96,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,360.18,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,493.97,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,618.74,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,89.72,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,125.39,100,,,Fee Schedule,100% of CMS OPPS Rate,129.96,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,64.32,14,,,percent of total billed charges,14% of total billed charges,64.32,618.74,
77334-RADIATION TREATMENT AID(S) COMPLEX,3400455,CDM,333,RC,77334,HCPCS,Outpatient,,,148.77,74.39,,111.58,75,,,percent of total billed charges,75% of total billed charges,111.58,75,,,percent of total billed charges,75% of total billed charges,337.24,100,,,Fee Schedule,100% of CMS OPPS Rate,81.11,100,,,Fee Schedule,100% of WV Medicaid Rate,556.45,165,,,Fee Schedule,165% of CMS OPPS Rate,349.52,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,968.72,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1328.52,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1664.11,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,81.11,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,337.24,100,,,Fee Schedule,100% of CMS OPPS Rate,349.52,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,20.83,14,,,percent of total billed charges,14% of total billed charges,20.83,1664.11,
77336-RADIATION PHYSICS CONSULT,3400456,CDM,333,RC,77336,HCPCS,Outpatient,,,194.37,97.19,,145.78,75,,,percent of total billed charges,75% of total billed charges,145.78,75,,,percent of total billed charges,75% of total billed charges,125.39,100,,,Fee Schedule,100% of CMS OPPS Rate,52.11,100,,,Fee Schedule,100% of WV Medicaid Rate,206.89,165,,,Fee Schedule,165% of CMS OPPS Rate,129.96,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,360.18,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,493.97,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,618.74,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,52.11,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,125.39,100,,,Fee Schedule,100% of CMS OPPS Rate,129.96,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,27.21,14,,,percent of total billed charges,14% of total billed charges,27.21,618.74,
77338-DESIGN MIC DEVICE FOR IMRT,3400457,CDM,333,RC,77338,HCPCS,Outpatient,,,546.86,273.43,,410.15,75,,,percent of total billed charges,75% of total billed charges,410.15,75,,,percent of total billed charges,75% of total billed charges,337.24,100,,,Fee Schedule,100% of CMS OPPS Rate,301.11,100,,,Fee Schedule,100% of WV Medicaid Rate,556.45,165,,,Fee Schedule,165% of CMS OPPS Rate,349.52,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,968.72,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1328.52,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1664.11,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,301.11,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,337.24,100,,,Fee Schedule,100% of CMS OPPS Rate,349.52,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,76.56,14,,,percent of total billed charges,14% of total billed charges,76.56,1664.11,
77370-SPECIAL MEDICAL RAD PHYSICS CONSULT,3400458,CDM,333,RC,77370,HCPCS,Outpatient,,,459.45,229.73,,344.59,75,,,percent of total billed charges,75% of total billed charges,344.59,75,,,percent of total billed charges,75% of total billed charges,125.39,100,,,Fee Schedule,100% of CMS OPPS Rate,82.59,100,,,Fee Schedule,100% of WV Medicaid Rate,206.89,165,,,Fee Schedule,165% of CMS OPPS Rate,129.96,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,360.18,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,493.97,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,618.74,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,82.59,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,125.39,100,,,Fee Schedule,100% of CMS OPPS Rate,129.96,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,64.32,14,,,percent of total billed charges,14% of total billed charges,64.32,618.74,
"77371-RADIATION DELIVERY STEREOTACTIC CRANIAL COBALT""",4169517,CDM,333,RC,77371,HCPCS,Outpatient,,,34259.03,17129.52,,25694.27,75,,,percent of total billed charges,75% of total billed charges,25694.27,75,,,percent of total billed charges,75% of total billed charges,7230.41,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,11930.17,165,,,Fee Schedule,165% of CMS OPPS Rate,7493.7,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,20768.37,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,28482.16,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,35676.8,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,7230.41,100,,,Fee Schedule,100% of CMS OPPS Rate,7493.7,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4796.26,14,,,percent of total billed charges,14% of total billed charges,4796.26,35676.8,
77372-SRS Linear Based,4169506,CDM,333,RC,77372,HCPCS,Outpatient,,,2055.9,1027.95,,1541.93,75,,,percent of total billed charges,75% of total billed charges,1541.93,75,,,percent of total billed charges,75% of total billed charges,7230.41,100,,,Fee Schedule,100% of CMS OPPS Rate,614.99,100,,,Fee Schedule,100% of WV Medicaid Rate,11930.17,165,,,Fee Schedule,165% of CMS OPPS Rate,7493.7,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,20768.37,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,28482.16,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,35676.8,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,614.99,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,7230.41,100,,,Fee Schedule,100% of CMS OPPS Rate,7493.7,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,287.83,14,,,percent of total billed charges,14% of total billed charges,287.83,35676.8,
77373-SBRT DELIVERY,3565235,CDM,333,RC,77373,HCPCS,Outpatient,,,2379.35,1189.68,,1784.51,75,,,percent of total billed charges,75% of total billed charges,1784.51,75,,,percent of total billed charges,75% of total billed charges,1661.68,100,,,Fee Schedule,100% of CMS OPPS Rate,635.39,100,,,Fee Schedule,100% of WV Medicaid Rate,2741.79,165,,,Fee Schedule,165% of CMS OPPS Rate,1722.2,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4772.99,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,6545.78,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,8199.25,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,635.39,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,1661.68,100,,,Fee Schedule,100% of CMS OPPS Rate,1722.2,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,333.11,14,,,percent of total billed charges,14% of total billed charges,333.11,8199.25,
77385-NTSTY MODUL RAD TX DIVR SMPL,3400459,CDM,333,RC,77385,HCPCS,Outpatient,,,2164.69,1082.35,,1623.52,75,,,percent of total billed charges,75% of total billed charges,1623.52,75,,,percent of total billed charges,75% of total billed charges,538.2,100,,,Fee Schedule,100% of CMS OPPS Rate,229.09,100,,,Fee Schedule,100% of WV Medicaid Rate,888.05,165,,,Fee Schedule,165% of CMS OPPS Rate,557.8,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1545.94,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2120.15,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,2655.7,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,229.09,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,538.2,100,,,Fee Schedule,100% of CMS OPPS Rate,557.8,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,303.06,14,,,percent of total billed charges,14% of total billed charges,229.09,2655.7,
77386-NTSTY MODUL RAD TX DIVR CPLX,3400460,CDM,333,RC,77386,HCPCS,Outpatient,,,2164.69,1082.35,,1623.52,75,,,percent of total billed charges,75% of total billed charges,1623.52,75,,,percent of total billed charges,75% of total billed charges,538.2,100,,,Fee Schedule,100% of CMS OPPS Rate,227.86,100,,,Fee Schedule,100% of WV Medicaid Rate,888.05,165,,,Fee Schedule,165% of CMS OPPS Rate,557.8,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1545.94,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2120.15,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,2655.7,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,227.86,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,538.2,100,,,Fee Schedule,100% of CMS OPPS Rate,557.8,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,303.06,14,,,percent of total billed charges,14% of total billed charges,227.86,2655.7,
77387 TC Guidance for localization of target volume for de,3623294,CDM,510,RC,77387,HCPCS,Outpatient,,,66.48,33.24,,49.86,75,,,percent of total billed charges,75% of total billed charges,49.86,75,,,percent of total billed charges,75% of total billed charges,21.27,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.31,14,,,percent of total billed charges,14% of total billed charges,9.31,49.86,
77387-GUIDANCE FOR RADJ TX DLVR,3400461,CDM,333,RC,77387,HCPCS,Outpatient,,,66.48,33.24,,49.86,75,,,percent of total billed charges,75% of total billed charges,49.86,75,,,percent of total billed charges,75% of total billed charges,21.27,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.31,14,,,percent of total billed charges,14% of total billed charges,9.31,49.86,
77412-RADIATION TREAT DELIVERY COMPLEX,3400462,CDM,333,RC,77412,HCPCS,Outpatient,,,894.86,447.43,,671.15,75,,,percent of total billed charges,75% of total billed charges,671.15,75,,,percent of total billed charges,75% of total billed charges,247.19,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,407.86,165,,,Fee Schedule,165% of CMS OPPS Rate,256.19,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,710.04,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,973.76,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1219.73,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,247.19,100,,,Fee Schedule,100% of CMS OPPS Rate,256.19,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,125.28,14,,,percent of total billed charges,14% of total billed charges,125.28,1219.73,
77417-RADIOLOGY PORT IMAGES(S),3400463,CDM,333,RC,77417,HCPCS,Outpatient,,,29.51,14.76,,22.13,75,,,percent of total billed charges,75% of total billed charges,22.13,75,,,percent of total billed charges,75% of total billed charges,9.44,32,,,percent of total billed charges,32% of total billed charges,7.87,100,,,Fee Schedule,100% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.87,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.13,14,,,percent of total billed charges,14% of total billed charges,4.13,22.13,
Hospital Outpatient Clinic Visit,3400485,CDM,510,RC,77427,HCPCS,Outpatient,,,225.57,112.79,,169.18,75,,,percent of total billed charges,75% of total billed charges,169.18,75,,,percent of total billed charges,75% of total billed charges,72.18,32,,,percent of total billed charges,32% of total billed charges,131.26,100,,,Fee Schedule,100% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,131.26,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.58,14,,,percent of total billed charges,14% of total billed charges,31.58,169.18,
77432-Sterotactic Radiation Treatment,4169511,CDM,333,RC,77432,HCPCS,Outpatient,,,985.49,492.75,,739.12,75,,,percent of total billed charges,75% of total billed charges,739.12,75,,,percent of total billed charges,75% of total billed charges,315.36,32,,,percent of total billed charges,32% of total billed charges,294.7,100,,,Fee Schedule,100% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,294.7,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,137.97,14,,,percent of total billed charges,14% of total billed charges,137.97,739.12,
77470-SPECIAL RADIATION TREATMENT,3565236,CDM,333,RC,77470,HCPCS,Outpatient,,,1932.76,966.38,,1449.57,75,,,percent of total billed charges,75% of total billed charges,1449.57,75,,,percent of total billed charges,75% of total billed charges,538.2,100,,,Fee Schedule,100% of CMS OPPS Rate,91.93,100,,,Fee Schedule,100% of WV Medicaid Rate,888.05,165,,,Fee Schedule,165% of CMS OPPS Rate,557.8,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1545.94,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2120.15,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,2655.7,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,91.93,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,538.2,100,,,Fee Schedule,100% of CMS OPPS Rate,557.8,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,270.59,14,,,percent of total billed charges,14% of total billed charges,91.93,2655.7,
77770 - (TC) Remote afterloading high dose rate radionuclide,3938962,CDM,333,RC,77770,HCPCS,Outpatient,,,567.71,283.86,,425.78,75,,,percent of total billed charges,75% of total billed charges,425.78,75,,,percent of total billed charges,75% of total billed charges,678.53,100,,,Fee Schedule,100% of CMS OPPS Rate,222.45,100,,,Fee Schedule,100% of WV Medicaid Rate,1119.56,165,,,Fee Schedule,165% of CMS OPPS Rate,703.23,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1948.99,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2672.9,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,3348.08,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,222.45,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,678.53,100,,,Fee Schedule,100% of CMS OPPS Rate,703.23,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,79.48,14,,,percent of total billed charges,14% of total billed charges,79.48,3348.08,
77770 - Remote afterloading high dose rate radionuclide brac,3938960,CDM,342,RC,77770,HCPCS,Outpatient,,,567.71,283.86,,425.78,75,,,percent of total billed charges,75% of total billed charges,425.78,75,,,percent of total billed charges,75% of total billed charges,678.53,100,,,Fee Schedule,100% of CMS OPPS Rate,222.45,100,,,Fee Schedule,100% of WV Medicaid Rate,1119.56,165,,,Fee Schedule,165% of CMS OPPS Rate,703.23,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1948.99,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2672.9,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,3348.08,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,222.45,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,678.53,100,,,Fee Schedule,100% of CMS OPPS Rate,703.23,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,79.48,14,,,percent of total billed charges,14% of total billed charges,79.48,3348.08,
77770-HDR RDNCL NTRSTL/ICAV BRCHTX,3537576,CDM,333,RC,77770,HCPCS,Outpatient,,,506.89,253.45,,380.17,75,,,percent of total billed charges,75% of total billed charges,380.17,75,,,percent of total billed charges,75% of total billed charges,678.53,100,,,Fee Schedule,100% of CMS OPPS Rate,222.45,100,,,Fee Schedule,100% of WV Medicaid Rate,1119.56,165,,,Fee Schedule,165% of CMS OPPS Rate,703.23,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1948.99,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2672.9,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,3348.08,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,222.45,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,678.53,100,,,Fee Schedule,100% of CMS OPPS Rate,703.23,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,70.96,14,,,percent of total billed charges,14% of total billed charges,70.96,3348.08,
77771 - (TC) Remote afterloading high dose rate radionuclide,3938959,CDM,333,RC,77771,HCPCS,Outpatient,,,925.88,462.94,,694.41,75,,,percent of total billed charges,75% of total billed charges,694.41,75,,,percent of total billed charges,75% of total billed charges,678.53,100,,,Fee Schedule,100% of CMS OPPS Rate,383.94,100,,,Fee Schedule,100% of WV Medicaid Rate,1119.56,165,,,Fee Schedule,165% of CMS OPPS Rate,703.23,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1948.99,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2672.9,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,3348.08,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,383.94,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,678.53,100,,,Fee Schedule,100% of CMS OPPS Rate,703.23,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,129.62,14,,,percent of total billed charges,14% of total billed charges,129.62,3348.08,
77771 - Remote afterloading high dose rate radionuclide brac,3938957,CDM,333,RC,77771,HCPCS,Outpatient,,,925.88,462.94,,694.41,75,,,percent of total billed charges,75% of total billed charges,694.41,75,,,percent of total billed charges,75% of total billed charges,678.53,100,,,Fee Schedule,100% of CMS OPPS Rate,383.94,100,,,Fee Schedule,100% of WV Medicaid Rate,1119.56,165,,,Fee Schedule,165% of CMS OPPS Rate,703.23,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1948.99,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2672.9,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,3348.08,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,383.94,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,678.53,100,,,Fee Schedule,100% of CMS OPPS Rate,703.23,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,129.62,14,,,percent of total billed charges,14% of total billed charges,129.62,3348.08,
77771-HDR RDNCL NTRSTL/ICAV BRCHTX 2-12,3537577,CDM,333,RC,77771,HCPCS,Outpatient,,,826.67,413.34,,620,75,,,percent of total billed charges,75% of total billed charges,620,75,,,percent of total billed charges,75% of total billed charges,678.53,100,,,Fee Schedule,100% of CMS OPPS Rate,383.94,100,,,Fee Schedule,100% of WV Medicaid Rate,1119.56,165,,,Fee Schedule,165% of CMS OPPS Rate,703.23,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1948.99,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2672.9,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,3348.08,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,383.94,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,678.53,100,,,Fee Schedule,100% of CMS OPPS Rate,703.23,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,115.73,14,,,percent of total billed charges,14% of total billed charges,115.73,3348.08,
Urinalysis Dipstick POC,3630956,CDM,300,RC,81003,HCPCS,Outpatient,,,13.36,6.68,,10.02,75,,,percent of total billed charges,75% of total billed charges,10.02,75,,,percent of total billed charges,75% of total billed charges,2.25,100,,,Fee Schedule,100% of CMS OPPS Rate,2.03,100,,,Fee Schedule,100% of WV Medicaid Rate,2.25,100,,,Fee Schedule,100% of CMS OPPS Rate,2.25,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,7.97,354.54,,,Fee Schedule,354.54% of CMS OPPS Fee Schedule Rate,9.64,428.7,,,Fee Schedule,428.7% of CMS OPPS Fee Schedule Rate,10.14,450.81,,,Fee Schedule,450.81% of CMS OPPS Fee Schedule Rate,2.03,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2.25,100,,,Fee Schedule,100% of CMS OPPS Rate,2.25,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,1.87,14,,,percent of total billed charges,14% of total billed charges,1.87,10.14,
"HCG, Urine POC",3444192,CDM,300,RC,81025,HCPCS,Outpatient,,,51.11,25.56,,38.33,75,,,percent of total billed charges,75% of total billed charges,38.33,75,,,percent of total billed charges,75% of total billed charges,8.61,100,,,Fee Schedule,100% of CMS OPPS Rate,7.75,100,,,Fee Schedule,100% of WV Medicaid Rate,8.61,100,,,Fee Schedule,100% of CMS OPPS Rate,8.61,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,30.52,354.54,,,Fee Schedule,354.54% of CMS OPPS Fee Schedule Rate,36.91,428.7,,,Fee Schedule,428.7% of CMS OPPS Fee Schedule Rate,38.81,450.81,,,Fee Schedule,450.81% of CMS OPPS Fee Schedule Rate,7.75,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,8.61,100,,,Fee Schedule,100% of CMS OPPS Rate,8.61,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,7.16,14,,,percent of total billed charges,14% of total billed charges,7.16,38.81,
Stool for Occult Blood POC,3444208,CDM,300,RC,82272,HCPCS,Outpatient,,,107.14,53.57,,80.36,75,,,percent of total billed charges,75% of total billed charges,80.36,75,,,percent of total billed charges,75% of total billed charges,4.23,100,,,Fee Schedule,100% of CMS OPPS Rate,3.81,100,,,Fee Schedule,100% of WV Medicaid Rate,4.23,100,,,Fee Schedule,100% of CMS OPPS Rate,4.23,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,14.99,354.54,,,Fee Schedule,354.54% of CMS OPPS Fee Schedule Rate,18.13,428.7,,,Fee Schedule,428.7% of CMS OPPS Fee Schedule Rate,19.06,450.81,,,Fee Schedule,450.81% of CMS OPPS Fee Schedule Rate,3.81,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,4.23,100,,,Fee Schedule,100% of CMS OPPS Rate,4.23,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,15,14,,,percent of total billed charges,14% of total billed charges,3.81,80.36,
85610- Prothrombin time,3430526,CDM,300,RC,85610,HCPCS,Outpatient,,,25.44,12.72,,19.08,75,,,percent of total billed charges,75% of total billed charges,19.08,75,,,percent of total billed charges,75% of total billed charges,4.29,100,,,Fee Schedule,100% of CMS OPPS Rate,3.86,100,,,Fee Schedule,100% of WV Medicaid Rate,4.29,100,,,Fee Schedule,100% of CMS OPPS Rate,4.29,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,15.2,354.54,,,Fee Schedule,354.54% of CMS OPPS Fee Schedule Rate,18.39,428.7,,,Fee Schedule,428.7% of CMS OPPS Fee Schedule Rate,19.33,450.81,,,Fee Schedule,450.81% of CMS OPPS Fee Schedule Rate,3.86,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,4.29,100,,,Fee Schedule,100% of CMS OPPS Rate,4.29,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,3.56,14,,,percent of total billed charges,14% of total billed charges,3.56,19.33,
BladderChek POC,3444187,CDM,300,RC,86386,HCPCS,Outpatient,,,51.72,25.86,,38.79,75,,,percent of total billed charges,75% of total billed charges,38.79,75,,,percent of total billed charges,75% of total billed charges,21.78,100,,,Fee Schedule,100% of CMS OPPS Rate,19.6,100,,,Fee Schedule,100% of WV Medicaid Rate,21.78,100,,,Fee Schedule,100% of CMS OPPS Rate,21.78,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,77.21,354.54,,,Fee Schedule,354.54% of CMS OPPS Fee Schedule Rate,93.37,428.7,,,Fee Schedule,428.7% of CMS OPPS Fee Schedule Rate,98.18,450.81,,,Fee Schedule,450.81% of CMS OPPS Fee Schedule Rate,19.6,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,21.78,100,,,Fee Schedule,100% of CMS OPPS Rate,21.78,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,7.24,14,,,percent of total billed charges,14% of total billed charges,7.24,98.18,
Culture Wound_NonSurgical,593562,CDM,300,RC,87070,HCPCS,Outpatient,,,51.17,25.59,,38.38,75,,,percent of total billed charges,75% of total billed charges,38.38,75,,,percent of total billed charges,75% of total billed charges,8.61,100,,,Fee Schedule,100% of CMS OPPS Rate,7.76,100,,,Fee Schedule,100% of WV Medicaid Rate,8.61,100,,,Fee Schedule,100% of CMS OPPS Rate,8.62,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,30.56,354.54,,,Fee Schedule,354.54% of CMS OPPS Fee Schedule Rate,36.95,428.7,,,Fee Schedule,428.7% of CMS OPPS Fee Schedule Rate,38.85,450.81,,,Fee Schedule,450.81% of CMS OPPS Fee Schedule Rate,7.76,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,8.61,100,,,Fee Schedule,100% of CMS OPPS Rate,8.62,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,7.16,14,,,percent of total billed charges,14% of total billed charges,7.16,38.85,
Culture Urine,593561,CDM,300,RC,87086,HCPCS,Outpatient,,,47.9,23.95,,35.93,75,,,percent of total billed charges,75% of total billed charges,35.93,75,,,percent of total billed charges,75% of total billed charges,8.07,100,,,Fee Schedule,100% of CMS OPPS Rate,7.26,100,,,Fee Schedule,100% of WV Medicaid Rate,8.07,100,,,Fee Schedule,100% of CMS OPPS Rate,8.07,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,28.61,354.54,,,Fee Schedule,354.54% of CMS OPPS Fee Schedule Rate,34.59,428.7,,,Fee Schedule,428.7% of CMS OPPS Fee Schedule Rate,36.38,450.81,,,Fee Schedule,450.81% of CMS OPPS Fee Schedule Rate,7.26,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,8.07,100,,,Fee Schedule,100% of CMS OPPS Rate,8.07,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,6.71,14,,,percent of total billed charges,14% of total billed charges,6.71,36.38,
88305- Tissue exam by pathologist; Level IV,3430541,CDM,310,RC,88305,HCPCS,Outpatient,,,103.69,51.85,,77.77,75,,,percent of total billed charges,75% of total billed charges,77.77,75,,,percent of total billed charges,75% of total billed charges,47.13,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,77.78,165,,,Fee Schedule,165% of CMS OPPS Rate,48.85,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,135.4,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,185.69,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,232.6,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,47.13,100,,,Fee Schedule,100% of CMS OPPS Rate,48.85,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,14.52,14,,,percent of total billed charges,14% of total billed charges,14.52,232.6,
90620 - Meningococcal (Bexsero),3918914,CDM,636,RC,90620,HCPCS,Outpatient,,,543.15,271.58,,407.36,75,,,percent of total billed charges,75% of total billed charges,407.36,75,,,percent of total billed charges,75% of total billed charges,173.81,32,,,percent of total billed charges,32% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.04,14,,,percent of total billed charges,14% of total billed charges,76.04,407.36,
"90670 - Pneumococcal conjugate vaccine, 13 valent (PCV13), f",3918923,CDM,636,RC,90670,HCPCS,Outpatient,,,611.03,305.52,,458.27,75,,,percent of total billed charges,75% of total billed charges,458.27,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,85.54,14,,,percent of total billed charges,14% of total billed charges,85.54,458.27,
90670 - Prevnar 13,3918924,CDM,636,RC,90670,HCPCS,Outpatient,,,611.03,305.52,,458.27,75,,,percent of total billed charges,75% of total billed charges,458.27,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,85.54,14,,,percent of total billed charges,14% of total billed charges,85.54,458.27,
Flu Adult Recombinant (egg-free),4183112,CDM,636,RC,90682,HCPCS,Outpatient,,,153.89,76.95,,115.42,75,,,percent of total billed charges,75% of total billed charges,115.42,75,,,percent of total billed charges,75% of total billed charges,69.94,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,73.4,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,260.23,354.54,,,Fee Schedule,354.54% of CMS OPPS Fee Schedule Rate,314.67,428.7,,,Fee Schedule,428.7% of CMS OPPS Fee Schedule Rate,330.89,450.81,,,Fee Schedule,450.81% of CMS OPPS Fee Schedule Rate,,,,,Other,Not Separately reimbursable,73.4,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,21.54,14,,,percent of total billed charges,14% of total billed charges,21.54,330.89,
"91035 Esophagus, gastroesophageal reflux test; with mucosal attached telemetry pH electrode pla",3696909,CDM,510,RC,91035,HCPCS,Outpatient,,,2329.3,1164.65,,1746.98,75,,,percent of total billed charges,75% of total billed charges,1746.98,75,,,percent of total billed charges,75% of total billed charges,454.5,100,,,Fee Schedule,100% of CMS OPPS Rate,309.22,100,,,Fee Schedule,100% of WV Medicaid Rate,749.91,165,,,Fee Schedule,165% of CMS OPPS Rate,471.04,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1305.49,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1790.39,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,2242.64,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,309.22,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,454.5,100,,,Fee Schedule,100% of CMS OPPS Rate,471.04,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,326.1,14,,,percent of total billed charges,14% of total billed charges,309.22,2242.64,
92060- Sensorimotor exam/mult measure/I&R,3435585,CDM,510,RC,92060,HCPCS,Outpatient,,,308.88,154.44,,231.66,75,,,percent of total billed charges,75% of total billed charges,231.66,75,,,percent of total billed charges,75% of total billed charges,54.04,100,,,Fee Schedule,100% of CMS OPPS Rate,41.29,100,,,Fee Schedule,100% of WV Medicaid Rate,89.16,165,,,Fee Schedule,165% of CMS OPPS Rate,56,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,155.22,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,212.87,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,266.65,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,41.29,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,54.04,100,,,Fee Schedule,100% of CMS OPPS Rate,56,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,43.24,14,,,percent of total billed charges,14% of total billed charges,41.29,266.65,
92526- Tx swallow dysfunc/oral func/feed,3435639,CDM,430,RC,92526,HCPCS,Outpatient,,,338,169,,253.5,75,,,percent of total billed charges,75% of total billed charges,253.5,75,,,percent of total billed charges,75% of total billed charges,80.63,100,,,Fee Schedule,100% of CMS OPPS Rate,58.01,100,,,Fee Schedule,100% of WV Medicaid Rate,133.04,165,,,Fee Schedule,165% of CMS OPPS Rate,78.67,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,285.87,354.54,,,Fee Schedule,354.54% of CMS OPPS Fee Schedule Rate,345.66,428.7,,,Fee Schedule,428.7% of CMS OPPS Fee Schedule Rate,363.49,450.81,,,Fee Schedule,450.81% of CMS OPPS Fee Schedule Rate,58.01,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,80.63,100,,,Fee Schedule,100% of CMS OPPS Rate,78.67,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,47.32,14,,,percent of total billed charges,14% of total billed charges,47.32,363.49,
92610- Eval/oral/pharyngeal swallow func,3435658,CDM,440,RC,92610,HCPCS,Outpatient,,,264.61,132.31,,198.46,75,,,percent of total billed charges,75% of total billed charges,198.46,75,,,percent of total billed charges,75% of total billed charges,67.33,100,,,Fee Schedule,100% of CMS OPPS Rate,48.42,100,,,Fee Schedule,100% of WV Medicaid Rate,111.09,165,,,Fee Schedule,165% of CMS OPPS Rate,65.69,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,238.71,354.54,,,Fee Schedule,354.54% of CMS OPPS Fee Schedule Rate,288.64,428.7,,,Fee Schedule,428.7% of CMS OPPS Fee Schedule Rate,303.53,450.81,,,Fee Schedule,450.81% of CMS OPPS Fee Schedule Rate,48.42,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,67.33,100,,,Fee Schedule,100% of CMS OPPS Rate,65.69,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,37.05,14,,,percent of total billed charges,14% of total billed charges,37.05,303.53,
Cardioversion,604545,CDM,480,RC,92960,HCPCS,Outpatient,,,3286.53,1643.27,,2464.9,75,,,percent of total billed charges,75% of total billed charges,2464.9,75,,,percent of total billed charges,75% of total billed charges,552.94,100,,,Fee Schedule,100% of CMS OPPS Rate,74.97,100,,,Fee Schedule,100% of WV Medicaid Rate,912.36,165,,,Fee Schedule,165% of CMS OPPS Rate,573.08,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1588.26,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2178.17,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,2728.39,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,74.97,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,552.94,100,,,Fee Schedule,100% of CMS OPPS Rate,573.08,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,460.11,14,,,percent of total billed charges,14% of total billed charges,74.97,2728.39,
Stress Test,,,480,RC,93017,HCPCS,Outpatient,,,1585.02,792.51,,1188.77,75,,,percent of total billed charges,75% of total billed charges,1188.77,75,,,percent of total billed charges,75% of total billed charges,263.3,100,,,Fee Schedule,100% of CMS OPPS Rate,22.12,100,,,Fee Schedule,100% of WV Medicaid Rate,434.45,165,,,Fee Schedule,165% of CMS OPPS Rate,272.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,756.3,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1037.2,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1299.2,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,22.12,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,263.3,100,,,Fee Schedule,100% of CMS OPPS Rate,272.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,221.9,14,,,percent of total billed charges,14% of total billed charges,22.12,1299.2,
93242 - Ext ECG >48HR <7D Recording,3896947,CDM,510,RC,93242,HCPCS,Outpatient,,,202.51,101.26,,151.88,75,,,percent of total billed charges,75% of total billed charges,151.88,75,,,percent of total billed charges,75% of total billed charges,31.92,100,,,Fee Schedule,100% of CMS OPPS Rate,8.85,100,,,Fee Schedule,100% of WV Medicaid Rate,52.68,165,,,Fee Schedule,165% of CMS OPPS Rate,33.09,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,91.7,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,125.77,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,157.54,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,8.85,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,31.92,100,,,Fee Schedule,100% of CMS OPPS Rate,33.09,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,28.35,14,,,percent of total billed charges,14% of total billed charges,8.85,157.54,
93246 - EXT ECG>7D<15D RECORDING,3997218,CDM,510,RC,93246,HCPCS,Outpatient,,,202.51,101.26,,151.88,75,,,percent of total billed charges,75% of total billed charges,151.88,75,,,percent of total billed charges,75% of total billed charges,54.04,100,,,Fee Schedule,100% of CMS OPPS Rate,8.85,100,,,Fee Schedule,100% of WV Medicaid Rate,89.16,165,,,Fee Schedule,165% of CMS OPPS Rate,56,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,155.22,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,212.87,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,266.65,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,8.85,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,54.04,100,,,Fee Schedule,100% of CMS OPPS Rate,56,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,28.35,14,,,percent of total billed charges,14% of total billed charges,8.85,266.65,
93264-CardioMEMS recalibration,3432003,CDM,960,RC,93264,HCPCS,Outpatient,,,33.95,16.98,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
CardioMEMS recalibration,3427124,CDM,480,RC,93264,HCPCS,Outpatient,,,33.95,16.98,,25.46,75,,,percent of total billed charges,75% of total billed charges,25.46,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,24.58,100,,,Fee Schedule,100% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.58,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.75,14,,,percent of total billed charges,14% of total billed charges,4.75,25.46,
Event Monitoring,604570,CDM,731,RC,93270,HCPCS,Outpatient,,,190.43,95.22,,142.82,75,,,percent of total billed charges,75% of total billed charges,142.82,75,,,percent of total billed charges,75% of total billed charges,32.9,100,,,Fee Schedule,100% of CMS OPPS Rate,5.41,100,,,Fee Schedule,100% of WV Medicaid Rate,54.29,165,,,Fee Schedule,165% of CMS OPPS Rate,34.1,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,94.51,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,129.62,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,162.36,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,5.41,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,32.9,100,,,Fee Schedule,100% of CMS OPPS Rate,34.1,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,26.66,14,,,percent of total billed charges,14% of total billed charges,5.41,162.36,
93279- PPM eval/test/program/sgn lead,3430968,CDM,480,RC,93279,HCPCS,Outpatient,,,190.43,95.22,,142.82,75,,,percent of total billed charges,75% of total billed charges,142.82,75,,,percent of total billed charges,75% of total billed charges,32.9,100,,,Fee Schedule,100% of CMS OPPS Rate,45.96,100,,,Fee Schedule,100% of WV Medicaid Rate,54.29,165,,,Fee Schedule,165% of CMS OPPS Rate,34.1,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,94.51,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,129.62,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,162.36,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,45.96,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,32.9,100,,,Fee Schedule,100% of CMS OPPS Rate,34.1,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,26.66,14,,,percent of total billed charges,14% of total billed charges,26.66,162.36,
93280- PPM eval/test/program/dual lead,3430969,CDM,480,RC,93280,HCPCS,Outpatient,,,190.43,95.22,,142.82,75,,,percent of total billed charges,75% of total billed charges,142.82,75,,,percent of total billed charges,75% of total billed charges,32.9,100,,,Fee Schedule,100% of CMS OPPS Rate,54.32,100,,,Fee Schedule,100% of WV Medicaid Rate,54.29,165,,,Fee Schedule,165% of CMS OPPS Rate,34.1,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,94.51,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,129.62,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,162.36,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,54.32,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,32.9,100,,,Fee Schedule,100% of CMS OPPS Rate,34.1,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,26.66,14,,,percent of total billed charges,14% of total billed charges,26.66,162.36,
93281- PPM eval/test/program/multi lead,3430970,CDM,480,RC,93281,HCPCS,Outpatient,,,190.43,95.22,,142.82,75,,,percent of total billed charges,75% of total billed charges,142.82,75,,,percent of total billed charges,75% of total billed charges,32.9,100,,,Fee Schedule,100% of CMS OPPS Rate,57.52,100,,,Fee Schedule,100% of WV Medicaid Rate,54.29,165,,,Fee Schedule,165% of CMS OPPS Rate,34.1,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,94.51,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,129.62,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,162.36,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,57.52,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,32.9,100,,,Fee Schedule,100% of CMS OPPS Rate,34.1,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,26.66,14,,,percent of total billed charges,14% of total billed charges,26.66,162.36,
93282- ICD eval/test/program/single lead,3430971,CDM,480,RC,93282,HCPCS,Outpatient,,,190.43,95.22,,142.82,75,,,percent of total billed charges,75% of total billed charges,142.82,75,,,percent of total billed charges,75% of total billed charges,32.9,100,,,Fee Schedule,100% of CMS OPPS Rate,55.06,100,,,Fee Schedule,100% of WV Medicaid Rate,54.29,165,,,Fee Schedule,165% of CMS OPPS Rate,34.1,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,94.51,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,129.62,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,162.36,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,55.06,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,32.9,100,,,Fee Schedule,100% of CMS OPPS Rate,34.1,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,26.66,14,,,percent of total billed charges,14% of total billed charges,26.66,162.36,
93283- ICD eval/test/program/dual lead,3430972,CDM,480,RC,93283,HCPCS,Outpatient,,,190.43,95.22,,142.82,75,,,percent of total billed charges,75% of total billed charges,142.82,75,,,percent of total billed charges,75% of total billed charges,32.9,100,,,Fee Schedule,100% of CMS OPPS Rate,67.34,100,,,Fee Schedule,100% of WV Medicaid Rate,54.29,165,,,Fee Schedule,165% of CMS OPPS Rate,34.1,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,94.51,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,129.62,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,162.36,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,67.34,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,32.9,100,,,Fee Schedule,100% of CMS OPPS Rate,34.1,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,26.66,14,,,percent of total billed charges,14% of total billed charges,26.66,162.36,
93284- ICD eval/test/program/mult lead,3430973,CDM,480,RC,93284,HCPCS,Outpatient,,,190.43,95.22,,142.82,75,,,percent of total billed charges,75% of total billed charges,142.82,75,,,percent of total billed charges,75% of total billed charges,32.9,100,,,Fee Schedule,100% of CMS OPPS Rate,72.51,100,,,Fee Schedule,100% of WV Medicaid Rate,54.29,165,,,Fee Schedule,165% of CMS OPPS Rate,34.1,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,94.51,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,129.62,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,162.36,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,72.51,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,32.9,100,,,Fee Schedule,100% of CMS OPPS Rate,34.1,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,26.66,14,,,percent of total billed charges,14% of total billed charges,26.66,162.36,
93285- ILR eval/test/program,3430974,CDM,480,RC,93285,HCPCS,Outpatient,,,190.43,95.22,,142.82,75,,,percent of total billed charges,75% of total billed charges,142.82,75,,,percent of total billed charges,75% of total billed charges,32.9,100,,,Fee Schedule,100% of CMS OPPS Rate,41.29,100,,,Fee Schedule,100% of WV Medicaid Rate,54.29,165,,,Fee Schedule,165% of CMS OPPS Rate,34.1,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,94.51,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,129.62,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,162.36,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,41.29,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,32.9,100,,,Fee Schedule,100% of CMS OPPS Rate,34.1,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,26.66,14,,,percent of total billed charges,14% of total billed charges,26.66,162.36,
93288 - Interrogation Eval in Person 1/Dual/Mlt Lead Pm,3430977,CDM,480,RC,93288,HCPCS,Outpatient,,,190.43,95.22,,142.82,75,,,percent of total billed charges,75% of total billed charges,142.82,75,,,percent of total billed charges,75% of total billed charges,32.9,100,,,Fee Schedule,100% of CMS OPPS Rate,38.34,100,,,Fee Schedule,100% of WV Medicaid Rate,54.29,165,,,Fee Schedule,165% of CMS OPPS Rate,34.1,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,94.51,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,129.62,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,162.36,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,38.34,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,32.9,100,,,Fee Schedule,100% of CMS OPPS Rate,34.1,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,26.66,14,,,percent of total billed charges,14% of total billed charges,26.66,162.36,
93289- ICD interr/in person/sng/dual/mult,3430978,CDM,480,RC,93289,HCPCS,Outpatient,,,190.43,95.22,,142.82,75,,,percent of total billed charges,75% of total billed charges,142.82,75,,,percent of total billed charges,75% of total billed charges,32.9,100,,,Fee Schedule,100% of CMS OPPS Rate,49.65,100,,,Fee Schedule,100% of WV Medicaid Rate,54.29,165,,,Fee Schedule,165% of CMS OPPS Rate,34.1,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,94.51,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,129.62,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,162.36,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,49.65,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,32.9,100,,,Fee Schedule,100% of CMS OPPS Rate,34.1,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,26.66,14,,,percent of total billed charges,14% of total billed charges,26.66,162.36,
ICD Generator Testing,3427177,CDM,480,RC,93289,HCPCS,Outpatient,,,190.43,95.22,,142.82,75,,,percent of total billed charges,75% of total billed charges,142.82,75,,,percent of total billed charges,75% of total billed charges,32.9,100,,,Fee Schedule,100% of CMS OPPS Rate,49.65,100,,,Fee Schedule,100% of WV Medicaid Rate,54.29,165,,,Fee Schedule,165% of CMS OPPS Rate,34.1,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,94.51,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,129.62,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,162.36,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,49.65,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,32.9,100,,,Fee Schedule,100% of CMS OPPS Rate,34.1,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,26.66,14,,,percent of total billed charges,14% of total billed charges,26.66,162.36,
93291- Internal loop rec/interr/in person,3430980,CDM,480,RC,93291,HCPCS,Outpatient,,,150.36,75.18,,112.77,75,,,percent of total billed charges,75% of total billed charges,112.77,75,,,percent of total billed charges,75% of total billed charges,23.46,100,,,Fee Schedule,100% of CMS OPPS Rate,33.43,100,,,Fee Schedule,100% of WV Medicaid Rate,38.71,165,,,Fee Schedule,165% of CMS OPPS Rate,24.32,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,67.4,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,92.43,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,115.79,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,33.43,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,23.46,100,,,Fee Schedule,100% of CMS OPPS Rate,24.32,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,21.05,14,,,percent of total billed charges,14% of total billed charges,21.05,115.79,
93306- TTE/2D/M-mode/spec dop/color flow,3430992,CDM,483,RC,93306,HCPCS,Outpatient,,,2785.84,1392.92,,2089.38,75,,,percent of total billed charges,75% of total billed charges,2089.38,75,,,percent of total billed charges,75% of total billed charges,473.01,100,,,Fee Schedule,100% of CMS OPPS Rate,130.52,100,,,Fee Schedule,100% of WV Medicaid Rate,780.48,165,,,Fee Schedule,165% of CMS OPPS Rate,490.24,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1358.69,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1863.34,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,2334.03,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,130.52,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,473.01,100,,,Fee Schedule,100% of CMS OPPS Rate,490.24,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,390.02,14,,,percent of total billed charges,14% of total billed charges,130.52,2334.03,
CL Adult Echocardiogram,3334933,CDM,483,RC,93306,HCPCS,Outpatient,,,2785.84,1392.92,,2089.38,75,,,percent of total billed charges,75% of total billed charges,2089.38,75,,,percent of total billed charges,75% of total billed charges,473.01,100,,,Fee Schedule,100% of CMS OPPS Rate,130.52,100,,,Fee Schedule,100% of WV Medicaid Rate,780.48,165,,,Fee Schedule,165% of CMS OPPS Rate,490.24,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1358.69,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1863.34,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,2334.03,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,130.52,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,473.01,100,,,Fee Schedule,100% of CMS OPPS Rate,490.24,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,390.02,14,,,percent of total billed charges,14% of total billed charges,130.52,2334.03,
Echocardiogram,604555,CDM,483,RC,93306,HCPCS,Outpatient,,,2785.84,1392.92,,2089.38,75,,,percent of total billed charges,75% of total billed charges,2089.38,75,,,percent of total billed charges,75% of total billed charges,473.01,100,,,Fee Schedule,100% of CMS OPPS Rate,130.52,100,,,Fee Schedule,100% of WV Medicaid Rate,780.48,165,,,Fee Schedule,165% of CMS OPPS Rate,490.24,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1358.69,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1863.34,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,2334.03,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,130.52,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,473.01,100,,,Fee Schedule,100% of CMS OPPS Rate,490.24,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,390.02,14,,,percent of total billed charges,14% of total billed charges,130.52,2334.03,
MCNH Echo Transthoracic Complete,3805223,CDM,483,RC,93306,HCPCS,Outpatient,,,2785.84,1392.92,,2089.38,75,,,percent of total billed charges,75% of total billed charges,2089.38,75,,,percent of total billed charges,75% of total billed charges,473.01,100,,,Fee Schedule,100% of CMS OPPS Rate,130.52,100,,,Fee Schedule,100% of WV Medicaid Rate,780.48,165,,,Fee Schedule,165% of CMS OPPS Rate,490.24,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1358.69,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1863.34,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,2334.03,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,130.52,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,473.01,100,,,Fee Schedule,100% of CMS OPPS Rate,490.24,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,390.02,14,,,percent of total billed charges,14% of total billed charges,130.52,2334.03,
93308- TTE/2D/M-mode/follow-up/limited  (GLOBAL),3430994,CDM,483,RC,93308,HCPCS,Outpatient,,,1237.39,618.7,,928.04,75,,,percent of total billed charges,75% of total billed charges,928.04,75,,,percent of total billed charges,75% of total billed charges,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,64.15,100,,,Fee Schedule,100% of WV Medicaid Rate,362.24,165,,,Fee Schedule,165% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,630.61,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,864.84,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1083.29,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,64.15,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,173.23,14,,,percent of total billed charges,14% of total billed charges,64.15,1083.29,
CL Limited Echocardiogram,3334936,CDM,483,RC,93308,HCPCS,Outpatient,,,1237.39,618.7,,928.04,75,,,percent of total billed charges,75% of total billed charges,928.04,75,,,percent of total billed charges,75% of total billed charges,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,64.15,100,,,Fee Schedule,100% of WV Medicaid Rate,362.24,165,,,Fee Schedule,165% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,630.61,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,864.84,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1083.29,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,64.15,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,173.23,14,,,percent of total billed charges,14% of total billed charges,64.15,1083.29,
Dobutamine Valve Study,4179565,CDM,483,RC,93308,HCPCS,Outpatient,,,1237.39,618.7,,928.04,75,,,percent of total billed charges,75% of total billed charges,928.04,75,,,percent of total billed charges,75% of total billed charges,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,64.15,100,,,Fee Schedule,100% of WV Medicaid Rate,362.24,165,,,Fee Schedule,165% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,630.61,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,864.84,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1083.29,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,64.15,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,173.23,14,,,percent of total billed charges,14% of total billed charges,64.15,1083.29,
Limited Study-Echo,645295,CDM,483,RC,93308,HCPCS,Outpatient,,,1237.39,618.7,,928.04,75,,,percent of total billed charges,75% of total billed charges,928.04,75,,,percent of total billed charges,75% of total billed charges,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,64.15,100,,,Fee Schedule,100% of WV Medicaid Rate,362.24,165,,,Fee Schedule,165% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,630.61,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,864.84,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1083.29,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,64.15,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,173.23,14,,,percent of total billed charges,14% of total billed charges,64.15,1083.29,
93325 Doppler echo color flow,4061247,CDM,483,RC,93325,HCPCS,Outpatient,,,511.92,255.96,,383.94,75,,,percent of total billed charges,75% of total billed charges,383.94,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,15.24,100,,,Fee Schedule,100% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.24,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,71.67,14,,,percent of total billed charges,14% of total billed charges,15.24,383.94,
93325- Doppler echo color flow,3431006,CDM,483,RC,93325,HCPCS,Outpatient,,,511.92,255.96,,383.94,75,,,percent of total billed charges,75% of total billed charges,383.94,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,15.24,100,,,Fee Schedule,100% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.24,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,71.67,14,,,percent of total billed charges,14% of total billed charges,15.24,383.94,
Color Flow Mapping,604586,CDM,483,RC,93325,HCPCS,Outpatient,,,511.92,255.96,,383.94,75,,,percent of total billed charges,75% of total billed charges,383.94,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,15.24,100,,,Fee Schedule,100% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.24,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,71.67,14,,,percent of total billed charges,14% of total billed charges,15.24,383.94,
93350 (26)- Stress Echo w/ I&R (PRO FEE),3431007,CDM,483,RC,93350,HCPCS,Outpatient,,,2785.84,1392.92,,2089.38,75,,,percent of total billed charges,75% of total billed charges,2089.38,75,,,percent of total billed charges,75% of total billed charges,473.01,100,,,Fee Schedule,100% of CMS OPPS Rate,124.13,100,,,Fee Schedule,100% of WV Medicaid Rate,780.48,165,,,Fee Schedule,165% of CMS OPPS Rate,490.24,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1358.69,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1863.34,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,2334.03,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,124.13,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,473.01,100,,,Fee Schedule,100% of CMS OPPS Rate,490.24,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,390.02,14,,,percent of total billed charges,14% of total billed charges,124.13,2334.03,
93350- Stress echo/2D/M-mode/I&R,3431008,CDM,483,RC,93350,HCPCS,Outpatient,,,2785.84,1392.92,,2089.38,75,,,percent of total billed charges,75% of total billed charges,2089.38,75,,,percent of total billed charges,75% of total billed charges,473.01,100,,,Fee Schedule,100% of CMS OPPS Rate,124.13,100,,,Fee Schedule,100% of WV Medicaid Rate,780.48,165,,,Fee Schedule,165% of CMS OPPS Rate,490.24,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1358.69,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1863.34,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,2334.03,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,124.13,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,473.01,100,,,Fee Schedule,100% of CMS OPPS Rate,490.24,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,390.02,14,,,percent of total billed charges,14% of total billed charges,124.13,2334.03,
CL Exercise Stress Echocardiogram,3334934,CDM,483,RC,93350,HCPCS,Outpatient,,,2785.84,1392.92,,2089.38,75,,,percent of total billed charges,75% of total billed charges,2089.38,75,,,percent of total billed charges,75% of total billed charges,473.01,100,,,Fee Schedule,100% of CMS OPPS Rate,124.13,100,,,Fee Schedule,100% of WV Medicaid Rate,780.48,165,,,Fee Schedule,165% of CMS OPPS Rate,490.24,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1358.69,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1863.34,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,2334.03,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,124.13,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,473.01,100,,,Fee Schedule,100% of CMS OPPS Rate,490.24,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,390.02,14,,,percent of total billed charges,14% of total billed charges,124.13,2334.03,
CVS Charge Stress Echo,1157011,CDM,483,RC,93350,HCPCS,Outpatient,,,2785.84,1392.92,,2089.38,75,,,percent of total billed charges,75% of total billed charges,2089.38,75,,,percent of total billed charges,75% of total billed charges,473.01,100,,,Fee Schedule,100% of CMS OPPS Rate,124.13,100,,,Fee Schedule,100% of WV Medicaid Rate,780.48,165,,,Fee Schedule,165% of CMS OPPS Rate,490.24,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1358.69,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1863.34,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,2334.03,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,124.13,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,473.01,100,,,Fee Schedule,100% of CMS OPPS Rate,490.24,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,390.02,14,,,percent of total billed charges,14% of total billed charges,124.13,2334.03,
Stress Echocardiogram,604568,CDM,483,RC,93350,HCPCS,Outpatient,,,2785.84,1392.92,,2089.38,75,,,percent of total billed charges,75% of total billed charges,2089.38,75,,,percent of total billed charges,75% of total billed charges,473.01,100,,,Fee Schedule,100% of CMS OPPS Rate,124.13,100,,,Fee Schedule,100% of WV Medicaid Rate,780.48,165,,,Fee Schedule,165% of CMS OPPS Rate,490.24,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1358.69,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1863.34,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,2334.03,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,124.13,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,473.01,100,,,Fee Schedule,100% of CMS OPPS Rate,490.24,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,390.02,14,,,percent of total billed charges,14% of total billed charges,124.13,2334.03,
Myocardial Strain Imaging,3824895,CDM,483,RC,93356,HCPCS,Outpatient,,,191.47,95.74,,143.6,75,,,percent of total billed charges,75% of total billed charges,143.6,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,8.36,100,,,Fee Schedule,100% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.36,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.81,14,,,percent of total billed charges,14% of total billed charges,8.36,143.6,
Coronary Angiography,604572,CDM,480,RC,93454,HCPCS,Outpatient,,,16455.07,8227.54,,12341.3,75,,,percent of total billed charges,75% of total billed charges,12341.3,75,,,percent of total billed charges,75% of total billed charges,2781.44,100,,,Fee Schedule,100% of CMS OPPS Rate,614.5,100,,,Fee Schedule,100% of WV Medicaid Rate,4589.37,165,,,Fee Schedule,165% of CMS OPPS Rate,2882.73,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,7989.31,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,10956.7,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,13724.38,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,614.5,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,2781.44,100,,,Fee Schedule,100% of CMS OPPS Rate,2882.73,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,2303.71,14,,,percent of total billed charges,14% of total billed charges,614.5,13724.38,
AV Nodal Ablation,3427172,CDM,480,RC,93650,HCPCS,Outpatient,,,37712.79,18856.4,,28284.59,75,,,percent of total billed charges,75% of total billed charges,28284.59,75,,,percent of total billed charges,75% of total billed charges,6329.89,100,,,Fee Schedule,100% of CMS OPPS Rate,420.81,100,,,Fee Schedule,100% of WV Medicaid Rate,10444.33,165,,,Fee Schedule,165% of CMS OPPS Rate,6560.4,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,18181.77,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,24934.86,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,31233.45,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,420.81,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,6329.89,100,,,Fee Schedule,100% of CMS OPPS Rate,6560.4,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,5279.79,14,,,percent of total billed charges,14% of total billed charges,420.81,31233.45,
AV Node Ablation,651265,CDM,480,RC,93650,HCPCS,Outpatient,,,37712.79,18856.4,,28284.59,75,,,percent of total billed charges,75% of total billed charges,28284.59,75,,,percent of total billed charges,75% of total billed charges,6329.89,100,,,Fee Schedule,100% of CMS OPPS Rate,420.81,100,,,Fee Schedule,100% of WV Medicaid Rate,10444.33,165,,,Fee Schedule,165% of CMS OPPS Rate,6560.4,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,18181.77,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,24934.86,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,31233.45,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,420.81,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,6329.89,100,,,Fee Schedule,100% of CMS OPPS Rate,6560.4,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,5279.79,14,,,percent of total billed charges,14% of total billed charges,420.81,31233.45,
93880 - Duplex scan of extracranial arteries; complete bilat,3898967,CDM,510,RC,93880,HCPCS,Outpatient,,,1237.39,618.7,,928.04,75,,,percent of total billed charges,75% of total billed charges,928.04,75,,,percent of total billed charges,75% of total billed charges,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,125.11,100,,,Fee Schedule,100% of WV Medicaid Rate,362.24,165,,,Fee Schedule,165% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,630.61,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,864.84,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1083.29,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,125.11,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,173.23,14,,,percent of total billed charges,14% of total billed charges,125.11,1083.29,
CL Carotid Duplex Complete BILAT,3427518,CDM,921,RC,93880,HCPCS,Outpatient,,,1237.39,618.7,,928.04,75,,,percent of total billed charges,75% of total billed charges,928.04,75,,,percent of total billed charges,75% of total billed charges,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,125.11,100,,,Fee Schedule,100% of WV Medicaid Rate,362.24,165,,,Fee Schedule,165% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,630.61,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,864.84,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1083.29,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,125.11,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,173.23,14,,,percent of total billed charges,14% of total billed charges,125.11,1083.29,
CL Carotid Duplex Complete LT,3427513,CDM,921,RC,93880,HCPCS,Outpatient,,,1237.39,618.7,,928.04,75,,,percent of total billed charges,75% of total billed charges,928.04,75,,,percent of total billed charges,75% of total billed charges,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,125.11,100,,,Fee Schedule,100% of WV Medicaid Rate,362.24,165,,,Fee Schedule,165% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,630.61,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,864.84,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1083.29,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,125.11,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,173.23,14,,,percent of total billed charges,14% of total billed charges,125.11,1083.29,
CL Carotid Duplex Complete RT,3427515,CDM,921,RC,93880,HCPCS,Outpatient,,,1237.39,618.7,,928.04,75,,,percent of total billed charges,75% of total billed charges,928.04,75,,,percent of total billed charges,75% of total billed charges,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,125.11,100,,,Fee Schedule,100% of WV Medicaid Rate,362.24,165,,,Fee Schedule,165% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,630.61,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,864.84,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1083.29,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,125.11,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,173.23,14,,,percent of total billed charges,14% of total billed charges,125.11,1083.29,
US Carotids Bilat,596598,CDM,921,RC,93880,HCPCS,Outpatient,,,1237.39,618.7,,928.04,75,,,percent of total billed charges,75% of total billed charges,928.04,75,,,percent of total billed charges,75% of total billed charges,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,125.11,100,,,Fee Schedule,100% of WV Medicaid Rate,362.24,165,,,Fee Schedule,165% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,630.61,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,864.84,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1083.29,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,125.11,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,173.23,14,,,percent of total billed charges,14% of total billed charges,125.11,1083.29,
93882- Dup scan/extracran art/unilat/ltd,3435543,CDM,921,RC,93882,HCPCS,Outpatient,,,555.18,277.59,,416.39,75,,,percent of total billed charges,75% of total billed charges,416.39,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,82.1,100,,,Fee Schedule,100% of WV Medicaid Rate,165.79,165,,,Fee Schedule,165% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.82,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,82.1,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,77.73,14,,,percent of total billed charges,14% of total billed charges,77.73,495.81,
CL Carotid Duplex Limited BILAT,3427517,CDM,921,RC,93882,HCPCS,Outpatient,,,555.18,277.59,,416.39,75,,,percent of total billed charges,75% of total billed charges,416.39,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,82.1,100,,,Fee Schedule,100% of WV Medicaid Rate,165.79,165,,,Fee Schedule,165% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.82,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,82.1,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,77.73,14,,,percent of total billed charges,14% of total billed charges,77.73,495.81,
CL Carotid Duplex Limited LT,3427514,CDM,921,RC,93882,HCPCS,Outpatient,,,555.18,277.59,,416.39,75,,,percent of total billed charges,75% of total billed charges,416.39,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,82.1,100,,,Fee Schedule,100% of WV Medicaid Rate,165.79,165,,,Fee Schedule,165% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.82,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,82.1,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,77.73,14,,,percent of total billed charges,14% of total billed charges,77.73,495.81,
CL Carotid Duplex Limited RT,3427516,CDM,921,RC,93882,HCPCS,Outpatient,,,555.18,277.59,,416.39,75,,,percent of total billed charges,75% of total billed charges,416.39,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,82.1,100,,,Fee Schedule,100% of WV Medicaid Rate,165.79,165,,,Fee Schedule,165% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.82,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,82.1,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,77.73,14,,,percent of total billed charges,14% of total billed charges,77.73,495.81,
CL Limited Carotid Post Procedure BILAT,3427524,CDM,921,RC,93882,HCPCS,Outpatient,,,555.18,277.59,,416.39,75,,,percent of total billed charges,75% of total billed charges,416.39,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,82.1,100,,,Fee Schedule,100% of WV Medicaid Rate,165.79,165,,,Fee Schedule,165% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.82,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,82.1,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,77.73,14,,,percent of total billed charges,14% of total billed charges,77.73,495.81,
CL Limited Carotid Post Procedure LT,3427522,CDM,921,RC,93882,HCPCS,Outpatient,,,555.18,277.59,,416.39,75,,,percent of total billed charges,75% of total billed charges,416.39,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,82.1,100,,,Fee Schedule,100% of WV Medicaid Rate,165.79,165,,,Fee Schedule,165% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.82,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,82.1,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,77.73,14,,,percent of total billed charges,14% of total billed charges,77.73,495.81,
CL Limited Carotid Post Procedure RT,3427523,CDM,921,RC,93882,HCPCS,Outpatient,,,555.18,277.59,,416.39,75,,,percent of total billed charges,75% of total billed charges,416.39,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,82.1,100,,,Fee Schedule,100% of WV Medicaid Rate,165.79,165,,,Fee Schedule,165% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.82,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,82.1,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,77.73,14,,,percent of total billed charges,14% of total billed charges,77.73,495.81,
93922 Non-Invas Physiologic STD Extremity Art 2 Level,3436059,CDM,761,RC,93922,HCPCS,Outpatient,,,645.06,322.53,,483.8,75,,,percent of total billed charges,75% of total billed charges,483.8,75,,,percent of total billed charges,75% of total billed charges,109.16,100,,,Fee Schedule,100% of CMS OPPS Rate,52.85,100,,,Fee Schedule,100% of WV Medicaid Rate,180.11,165,,,Fee Schedule,165% of CMS OPPS Rate,113.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,313.55,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,430.01,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,538.63,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,52.85,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,109.16,100,,,Fee Schedule,100% of CMS OPPS Rate,113.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,90.31,14,,,percent of total billed charges,14% of total billed charges,52.85,538.63,
SCSN US Exam,3575290,CDM,510,RC,93922,HCPCS,Outpatient,,,645.06,322.53,,483.8,75,,,percent of total billed charges,75% of total billed charges,483.8,75,,,percent of total billed charges,75% of total billed charges,109.16,100,,,Fee Schedule,100% of CMS OPPS Rate,52.85,100,,,Fee Schedule,100% of WV Medicaid Rate,180.11,165,,,Fee Schedule,165% of CMS OPPS Rate,113.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,313.55,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,430.01,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,538.63,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,52.85,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,109.16,100,,,Fee Schedule,100% of CMS OPPS Rate,113.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,90.31,14,,,percent of total billed charges,14% of total billed charges,52.85,538.63,
93923 - Non-Invasive Physiologic Study Extremity 3 Lvls,3897046,CDM,510,RC,93923,HCPCS,Outpatient,,,788.8,394.4,,591.6,75,,,percent of total billed charges,75% of total billed charges,591.6,75,,,percent of total billed charges,75% of total billed charges,136.72,100,,,Fee Schedule,100% of CMS OPPS Rate,83.33,100,,,Fee Schedule,100% of WV Medicaid Rate,225.58,165,,,Fee Schedule,165% of CMS OPPS Rate,141.69,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,392.72,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,538.59,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,674.64,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,83.33,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,136.72,100,,,Fee Schedule,100% of CMS OPPS Rate,141.69,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,110.43,14,,,percent of total billed charges,14% of total billed charges,83.33,674.64,
93923- Upr/lxtr art stdy 3+ lvls,3430796,CDM,920,RC,93923,HCPCS,Outpatient,,,788.8,394.4,,591.6,75,,,percent of total billed charges,75% of total billed charges,591.6,75,,,percent of total billed charges,75% of total billed charges,136.72,100,,,Fee Schedule,100% of CMS OPPS Rate,83.33,100,,,Fee Schedule,100% of WV Medicaid Rate,225.58,165,,,Fee Schedule,165% of CMS OPPS Rate,141.69,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,392.72,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,538.59,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,674.64,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,83.33,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,136.72,100,,,Fee Schedule,100% of CMS OPPS Rate,141.69,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,110.43,14,,,percent of total billed charges,14% of total billed charges,83.33,674.64,
CL Lower Extrem Art Physiologic BILAT,3427525,CDM,921,RC,93923,HCPCS,Outpatient,,,788.8,394.4,,591.6,75,,,percent of total billed charges,75% of total billed charges,591.6,75,,,percent of total billed charges,75% of total billed charges,136.72,100,,,Fee Schedule,100% of CMS OPPS Rate,83.33,100,,,Fee Schedule,100% of WV Medicaid Rate,225.58,165,,,Fee Schedule,165% of CMS OPPS Rate,141.69,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,392.72,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,538.59,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,674.64,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,83.33,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,136.72,100,,,Fee Schedule,100% of CMS OPPS Rate,141.69,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,110.43,14,,,percent of total billed charges,14% of total billed charges,83.33,674.64,
CL Lower Extrem Art Physiologic LT,3427526,CDM,921,RC,93923,HCPCS,Outpatient,,,788.8,394.4,,591.6,75,,,percent of total billed charges,75% of total billed charges,591.6,75,,,percent of total billed charges,75% of total billed charges,136.72,100,,,Fee Schedule,100% of CMS OPPS Rate,83.33,100,,,Fee Schedule,100% of WV Medicaid Rate,225.58,165,,,Fee Schedule,165% of CMS OPPS Rate,141.69,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,392.72,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,538.59,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,674.64,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,83.33,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,136.72,100,,,Fee Schedule,100% of CMS OPPS Rate,141.69,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,110.43,14,,,percent of total billed charges,14% of total billed charges,83.33,674.64,
CL Lower Extrem Art Physiologic RT,3427527,CDM,921,RC,93923,HCPCS,Outpatient,,,788.8,394.4,,591.6,75,,,percent of total billed charges,75% of total billed charges,591.6,75,,,percent of total billed charges,75% of total billed charges,136.72,100,,,Fee Schedule,100% of CMS OPPS Rate,83.33,100,,,Fee Schedule,100% of WV Medicaid Rate,225.58,165,,,Fee Schedule,165% of CMS OPPS Rate,141.69,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,392.72,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,538.59,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,674.64,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,83.33,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,136.72,100,,,Fee Schedule,100% of CMS OPPS Rate,141.69,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,110.43,14,,,percent of total billed charges,14% of total billed charges,83.33,674.64,
CL Lower Periph Art Duplex wo Exer BILAT,3427532,CDM,921,RC,93923,HCPCS,Outpatient,,,788.8,394.4,,591.6,75,,,percent of total billed charges,75% of total billed charges,591.6,75,,,percent of total billed charges,75% of total billed charges,136.72,100,,,Fee Schedule,100% of CMS OPPS Rate,83.33,100,,,Fee Schedule,100% of WV Medicaid Rate,225.58,165,,,Fee Schedule,165% of CMS OPPS Rate,141.69,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,392.72,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,538.59,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,674.64,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,83.33,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,136.72,100,,,Fee Schedule,100% of CMS OPPS Rate,141.69,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,110.43,14,,,percent of total billed charges,14% of total billed charges,83.33,674.64,
CL Lower Periph Art Duplex wo Exer LT,3427528,CDM,921,RC,93923,HCPCS,Outpatient,,,788.8,394.4,,591.6,75,,,percent of total billed charges,75% of total billed charges,591.6,75,,,percent of total billed charges,75% of total billed charges,136.72,100,,,Fee Schedule,100% of CMS OPPS Rate,83.33,100,,,Fee Schedule,100% of WV Medicaid Rate,225.58,165,,,Fee Schedule,165% of CMS OPPS Rate,141.69,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,392.72,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,538.59,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,674.64,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,83.33,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,136.72,100,,,Fee Schedule,100% of CMS OPPS Rate,141.69,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,110.43,14,,,percent of total billed charges,14% of total billed charges,83.33,674.64,
CL Lower Periph Art Duplex wo Exer RT,3427530,CDM,921,RC,93923,HCPCS,Outpatient,,,788.8,394.4,,591.6,75,,,percent of total billed charges,75% of total billed charges,591.6,75,,,percent of total billed charges,75% of total billed charges,136.72,100,,,Fee Schedule,100% of CMS OPPS Rate,83.33,100,,,Fee Schedule,100% of WV Medicaid Rate,225.58,165,,,Fee Schedule,165% of CMS OPPS Rate,141.69,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,392.72,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,538.59,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,674.64,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,83.33,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,136.72,100,,,Fee Schedule,100% of CMS OPPS Rate,141.69,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,110.43,14,,,percent of total billed charges,14% of total billed charges,83.33,674.64,
CL US Lower Extrem Art Comp w ABI BILAT,3427501,CDM,921,RC,93923,HCPCS,Outpatient,,,788.8,394.4,,591.6,75,,,percent of total billed charges,75% of total billed charges,591.6,75,,,percent of total billed charges,75% of total billed charges,136.72,100,,,Fee Schedule,100% of CMS OPPS Rate,83.33,100,,,Fee Schedule,100% of WV Medicaid Rate,225.58,165,,,Fee Schedule,165% of CMS OPPS Rate,141.69,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,392.72,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,538.59,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,674.64,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,83.33,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,136.72,100,,,Fee Schedule,100% of CMS OPPS Rate,141.69,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,110.43,14,,,percent of total billed charges,14% of total billed charges,83.33,674.64,
CL US Lower Extrem Art Complete LT,3427503,CDM,921,RC,93923,HCPCS,Outpatient,,,788.8,394.4,,591.6,75,,,percent of total billed charges,75% of total billed charges,591.6,75,,,percent of total billed charges,75% of total billed charges,136.72,100,,,Fee Schedule,100% of CMS OPPS Rate,83.33,100,,,Fee Schedule,100% of WV Medicaid Rate,225.58,165,,,Fee Schedule,165% of CMS OPPS Rate,141.69,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,392.72,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,538.59,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,674.64,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,83.33,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,136.72,100,,,Fee Schedule,100% of CMS OPPS Rate,141.69,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,110.43,14,,,percent of total billed charges,14% of total billed charges,83.33,674.64,
CL US Lower Extrem Art Complete RT,3427505,CDM,921,RC,93923,HCPCS,Outpatient,,,788.8,394.4,,591.6,75,,,percent of total billed charges,75% of total billed charges,591.6,75,,,percent of total billed charges,75% of total billed charges,136.72,100,,,Fee Schedule,100% of CMS OPPS Rate,83.33,100,,,Fee Schedule,100% of WV Medicaid Rate,225.58,165,,,Fee Schedule,165% of CMS OPPS Rate,141.69,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,392.72,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,538.59,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,674.64,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,83.33,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,136.72,100,,,Fee Schedule,100% of CMS OPPS Rate,141.69,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,110.43,14,,,percent of total billed charges,14% of total billed charges,83.33,674.64,
93924 - Lwr xtr vasc stdy bilat,3435544,CDM,921,RC,93924,HCPCS,Outpatient,,,788.8,394.4,,591.6,75,,,percent of total billed charges,75% of total billed charges,591.6,75,,,percent of total billed charges,75% of total billed charges,263.29,100,,,Fee Schedule,100% of CMS OPPS Rate,102.5,100,,,Fee Schedule,100% of WV Medicaid Rate,434.44,165,,,Fee Schedule,165% of CMS OPPS Rate,272.88,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,756.29,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1037.2,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1299.2,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,102.5,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,263.29,100,,,Fee Schedule,100% of CMS OPPS Rate,272.88,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,110.43,14,,,percent of total billed charges,14% of total billed charges,102.5,1299.2,
CL Lower Ext Art Physio w Exer BILAT,3569307,CDM,921,RC,93924,HCPCS,Outpatient,,,788.8,394.4,,591.6,75,,,percent of total billed charges,75% of total billed charges,591.6,75,,,percent of total billed charges,75% of total billed charges,263.29,100,,,Fee Schedule,100% of CMS OPPS Rate,102.5,100,,,Fee Schedule,100% of WV Medicaid Rate,434.44,165,,,Fee Schedule,165% of CMS OPPS Rate,272.88,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,756.29,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1037.2,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1299.2,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,102.5,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,263.29,100,,,Fee Schedule,100% of CMS OPPS Rate,272.88,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,110.43,14,,,percent of total billed charges,14% of total billed charges,102.5,1299.2,
CL Lower Periph Art Duplex w Exer BILAT,3427533,CDM,921,RC,93924,HCPCS,Outpatient,,,788.8,394.4,,591.6,75,,,percent of total billed charges,75% of total billed charges,591.6,75,,,percent of total billed charges,75% of total billed charges,263.29,100,,,Fee Schedule,100% of CMS OPPS Rate,102.5,100,,,Fee Schedule,100% of WV Medicaid Rate,434.44,165,,,Fee Schedule,165% of CMS OPPS Rate,272.88,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,756.29,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1037.2,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1299.2,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,102.5,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,263.29,100,,,Fee Schedule,100% of CMS OPPS Rate,272.88,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,110.43,14,,,percent of total billed charges,14% of total billed charges,102.5,1299.2,
CL Lower Periph Art Duplex w Exer LT,3427529,CDM,921,RC,93924,HCPCS,Outpatient,,,788.8,394.4,,591.6,75,,,percent of total billed charges,75% of total billed charges,591.6,75,,,percent of total billed charges,75% of total billed charges,263.29,100,,,Fee Schedule,100% of CMS OPPS Rate,102.5,100,,,Fee Schedule,100% of WV Medicaid Rate,434.44,165,,,Fee Schedule,165% of CMS OPPS Rate,272.88,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,756.29,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1037.2,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1299.2,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,102.5,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,263.29,100,,,Fee Schedule,100% of CMS OPPS Rate,272.88,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,110.43,14,,,percent of total billed charges,14% of total billed charges,102.5,1299.2,
CL Lower Periph Art Duplex w Exer RT,3427531,CDM,921,RC,93924,HCPCS,Outpatient,,,788.8,394.4,,591.6,75,,,percent of total billed charges,75% of total billed charges,591.6,75,,,percent of total billed charges,75% of total billed charges,263.29,100,,,Fee Schedule,100% of CMS OPPS Rate,102.5,100,,,Fee Schedule,100% of WV Medicaid Rate,434.44,165,,,Fee Schedule,165% of CMS OPPS Rate,272.88,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,756.29,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1037.2,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1299.2,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,102.5,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,263.29,100,,,Fee Schedule,100% of CMS OPPS Rate,272.88,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,110.43,14,,,percent of total billed charges,14% of total billed charges,102.5,1299.2,
93925 - PF Duplex scan of lower extremity arteries or arterial bypass grafts; complete bilateral stu,3641209,CDM,510,RC,93925,HCPCS,Outpatient,,,387.36,193.68,,290.52,75,,,percent of total billed charges,75% of total billed charges,290.52,75,,,percent of total billed charges,75% of total billed charges,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,157.31,100,,,Fee Schedule,100% of WV Medicaid Rate,362.24,165,,,Fee Schedule,165% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,630.61,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,864.84,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1083.29,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,157.31,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,54.23,14,,,percent of total billed charges,14% of total billed charges,54.23,1083.29,
93925 26 Duplex scan of lower extremity arteries or arteri,3622799,CDM,510,RC,93925,HCPCS,Outpatient,,,387.36,193.68,,290.52,75,,,percent of total billed charges,75% of total billed charges,290.52,75,,,percent of total billed charges,75% of total billed charges,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,157.31,100,,,Fee Schedule,100% of WV Medicaid Rate,362.24,165,,,Fee Schedule,165% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,630.61,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,864.84,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1083.29,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,157.31,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,54.23,14,,,percent of total billed charges,14% of total billed charges,54.23,1083.29,
93925- Dup scan/LE art/graft/bilat/comp,3435545,CDM,921,RC,93925,HCPCS,Outpatient,,,387.36,193.68,,290.52,75,,,percent of total billed charges,75% of total billed charges,290.52,75,,,percent of total billed charges,75% of total billed charges,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,157.31,100,,,Fee Schedule,100% of WV Medicaid Rate,362.24,165,,,Fee Schedule,165% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,630.61,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,864.84,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1083.29,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,157.31,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,54.23,14,,,percent of total billed charges,14% of total billed charges,54.23,1083.29,
93926 - Duplex scan of lower extremity arteries or arterial bypass grafts; unilateral or limited,3620984,CDM,510,RC,93926,HCPCS,Outpatient,,,555.18,277.59,,416.39,75,,,percent of total billed charges,75% of total billed charges,416.39,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,84.58,100,,,Fee Schedule,100% of WV Medicaid Rate,165.79,165,,,Fee Schedule,165% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.82,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,84.58,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,77.73,14,,,percent of total billed charges,14% of total billed charges,77.73,495.81,
93926- Dup scan/LE art/graft/unilat/ltd,3435546,CDM,921,RC,93926,HCPCS,Outpatient,,,555.18,277.59,,416.39,75,,,percent of total billed charges,75% of total billed charges,416.39,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,84.58,100,,,Fee Schedule,100% of WV Medicaid Rate,165.79,165,,,Fee Schedule,165% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.82,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,84.58,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,77.73,14,,,percent of total billed charges,14% of total billed charges,77.73,495.81,
CL Femoral Groin Artery BILAT,3427521,CDM,921,RC,93926,HCPCS,Outpatient,,,555.18,277.59,,416.39,75,,,percent of total billed charges,75% of total billed charges,416.39,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,84.58,100,,,Fee Schedule,100% of WV Medicaid Rate,165.79,165,,,Fee Schedule,165% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.82,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,84.58,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,77.73,14,,,percent of total billed charges,14% of total billed charges,77.73,495.81,
CL Femoral Groin Artery LT,3427519,CDM,921,RC,93926,HCPCS,Outpatient,,,555.18,277.59,,416.39,75,,,percent of total billed charges,75% of total billed charges,416.39,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,84.58,100,,,Fee Schedule,100% of WV Medicaid Rate,165.79,165,,,Fee Schedule,165% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.82,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,84.58,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,77.73,14,,,percent of total billed charges,14% of total billed charges,77.73,495.81,
CL Femoral Groin Artery RT,3427520,CDM,921,RC,93926,HCPCS,Outpatient,,,555.18,277.59,,416.39,75,,,percent of total billed charges,75% of total billed charges,416.39,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,84.58,100,,,Fee Schedule,100% of WV Medicaid Rate,165.79,165,,,Fee Schedule,165% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.82,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,84.58,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,77.73,14,,,percent of total billed charges,14% of total billed charges,77.73,495.81,
US Lower Ext Arterial Lt Limited,3374600,CDM,921,RC,93926,HCPCS,Outpatient,,,555.18,277.59,,416.39,75,,,percent of total billed charges,75% of total billed charges,416.39,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,84.58,100,,,Fee Schedule,100% of WV Medicaid Rate,165.79,165,,,Fee Schedule,165% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.82,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,84.58,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,77.73,14,,,percent of total billed charges,14% of total billed charges,77.73,495.81,
US Lower Ext Arterial Rt Complete,3374602,CDM,921,RC,93926,HCPCS,Outpatient,,,555.18,277.59,,416.39,75,,,percent of total billed charges,75% of total billed charges,416.39,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,84.58,100,,,Fee Schedule,100% of WV Medicaid Rate,165.79,165,,,Fee Schedule,165% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.82,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,84.58,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,77.73,14,,,percent of total billed charges,14% of total billed charges,77.73,495.81,
US Lower Ext Arterial Rt Limited,3374604,CDM,921,RC,93926,HCPCS,Outpatient,,,555.18,277.59,,416.39,75,,,percent of total billed charges,75% of total billed charges,416.39,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,84.58,100,,,Fee Schedule,100% of WV Medicaid Rate,165.79,165,,,Fee Schedule,165% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.82,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,84.58,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,77.73,14,,,percent of total billed charges,14% of total billed charges,77.73,495.81,
93930- Dup scan/UE art/graft/bilat/comp,3435547,CDM,921,RC,93930,HCPCS,Outpatient,,,276.2,138.1,,207.15,75,,,percent of total billed charges,75% of total billed charges,207.15,75,,,percent of total billed charges,75% of total billed charges,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,128.55,100,,,Fee Schedule,100% of WV Medicaid Rate,362.24,165,,,Fee Schedule,165% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,630.61,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,864.84,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1083.29,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,128.55,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,38.67,14,,,percent of total billed charges,14% of total billed charges,38.67,1083.29,
93931- Dup scan/UE/art/graft/unilat/ltd,3435548,CDM,921,RC,93931,HCPCS,Outpatient,,,177.3,88.65,,132.98,75,,,percent of total billed charges,75% of total billed charges,132.98,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,81.11,100,,,Fee Schedule,100% of WV Medicaid Rate,165.79,165,,,Fee Schedule,165% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.82,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,81.11,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,24.82,14,,,percent of total billed charges,14% of total billed charges,24.82,495.81,
93970- Dup scan/extremity vein/bilat/comp,3435549,CDM,921,RC,93970,HCPCS,Outpatient,,,1237.39,618.7,,928.04,75,,,percent of total billed charges,75% of total billed charges,928.04,75,,,percent of total billed charges,75% of total billed charges,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,122.65,100,,,Fee Schedule,100% of WV Medicaid Rate,362.24,165,,,Fee Schedule,165% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,630.61,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,864.84,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1083.29,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,122.65,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,173.23,14,,,percent of total billed charges,14% of total billed charges,122.65,1083.29,
93970 Dup-Scan XTR Veins Complete Bilateral Study,3436060,CDM,761,RC,93970,HCPCS,Outpatient,,,1237.39,618.7,,928.04,75,,,percent of total billed charges,75% of total billed charges,928.04,75,,,percent of total billed charges,75% of total billed charges,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,122.65,100,,,Fee Schedule,100% of WV Medicaid Rate,362.24,165,,,Fee Schedule,165% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,630.61,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,864.84,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1083.29,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,122.65,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,173.23,14,,,percent of total billed charges,14% of total billed charges,122.65,1083.29,
93970-CL Periph Venous US Lower BILAT,3432087,CDM,481,RC,93970,HCPCS,Outpatient,,,1237.39,618.7,,928.04,75,,,percent of total billed charges,75% of total billed charges,928.04,75,,,percent of total billed charges,75% of total billed charges,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,122.65,100,,,Fee Schedule,100% of WV Medicaid Rate,362.24,165,,,Fee Schedule,165% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,630.61,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,864.84,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1083.29,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,122.65,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,173.23,14,,,percent of total billed charges,14% of total billed charges,122.65,1083.29,
93970-CL Periph Venous US Upper BILAT,3432088,CDM,481,RC,93970,HCPCS,Outpatient,,,1237.39,618.7,,928.04,75,,,percent of total billed charges,75% of total billed charges,928.04,75,,,percent of total billed charges,75% of total billed charges,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,122.65,100,,,Fee Schedule,100% of WV Medicaid Rate,362.24,165,,,Fee Schedule,165% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,630.61,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,864.84,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1083.29,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,122.65,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,173.23,14,,,percent of total billed charges,14% of total billed charges,122.65,1083.29,
93970-CL Upper Periph Arterial Duplex BILAT,3432089,CDM,481,RC,93970,HCPCS,Outpatient,,,1237.39,618.7,,928.04,75,,,percent of total billed charges,75% of total billed charges,928.04,75,,,percent of total billed charges,75% of total billed charges,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,122.65,100,,,Fee Schedule,100% of WV Medicaid Rate,362.24,165,,,Fee Schedule,165% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,630.61,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,864.84,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1083.29,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,122.65,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,173.23,14,,,percent of total billed charges,14% of total billed charges,122.65,1083.29,
93970-CL US Vein Map Mark Lower Extrem BILAT,3432090,CDM,481,RC,93970,HCPCS,Outpatient,,,1237.39,618.7,,928.04,75,,,percent of total billed charges,75% of total billed charges,928.04,75,,,percent of total billed charges,75% of total billed charges,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,122.65,100,,,Fee Schedule,100% of WV Medicaid Rate,362.24,165,,,Fee Schedule,165% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,630.61,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,864.84,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1083.29,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,122.65,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,173.23,14,,,percent of total billed charges,14% of total billed charges,122.65,1083.29,
93970-CL US Vein Map Mark Upper Extrem BILAT,3432091,CDM,481,RC,93970,HCPCS,Outpatient,,,1237.39,618.7,,928.04,75,,,percent of total billed charges,75% of total billed charges,928.04,75,,,percent of total billed charges,75% of total billed charges,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,122.65,100,,,Fee Schedule,100% of WV Medicaid Rate,362.24,165,,,Fee Schedule,165% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,630.61,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,864.84,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1083.29,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,122.65,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,173.23,14,,,percent of total billed charges,14% of total billed charges,122.65,1083.29,
93970-CL US Venous Insuff Lower Extrem BILAT,3432092,CDM,481,RC,93970,HCPCS,Outpatient,,,1237.39,618.7,,928.04,75,,,percent of total billed charges,75% of total billed charges,928.04,75,,,percent of total billed charges,75% of total billed charges,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,122.65,100,,,Fee Schedule,100% of WV Medicaid Rate,362.24,165,,,Fee Schedule,165% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,630.61,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,864.84,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1083.29,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,122.65,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,173.23,14,,,percent of total billed charges,14% of total billed charges,122.65,1083.29,
93970-CL US Venous Insuff Upper Extrem BILAT,3432093,CDM,481,RC,93970,HCPCS,Outpatient,,,1237.39,618.7,,928.04,75,,,percent of total billed charges,75% of total billed charges,928.04,75,,,percent of total billed charges,75% of total billed charges,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,122.65,100,,,Fee Schedule,100% of WV Medicaid Rate,362.24,165,,,Fee Schedule,165% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,630.61,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,864.84,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1083.29,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,122.65,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,173.23,14,,,percent of total billed charges,14% of total billed charges,122.65,1083.29,
CL Periph Venous US Lower BILAT,3427536,CDM,921,RC,93970,HCPCS,Outpatient,,,1237.39,618.7,,928.04,75,,,percent of total billed charges,75% of total billed charges,928.04,75,,,percent of total billed charges,75% of total billed charges,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,122.65,100,,,Fee Schedule,100% of WV Medicaid Rate,362.24,165,,,Fee Schedule,165% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,630.61,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,864.84,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1083.29,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,122.65,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,173.23,14,,,percent of total billed charges,14% of total billed charges,122.65,1083.29,
CL Periph Venous US Upper BILAT,3427537,CDM,921,RC,93970,HCPCS,Outpatient,,,1237.39,618.7,,928.04,75,,,percent of total billed charges,75% of total billed charges,928.04,75,,,percent of total billed charges,75% of total billed charges,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,122.65,100,,,Fee Schedule,100% of WV Medicaid Rate,362.24,165,,,Fee Schedule,165% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,630.61,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,864.84,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1083.29,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,122.65,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,173.23,14,,,percent of total billed charges,14% of total billed charges,122.65,1083.29,
CL Upper Periph Arterial Duplex BILAT,3427571,CDM,921,RC,93970,HCPCS,Outpatient,,,1237.39,618.7,,928.04,75,,,percent of total billed charges,75% of total billed charges,928.04,75,,,percent of total billed charges,75% of total billed charges,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,122.65,100,,,Fee Schedule,100% of WV Medicaid Rate,362.24,165,,,Fee Schedule,165% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,630.61,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,864.84,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1083.29,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,122.65,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,173.23,14,,,percent of total billed charges,14% of total billed charges,122.65,1083.29,
CL US Vein Map Mark Lower Extrem BILAT,3427463,CDM,921,RC,93970,HCPCS,Outpatient,,,1237.39,618.7,,928.04,75,,,percent of total billed charges,75% of total billed charges,928.04,75,,,percent of total billed charges,75% of total billed charges,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,122.65,100,,,Fee Schedule,100% of WV Medicaid Rate,362.24,165,,,Fee Schedule,165% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,630.61,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,864.84,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1083.29,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,122.65,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,173.23,14,,,percent of total billed charges,14% of total billed charges,122.65,1083.29,
CL US Vein Map Mark Upper Extrem BILAT,3427498,CDM,921,RC,93970,HCPCS,Outpatient,,,1237.39,618.7,,928.04,75,,,percent of total billed charges,75% of total billed charges,928.04,75,,,percent of total billed charges,75% of total billed charges,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,122.65,100,,,Fee Schedule,100% of WV Medicaid Rate,362.24,165,,,Fee Schedule,165% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,630.61,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,864.84,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1083.29,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,122.65,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,173.23,14,,,percent of total billed charges,14% of total billed charges,122.65,1083.29,
CL US Venous Insuff Lower Extrem BILAT,3427507,CDM,921,RC,93970,HCPCS,Outpatient,,,1237.39,618.7,,928.04,75,,,percent of total billed charges,75% of total billed charges,928.04,75,,,percent of total billed charges,75% of total billed charges,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,122.65,100,,,Fee Schedule,100% of WV Medicaid Rate,362.24,165,,,Fee Schedule,165% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,630.61,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,864.84,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1083.29,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,122.65,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,173.23,14,,,percent of total billed charges,14% of total billed charges,122.65,1083.29,
CL US Venous Insuff Upper Extrem BILAT,3427510,CDM,921,RC,93970,HCPCS,Outpatient,,,1237.39,618.7,,928.04,75,,,percent of total billed charges,75% of total billed charges,928.04,75,,,percent of total billed charges,75% of total billed charges,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,122.65,100,,,Fee Schedule,100% of WV Medicaid Rate,362.24,165,,,Fee Schedule,165% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,630.61,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,864.84,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1083.29,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,122.65,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,173.23,14,,,percent of total billed charges,14% of total billed charges,122.65,1083.29,
SCSN US Exam,4345743,CDM,402,RC,93970,HCPCS,Outpatient,,,1041.7,520.85,,781.28,75,,,percent of total billed charges,75% of total billed charges,781.28,75,,,percent of total billed charges,75% of total billed charges,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,122.65,100,,,Fee Schedule,100% of WV Medicaid Rate,362.24,165,,,Fee Schedule,165% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,630.61,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,864.84,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1083.29,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,122.65,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,145.84,14,,,percent of total billed charges,14% of total billed charges,122.65,1083.29,
SCSN US Exam,4345745,CDM,402,RC,93970,HCPCS,Outpatient,,,1041.7,520.85,,781.28,75,,,percent of total billed charges,75% of total billed charges,781.28,75,,,percent of total billed charges,75% of total billed charges,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,122.65,100,,,Fee Schedule,100% of WV Medicaid Rate,362.24,165,,,Fee Schedule,165% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,630.61,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,864.84,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1083.29,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,122.65,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,145.84,14,,,percent of total billed charges,14% of total billed charges,122.65,1083.29,
SCSN US Venous Lower Bilat Interp,3575318,CDM,510,RC,93970,HCPCS,Outpatient,,,279.87,139.94,,209.9,75,,,percent of total billed charges,75% of total billed charges,209.9,75,,,percent of total billed charges,75% of total billed charges,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,122.65,100,,,Fee Schedule,100% of WV Medicaid Rate,362.24,165,,,Fee Schedule,165% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,630.61,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,864.84,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1083.29,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,122.65,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,39.18,14,,,percent of total billed charges,14% of total billed charges,39.18,1083.29,
SCSN US Venous Upper BILAT,3569783,CDM,402,RC,93970,HCPCS,Outpatient,,,279.87,139.94,,209.9,75,,,percent of total billed charges,75% of total billed charges,209.9,75,,,percent of total billed charges,75% of total billed charges,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,122.65,100,,,Fee Schedule,100% of WV Medicaid Rate,362.24,165,,,Fee Schedule,165% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,630.61,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,864.84,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1083.29,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,122.65,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,39.18,14,,,percent of total billed charges,14% of total billed charges,39.18,1083.29,
SCSN Venous Insuff Bilat,3569789,CDM,920,RC,93970,HCPCS,Outpatient,,,279.87,139.94,,209.9,75,,,percent of total billed charges,75% of total billed charges,209.9,75,,,percent of total billed charges,75% of total billed charges,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,122.65,100,,,Fee Schedule,100% of WV Medicaid Rate,362.24,165,,,Fee Schedule,165% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,630.61,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,864.84,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1083.29,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,122.65,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,39.18,14,,,percent of total billed charges,14% of total billed charges,39.18,1083.29,
US Extremity Complete Bilat Upper for DVT,3347591,CDM,921,RC,93970,HCPCS,Outpatient,,,1237.39,618.7,,928.04,75,,,percent of total billed charges,75% of total billed charges,928.04,75,,,percent of total billed charges,75% of total billed charges,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,122.65,100,,,Fee Schedule,100% of WV Medicaid Rate,362.24,165,,,Fee Schedule,165% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,630.61,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,864.84,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1083.29,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,122.65,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,173.23,14,,,percent of total billed charges,14% of total billed charges,122.65,1083.29,
US Extremity Vein Complete Bilat for DVT,1257040,CDM,921,RC,93970,HCPCS,Outpatient,,,1237.39,618.7,,928.04,75,,,percent of total billed charges,75% of total billed charges,928.04,75,,,percent of total billed charges,75% of total billed charges,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,122.65,100,,,Fee Schedule,100% of WV Medicaid Rate,362.24,165,,,Fee Schedule,165% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,630.61,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,864.84,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1083.29,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,122.65,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,219.54,100,,,Fee Schedule,100% of CMS OPPS Rate,227.53,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,173.23,14,,,percent of total billed charges,14% of total billed charges,122.65,1083.29,
93971 - PB Tech Duplex scan of extremity veins including responses to compression and other maneuver,3641197,CDM,510,RC,93971,HCPCS,Outpatient,,,571.2,285.6,,428.4,75,,,percent of total billed charges,75% of total billed charges,428.4,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,77.67,100,,,Fee Schedule,100% of WV Medicaid Rate,165.79,165,,,Fee Schedule,165% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.82,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,77.67,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,79.97,14,,,percent of total billed charges,14% of total billed charges,77.67,495.81,
93971- Dup scan/extremity vein/unilat/ltd,3435550,CDM,921,RC,93971,HCPCS,Outpatient,,,571.2,285.6,,428.4,75,,,percent of total billed charges,75% of total billed charges,428.4,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,77.67,100,,,Fee Schedule,100% of WV Medicaid Rate,165.79,165,,,Fee Schedule,165% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.82,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,77.67,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,79.97,14,,,percent of total billed charges,14% of total billed charges,77.67,495.81,
93971 -Duplex scan of extremity veins including responses to compression and other maneuvers; unilat,3641196,CDM,510,RC,93971,HCPCS,Outpatient,,,571.2,285.6,,428.4,75,,,percent of total billed charges,75% of total billed charges,428.4,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,77.67,100,,,Fee Schedule,100% of WV Medicaid Rate,165.79,165,,,Fee Schedule,165% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.82,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,77.67,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,79.97,14,,,percent of total billed charges,14% of total billed charges,77.67,495.81,
93971 Dup-Scan XTR Veins Unilateral/Limited Study,3436061,CDM,761,RC,93971,HCPCS,Outpatient,,,571.2,285.6,,428.4,75,,,percent of total billed charges,75% of total billed charges,428.4,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,77.67,100,,,Fee Schedule,100% of WV Medicaid Rate,165.79,165,,,Fee Schedule,165% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.82,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,77.67,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,79.97,14,,,percent of total billed charges,14% of total billed charges,77.67,495.81,
CL Periph Venous US Lower LT,3427534,CDM,921,RC,93971,HCPCS,Outpatient,,,555.18,277.59,,416.39,75,,,percent of total billed charges,75% of total billed charges,416.39,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,77.67,100,,,Fee Schedule,100% of WV Medicaid Rate,165.79,165,,,Fee Schedule,165% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.82,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,77.67,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,77.73,14,,,percent of total billed charges,14% of total billed charges,77.67,495.81,
CL Upper Periph Arterial Duplex RT,3427570,CDM,921,RC,93971,HCPCS,Outpatient,,,555.18,277.59,,416.39,75,,,percent of total billed charges,75% of total billed charges,416.39,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,77.67,100,,,Fee Schedule,100% of WV Medicaid Rate,165.79,165,,,Fee Schedule,165% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.82,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,77.67,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,77.73,14,,,percent of total billed charges,14% of total billed charges,77.67,495.81,
CL US Venous Insuff Lower Extrem LT,3427508,CDM,921,RC,93971,HCPCS,Outpatient,,,555.18,277.59,,416.39,75,,,percent of total billed charges,75% of total billed charges,416.39,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,77.67,100,,,Fee Schedule,100% of WV Medicaid Rate,165.79,165,,,Fee Schedule,165% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.82,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,77.67,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,77.73,14,,,percent of total billed charges,14% of total billed charges,77.67,495.81,
CL US Venous Insuff Lower Extrem RT,3427509,CDM,921,RC,93971,HCPCS,Outpatient,,,555.18,277.59,,416.39,75,,,percent of total billed charges,75% of total billed charges,416.39,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,77.67,100,,,Fee Schedule,100% of WV Medicaid Rate,165.79,165,,,Fee Schedule,165% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.82,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,77.67,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,77.73,14,,,percent of total billed charges,14% of total billed charges,77.67,495.81,
US Extremity Vein Unilat Lt for DVT,1257042,CDM,921,RC,93971,HCPCS,Outpatient,,,571.2,285.6,,428.4,75,,,percent of total billed charges,75% of total billed charges,428.4,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,77.67,100,,,Fee Schedule,100% of WV Medicaid Rate,165.79,165,,,Fee Schedule,165% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.82,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,77.67,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,79.97,14,,,percent of total billed charges,14% of total billed charges,77.67,495.81,
US Extremity Vein Unilat Lt Lower for DVT,3347593,CDM,921,RC,93971,HCPCS,Outpatient,,,571.2,285.6,,428.4,75,,,percent of total billed charges,75% of total billed charges,428.4,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,77.67,100,,,Fee Schedule,100% of WV Medicaid Rate,165.79,165,,,Fee Schedule,165% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.82,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,77.67,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,79.97,14,,,percent of total billed charges,14% of total billed charges,77.67,495.81,
US Extremity Vein Unilat Lt Upper for DVT,3347595,CDM,921,RC,93971,HCPCS,Outpatient,,,571.2,285.6,,428.4,75,,,percent of total billed charges,75% of total billed charges,428.4,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,77.67,100,,,Fee Schedule,100% of WV Medicaid Rate,165.79,165,,,Fee Schedule,165% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.82,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,77.67,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,79.97,14,,,percent of total billed charges,14% of total billed charges,77.67,495.81,
US Extremity Vein Unilat Rt,596566,CDM,921,RC,93971,HCPCS,Outpatient,,,571.2,285.6,,428.4,75,,,percent of total billed charges,75% of total billed charges,428.4,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,77.67,100,,,Fee Schedule,100% of WV Medicaid Rate,165.79,165,,,Fee Schedule,165% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.82,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,77.67,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,79.97,14,,,percent of total billed charges,14% of total billed charges,77.67,495.81,
US Extremity Vein Unilat Rt for DVT,1257044,CDM,921,RC,93971,HCPCS,Outpatient,,,571.2,285.6,,428.4,75,,,percent of total billed charges,75% of total billed charges,428.4,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,77.67,100,,,Fee Schedule,100% of WV Medicaid Rate,165.79,165,,,Fee Schedule,165% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.82,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,77.67,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,79.97,14,,,percent of total billed charges,14% of total billed charges,77.67,495.81,
US Extremity Vein Unilat Rt Lower for DVT,3347597,CDM,921,RC,93971,HCPCS,Outpatient,,,571.2,285.6,,428.4,75,,,percent of total billed charges,75% of total billed charges,428.4,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,77.67,100,,,Fee Schedule,100% of WV Medicaid Rate,165.79,165,,,Fee Schedule,165% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.82,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,77.67,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,79.97,14,,,percent of total billed charges,14% of total billed charges,77.67,495.81,
US Extremity Vein Unilat Rt Upper for DVT,3347599,CDM,921,RC,93971,HCPCS,Outpatient,,,571.2,285.6,,428.4,75,,,percent of total billed charges,75% of total billed charges,428.4,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,77.67,100,,,Fee Schedule,100% of WV Medicaid Rate,165.79,165,,,Fee Schedule,165% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.82,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,77.67,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,79.97,14,,,percent of total billed charges,14% of total billed charges,77.67,495.81,
US Vein Map/Marking Lower Extremity Lt,3352010,CDM,921,RC,93971,HCPCS,Outpatient,,,571.2,285.6,,428.4,75,,,percent of total billed charges,75% of total billed charges,428.4,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,77.67,100,,,Fee Schedule,100% of WV Medicaid Rate,165.79,165,,,Fee Schedule,165% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.82,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,77.67,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,79.97,14,,,percent of total billed charges,14% of total billed charges,77.67,495.81,
US Vein Map/Marking Lower Extremity Rt,3352014,CDM,921,RC,93971,HCPCS,Outpatient,,,571.2,285.6,,428.4,75,,,percent of total billed charges,75% of total billed charges,428.4,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,77.67,100,,,Fee Schedule,100% of WV Medicaid Rate,165.79,165,,,Fee Schedule,165% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.82,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,77.67,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,79.97,14,,,percent of total billed charges,14% of total billed charges,77.67,495.81,
US Vein Map/Marking Upper Extrem Bilat,3352016,CDM,921,RC,93971,HCPCS,Outpatient,,,571.2,285.6,,428.4,75,,,percent of total billed charges,75% of total billed charges,428.4,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,77.67,100,,,Fee Schedule,100% of WV Medicaid Rate,165.79,165,,,Fee Schedule,165% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.82,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,77.67,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,79.97,14,,,percent of total billed charges,14% of total billed charges,77.67,495.81,
US Vein Map/Marking Upper Extrem Lt,3352018,CDM,921,RC,93971,HCPCS,Outpatient,,,571.2,285.6,,428.4,75,,,percent of total billed charges,75% of total billed charges,428.4,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,77.67,100,,,Fee Schedule,100% of WV Medicaid Rate,165.79,165,,,Fee Schedule,165% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.82,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,77.67,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,79.97,14,,,percent of total billed charges,14% of total billed charges,77.67,495.81,
US Vein Map/Marking Upper Extrem Rt,3352020,CDM,921,RC,93971,HCPCS,Outpatient,,,571.2,285.6,,428.4,75,,,percent of total billed charges,75% of total billed charges,428.4,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,77.67,100,,,Fee Schedule,100% of WV Medicaid Rate,165.79,165,,,Fee Schedule,165% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.82,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,77.67,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,79.97,14,,,percent of total billed charges,14% of total billed charges,77.67,495.81,
US Venous Insufficiency Lower Extrem Lt,3352022,CDM,921,RC,93971,HCPCS,Outpatient,,,571.2,285.6,,428.4,75,,,percent of total billed charges,75% of total billed charges,428.4,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,77.67,100,,,Fee Schedule,100% of WV Medicaid Rate,165.79,165,,,Fee Schedule,165% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.82,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,77.67,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,79.97,14,,,percent of total billed charges,14% of total billed charges,77.67,495.81,
US Venous Insufficiency Lower Extrem Rt,3352024,CDM,921,RC,93971,HCPCS,Outpatient,,,571.2,285.6,,428.4,75,,,percent of total billed charges,75% of total billed charges,428.4,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,77.67,100,,,Fee Schedule,100% of WV Medicaid Rate,165.79,165,,,Fee Schedule,165% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.82,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,77.67,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,79.97,14,,,percent of total billed charges,14% of total billed charges,77.67,495.81,
93990- Dup scan/hemodialysis access,3435559,CDM,921,RC,93990,HCPCS,Outpatient,,,231.31,115.66,,173.48,75,,,percent of total billed charges,75% of total billed charges,173.48,75,,,percent of total billed charges,75% of total billed charges,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,96.35,100,,,Fee Schedule,100% of WV Medicaid Rate,165.8,165,,,Fee Schedule,165% of CMS OPPS Rate,104.14,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,288.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,395.83,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,495.81,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,96.35,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,100.48,100,,,Fee Schedule,100% of CMS OPPS Rate,104.14,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,32.38,14,,,percent of total billed charges,14% of total billed charges,32.38,495.81,
94060- Spirometry/pre/post bronchodilator,3435316,CDM,460,RC,94060,HCPCS,Outpatient,,,1585.02,792.51,,1188.77,75,,,percent of total billed charges,75% of total billed charges,1188.77,75,,,percent of total billed charges,75% of total billed charges,263.29,100,,,Fee Schedule,100% of CMS OPPS Rate,25.07,100,,,Fee Schedule,100% of WV Medicaid Rate,434.44,165,,,Fee Schedule,165% of CMS OPPS Rate,272.88,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,756.29,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1037.2,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1299.2,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,25.07,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,263.29,100,,,Fee Schedule,100% of CMS OPPS Rate,272.88,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,221.9,14,,,percent of total billed charges,14% of total billed charges,25.07,1299.2,
Clinic Spirometry w/ Diffusion Capacity,3435733,CDM,460,RC,94060,HCPCS,Outpatient,,,1585.02,792.51,,1188.77,75,,,percent of total billed charges,75% of total billed charges,1188.77,75,,,percent of total billed charges,75% of total billed charges,263.29,100,,,Fee Schedule,100% of CMS OPPS Rate,25.07,100,,,Fee Schedule,100% of WV Medicaid Rate,434.44,165,,,Fee Schedule,165% of CMS OPPS Rate,272.88,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,756.29,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1037.2,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1299.2,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,25.07,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,263.29,100,,,Fee Schedule,100% of CMS OPPS Rate,272.88,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,221.9,14,,,percent of total billed charges,14% of total billed charges,25.07,1299.2,
Clinic Spirometry with and without,3435734,CDM,460,RC,94060,HCPCS,Outpatient,,,1585.02,792.51,,1188.77,75,,,percent of total billed charges,75% of total billed charges,1188.77,75,,,percent of total billed charges,75% of total billed charges,263.29,100,,,Fee Schedule,100% of CMS OPPS Rate,25.07,100,,,Fee Schedule,100% of WV Medicaid Rate,434.44,165,,,Fee Schedule,165% of CMS OPPS Rate,272.88,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,756.29,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1037.2,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1299.2,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,25.07,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,263.29,100,,,Fee Schedule,100% of CMS OPPS Rate,272.88,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,221.9,14,,,percent of total billed charges,14% of total billed charges,25.07,1299.2,
PFT,617666,CDM,460,RC,94060,HCPCS,Outpatient,,,1585.02,792.51,,1188.77,75,,,percent of total billed charges,75% of total billed charges,1188.77,75,,,percent of total billed charges,75% of total billed charges,263.29,100,,,Fee Schedule,100% of CMS OPPS Rate,25.07,100,,,Fee Schedule,100% of WV Medicaid Rate,434.44,165,,,Fee Schedule,165% of CMS OPPS Rate,272.88,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,756.29,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1037.2,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1299.2,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,25.07,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,263.29,100,,,Fee Schedule,100% of CMS OPPS Rate,272.88,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,221.9,14,,,percent of total billed charges,14% of total billed charges,25.07,1299.2,
6 Minute Walk,658839,CDM,460,RC,94618,HCPCS,Outpatient,,,645.06,322.53,,483.8,75,,,percent of total billed charges,75% of total billed charges,483.8,75,,,percent of total billed charges,75% of total billed charges,109.16,100,,,Fee Schedule,100% of CMS OPPS Rate,22.61,100,,,Fee Schedule,100% of WV Medicaid Rate,180.11,165,,,Fee Schedule,165% of CMS OPPS Rate,113.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,313.55,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,430.01,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,538.63,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,22.61,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,109.16,100,,,Fee Schedule,100% of CMS OPPS Rate,113.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,90.31,14,,,percent of total billed charges,14% of total billed charges,22.61,538.63,
Clinic 6 min walk,3435728,CDM,460,RC,94618,HCPCS,Outpatient,,,645.06,322.53,,483.8,75,,,percent of total billed charges,75% of total billed charges,483.8,75,,,percent of total billed charges,75% of total billed charges,109.16,100,,,Fee Schedule,100% of CMS OPPS Rate,22.61,100,,,Fee Schedule,100% of WV Medicaid Rate,180.11,165,,,Fee Schedule,165% of CMS OPPS Rate,113.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,313.55,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,430.01,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,538.63,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,22.61,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,109.16,100,,,Fee Schedule,100% of CMS OPPS Rate,113.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,90.31,14,,,percent of total billed charges,14% of total billed charges,22.61,538.63,
Clinic 6 min walk with Oxygen titration,3435729,CDM,460,RC,94618,HCPCS,Outpatient,,,645.06,322.53,,483.8,75,,,percent of total billed charges,75% of total billed charges,483.8,75,,,percent of total billed charges,75% of total billed charges,109.16,100,,,Fee Schedule,100% of CMS OPPS Rate,22.61,100,,,Fee Schedule,100% of WV Medicaid Rate,180.11,165,,,Fee Schedule,165% of CMS OPPS Rate,113.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,313.55,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,430.01,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,538.63,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,22.61,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,109.16,100,,,Fee Schedule,100% of CMS OPPS Rate,113.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,90.31,14,,,percent of total billed charges,14% of total billed charges,22.61,538.63,
Six Minute Walk Test,634111,CDM,460,RC,94618,HCPCS,Outpatient,,,645.06,322.53,,483.8,75,,,percent of total billed charges,75% of total billed charges,483.8,75,,,percent of total billed charges,75% of total billed charges,109.16,100,,,Fee Schedule,100% of CMS OPPS Rate,22.61,100,,,Fee Schedule,100% of WV Medicaid Rate,180.11,165,,,Fee Schedule,165% of CMS OPPS Rate,113.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,313.55,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,430.01,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,538.63,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,22.61,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,109.16,100,,,Fee Schedule,100% of CMS OPPS Rate,113.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,90.31,14,,,percent of total billed charges,14% of total billed charges,22.61,538.63,
Nebulizer,617710,CDM,410,RC,94640,HCPCS,Outpatient,,,927.37,463.69,,695.53,75,,,percent of total billed charges,75% of total billed charges,695.53,75,,,percent of total billed charges,75% of total billed charges,180.04,100,,,Fee Schedule,100% of CMS OPPS Rate,6.88,100,,,Fee Schedule,100% of WV Medicaid Rate,297.06,165,,,Fee Schedule,165% of CMS OPPS Rate,186.59,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,517.14,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,709.22,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,888.37,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,6.88,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,180.04,100,,,Fee Schedule,100% of CMS OPPS Rate,186.59,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,129.83,14,,,percent of total billed charges,14% of total billed charges,6.88,888.37,
94726 - (TC) Plethysmography Lung Volumes w/wo airway resist,3896962,CDM,460,RC,94726,HCPCS,Outpatient,,,1585.02,792.51,,1188.77,75,,,percent of total billed charges,75% of total billed charges,1188.77,75,,,percent of total billed charges,75% of total billed charges,263.3,100,,,Fee Schedule,100% of CMS OPPS Rate,35.15,100,,,Fee Schedule,100% of WV Medicaid Rate,434.45,165,,,Fee Schedule,165% of CMS OPPS Rate,272.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,756.3,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1037.2,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1299.2,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,35.15,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,263.3,100,,,Fee Schedule,100% of CMS OPPS Rate,272.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,221.9,14,,,percent of total billed charges,14% of total billed charges,35.15,1299.2,
94726 - Plethysmography Lung Volumes w/wo airway resist,3896968,CDM,510,RC,94726,HCPCS,Outpatient,,,1585.02,792.51,,1188.77,75,,,percent of total billed charges,75% of total billed charges,1188.77,75,,,percent of total billed charges,75% of total billed charges,263.3,100,,,Fee Schedule,100% of CMS OPPS Rate,35.15,100,,,Fee Schedule,100% of WV Medicaid Rate,434.45,165,,,Fee Schedule,165% of CMS OPPS Rate,272.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,756.3,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1037.2,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1299.2,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,35.15,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,263.3,100,,,Fee Schedule,100% of CMS OPPS Rate,272.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,221.9,14,,,percent of total billed charges,14% of total billed charges,35.15,1299.2,
94726- Plethysmography/lung volume,3435709,CDM,460,RC,94726,HCPCS,Outpatient,,,1585.02,792.51,,1188.77,75,,,percent of total billed charges,75% of total billed charges,1188.77,75,,,percent of total billed charges,75% of total billed charges,263.3,100,,,Fee Schedule,100% of CMS OPPS Rate,35.15,100,,,Fee Schedule,100% of WV Medicaid Rate,434.45,165,,,Fee Schedule,165% of CMS OPPS Rate,272.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,756.3,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1037.2,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1299.2,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,35.15,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,263.3,100,,,Fee Schedule,100% of CMS OPPS Rate,272.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,221.9,14,,,percent of total billed charges,14% of total billed charges,35.15,1299.2,
Clinic Lung Volumes,3435732,CDM,460,RC,94726,HCPCS,Outpatient,,,1585.02,792.51,,1188.77,75,,,percent of total billed charges,75% of total billed charges,1188.77,75,,,percent of total billed charges,75% of total billed charges,263.3,100,,,Fee Schedule,100% of CMS OPPS Rate,35.15,100,,,Fee Schedule,100% of WV Medicaid Rate,434.45,165,,,Fee Schedule,165% of CMS OPPS Rate,272.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,756.3,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1037.2,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1299.2,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,35.15,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,263.3,100,,,Fee Schedule,100% of CMS OPPS Rate,272.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,221.9,14,,,percent of total billed charges,14% of total billed charges,35.15,1299.2,
Lung Vol & Capacity,617686,CDM,460,RC,94726,HCPCS,Outpatient,,,1585.02,792.51,,1188.77,75,,,percent of total billed charges,75% of total billed charges,1188.77,75,,,percent of total billed charges,75% of total billed charges,263.3,100,,,Fee Schedule,100% of CMS OPPS Rate,35.15,100,,,Fee Schedule,100% of WV Medicaid Rate,434.45,165,,,Fee Schedule,165% of CMS OPPS Rate,272.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,756.3,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1037.2,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1299.2,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,35.15,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,263.3,100,,,Fee Schedule,100% of CMS OPPS Rate,272.89,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,221.9,14,,,percent of total billed charges,14% of total billed charges,35.15,1299.2,
94729- Diffusing capacity/CO2/add on,3435712,CDM,460,RC,94729,HCPCS,Outpatient,,,230.03,115.02,,172.52,75,,,percent of total billed charges,75% of total billed charges,172.52,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,37.11,100,,,Fee Schedule,100% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.11,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.2,14,,,percent of total billed charges,14% of total billed charges,32.2,172.52,
Carbon Monoxide Diffusing Capacity,625084,CDM,460,RC,94729,HCPCS,Outpatient,,,230.03,115.02,,172.52,75,,,percent of total billed charges,75% of total billed charges,172.52,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,37.11,100,,,Fee Schedule,100% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.11,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.2,14,,,percent of total billed charges,14% of total billed charges,32.2,172.52,
Clinic Diffusion Capacity,3435730,CDM,460,RC,94729,HCPCS,Outpatient,,,230.03,115.02,,172.52,75,,,percent of total billed charges,75% of total billed charges,172.52,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,37.11,100,,,Fee Schedule,100% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.11,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.2,14,,,percent of total billed charges,14% of total billed charges,32.2,172.52,
DLCO,617682,CDM,460,RC,94729,HCPCS,Outpatient,,,230.03,115.02,,172.52,75,,,percent of total billed charges,75% of total billed charges,172.52,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,37.11,100,,,Fee Schedule,100% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.11,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.2,14,,,percent of total billed charges,14% of total billed charges,32.2,172.52,
95800- Stdy Unatnd w/Hrt Rt/O2 Sat/Resp/Slp Time,4347083,CDM,510,RC,95800,HCPCS,Outpatient,,,788.8,394.4,,591.6,75,,,percent of total billed charges,75% of total billed charges,591.6,75,,,percent of total billed charges,75% of total billed charges,136.72,100,,,Fee Schedule,100% of CMS OPPS Rate,103.24,100,,,Fee Schedule,100% of WV Medicaid Rate,225.58,165,,,Fee Schedule,165% of CMS OPPS Rate,141.69,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,392.72,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,538.59,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,674.64,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,103.24,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,136.72,100,,,Fee Schedule,100% of CMS OPPS Rate,141.69,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,110.43,14,,,percent of total billed charges,14% of total billed charges,103.24,674.64,
95801- Slp Stdy Unatnd w/Min Hrt Rt/O2 Sat/Resp Analys,4347084,CDM,510,RC,95801,HCPCS,Outpatient,,,308.88,154.44,,231.66,75,,,percent of total billed charges,75% of total billed charges,231.66,75,,,percent of total billed charges,75% of total billed charges,109.16,100,,,Fee Schedule,100% of CMS OPPS Rate,59.98,100,,,Fee Schedule,100% of WV Medicaid Rate,180.11,165,,,Fee Schedule,165% of CMS OPPS Rate,113.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,313.55,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,430.01,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,538.63,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,59.98,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,109.16,100,,,Fee Schedule,100% of CMS OPPS Rate,113.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,43.24,14,,,percent of total billed charges,14% of total billed charges,43.24,538.63,
Sleep Study - In Lab MSLT 95805,3575514,CDM,920,RC,95805,HCPCS,Outpatient,,,2706.6,1353.3,,2029.95,75,,,percent of total billed charges,75% of total billed charges,2029.95,75,,,percent of total billed charges,75% of total billed charges,454.5,100,,,Fee Schedule,100% of CMS OPPS Rate,265.7,100,,,Fee Schedule,100% of WV Medicaid Rate,749.91,165,,,Fee Schedule,165% of CMS OPPS Rate,471.04,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1305.49,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1790.39,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,2242.64,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,265.7,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,454.5,100,,,Fee Schedule,100% of CMS OPPS Rate,471.04,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,378.92,14,,,percent of total billed charges,14% of total billed charges,265.7,2242.64,
Sleep Study - Home Study 95806,3575513,CDM,920,RC,95806,HCPCS,Outpatient,,,788.8,394.4,,591.6,75,,,percent of total billed charges,75% of total billed charges,591.6,75,,,percent of total billed charges,75% of total billed charges,136.72,100,,,Fee Schedule,100% of CMS OPPS Rate,60.71,100,,,Fee Schedule,100% of WV Medicaid Rate,225.58,165,,,Fee Schedule,165% of CMS OPPS Rate,141.69,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,392.72,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,538.59,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,674.64,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,60.71,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,136.72,100,,,Fee Schedule,100% of CMS OPPS Rate,141.69,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,110.43,14,,,percent of total billed charges,14% of total billed charges,60.71,674.64,
95807 - Sleep Study - Attended,4347085,CDM,510,RC,95807,HCPCS,Outpatient,,,2415.26,1207.63,,1811.45,75,,,percent of total billed charges,75% of total billed charges,1811.45,75,,,percent of total billed charges,75% of total billed charges,454.5,100,,,Fee Schedule,100% of CMS OPPS Rate,242.11,100,,,Fee Schedule,100% of WV Medicaid Rate,749.91,165,,,Fee Schedule,165% of CMS OPPS Rate,471.04,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1305.49,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1790.39,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,2242.64,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,242.11,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,454.5,100,,,Fee Schedule,100% of CMS OPPS Rate,471.04,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,338.14,14,,,percent of total billed charges,14% of total billed charges,242.11,2242.64,
95808- Polysomnography/any age/tech,3430545,CDM,510,RC,95808,HCPCS,Outpatient,,,5279.75,2639.88,,3959.81,75,,,percent of total billed charges,75% of total billed charges,3959.81,75,,,percent of total billed charges,75% of total billed charges,878.46,100,,,Fee Schedule,100% of CMS OPPS Rate,425.48,100,,,Fee Schedule,100% of WV Medicaid Rate,1449.46,165,,,Fee Schedule,165% of CMS OPPS Rate,910.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,2523.29,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,3460.48,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,4334.6,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,425.48,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,878.46,100,,,Fee Schedule,100% of CMS OPPS Rate,910.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,739.17,14,,,percent of total billed charges,14% of total billed charges,425.48,4334.6,
Sleep Study - In Lab PSG 95810,3575515,CDM,740,RC,95810,HCPCS,Outpatient,,,5279.75,2639.88,,3959.81,75,,,percent of total billed charges,75% of total billed charges,3959.81,75,,,percent of total billed charges,75% of total billed charges,878.46,100,,,Fee Schedule,100% of CMS OPPS Rate,389.35,100,,,Fee Schedule,100% of WV Medicaid Rate,1449.46,165,,,Fee Schedule,165% of CMS OPPS Rate,910.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,2523.29,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,3460.48,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,4334.6,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,389.35,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,878.46,100,,,Fee Schedule,100% of CMS OPPS Rate,910.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,739.17,14,,,percent of total billed charges,14% of total billed charges,389.35,4334.6,
Sleep Study - In Lab Titration 95811,3575516,CDM,740,RC,95811,HCPCS,Outpatient,,,5279.75,2639.88,,3959.81,75,,,percent of total billed charges,75% of total billed charges,3959.81,75,,,percent of total billed charges,75% of total billed charges,878.46,100,,,Fee Schedule,100% of CMS OPPS Rate,406.55,100,,,Fee Schedule,100% of WV Medicaid Rate,1449.46,165,,,Fee Schedule,165% of CMS OPPS Rate,910.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,2523.29,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,3460.48,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,4334.6,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,406.55,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,878.46,100,,,Fee Schedule,100% of CMS OPPS Rate,910.46,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,739.17,14,,,percent of total billed charges,14% of total billed charges,406.55,4334.6,
Clinic EEG,3435538,CDM,740,RC,95812,HCPCS,Outpatient,,,1273,636.5,,954.75,75,,,percent of total billed charges,75% of total billed charges,954.75,75,,,percent of total billed charges,75% of total billed charges,263.29,100,,,Fee Schedule,100% of CMS OPPS Rate,221.47,100,,,Fee Schedule,100% of WV Medicaid Rate,434.44,165,,,Fee Schedule,165% of CMS OPPS Rate,272.88,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,756.29,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1037.2,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1299.2,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,221.47,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,263.29,100,,,Fee Schedule,100% of CMS OPPS Rate,272.88,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,178.22,14,,,percent of total billed charges,14% of total billed charges,178.22,1299.2,
"EEG, ROUTINE 41-60 MINS",3435541,CDM,740,RC,95812,HCPCS,Outpatient,,,1273,636.5,,954.75,75,,,percent of total billed charges,75% of total billed charges,954.75,75,,,percent of total billed charges,75% of total billed charges,263.29,100,,,Fee Schedule,100% of CMS OPPS Rate,221.47,100,,,Fee Schedule,100% of WV Medicaid Rate,434.44,165,,,Fee Schedule,165% of CMS OPPS Rate,272.88,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,756.29,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1037.2,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1299.2,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,221.47,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,263.29,100,,,Fee Schedule,100% of CMS OPPS Rate,272.88,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,178.22,14,,,percent of total billed charges,14% of total billed charges,178.22,1299.2,
95813- EEG Routine 61 - 199 Minutes,3435464,CDM,740,RC,95813,HCPCS,Outpatient,,,1273,636.5,,954.75,75,,,percent of total billed charges,75% of total billed charges,954.75,75,,,percent of total billed charges,75% of total billed charges,263.29,100,,,Fee Schedule,100% of CMS OPPS Rate,275.05,100,,,Fee Schedule,100% of WV Medicaid Rate,434.44,165,,,Fee Schedule,165% of CMS OPPS Rate,272.88,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,756.29,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1037.2,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1299.2,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,275.05,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,263.29,100,,,Fee Schedule,100% of CMS OPPS Rate,272.88,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,178.22,14,,,percent of total billed charges,14% of total billed charges,178.22,1299.2,
CL EEG Routine 61- 199 Minutes 95813,4339185,CDM,740,RC,95813,HCPCS,Outpatient,,,1273,636.5,,954.75,75,,,percent of total billed charges,75% of total billed charges,954.75,75,,,percent of total billed charges,75% of total billed charges,263.29,100,,,Fee Schedule,100% of CMS OPPS Rate,275.05,100,,,Fee Schedule,100% of WV Medicaid Rate,434.44,165,,,Fee Schedule,165% of CMS OPPS Rate,272.88,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,756.29,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1037.2,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1299.2,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,275.05,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,263.29,100,,,Fee Schedule,100% of CMS OPPS Rate,272.88,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,178.22,14,,,percent of total billed charges,14% of total billed charges,178.22,1299.2,
95816- EEG w/recording/awake/drowsy,3435465,CDM,740,RC,95816,HCPCS,Outpatient,,,1334.35,667.18,,1000.76,75,,,percent of total billed charges,75% of total billed charges,1000.76,75,,,percent of total billed charges,75% of total billed charges,263.29,100,,,Fee Schedule,100% of CMS OPPS Rate,243.83,100,,,Fee Schedule,100% of WV Medicaid Rate,434.44,165,,,Fee Schedule,165% of CMS OPPS Rate,272.88,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,756.29,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1037.2,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1299.2,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,243.83,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,263.29,100,,,Fee Schedule,100% of CMS OPPS Rate,272.88,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,186.81,14,,,percent of total billed charges,14% of total billed charges,186.81,1299.2,
95822 - (TC) Electroencephalogram (EEG); recording in coma or sleep only,3899092,CDM,983,RC,95822,HCPCS,Outpatient,,,1585.02,792.51,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
95822 - Electroencephalogram (EEG); recording in coma or sleep only,3800934,CDM,983,RC,95822,HCPCS,Outpatient,,,1585.02,792.51,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
95860 - Needle electromyography; 1 extremity with or without related paraspinal areas,3715346,CDM,510,RC,95860,HCPCS,Outpatient,,,18.88,9.44,,14.16,75,,,percent of total billed charges,75% of total billed charges,14.16,75,,,percent of total billed charges,75% of total billed charges,109.16,100,,,Fee Schedule,100% of CMS OPPS Rate,18.88,100,,,Fee Schedule,100% of WV Medicaid Rate,180.11,165,,,Fee Schedule,165% of CMS OPPS Rate,113.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,313.55,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,430.01,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,538.63,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,18.88,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,109.16,100,,,Fee Schedule,100% of CMS OPPS Rate,113.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,2.64,14,,,percent of total billed charges,14% of total billed charges,2.64,538.63,
95861 - Needle electromyography; 2 extremities with or without related paraspinal areas,3715353,CDM,510,RC,95861,HCPCS,Outpatient,,,12.83,6.42,,9.62,75,,,percent of total billed charges,75% of total billed charges,9.62,75,,,percent of total billed charges,75% of total billed charges,109.16,100,,,Fee Schedule,100% of CMS OPPS Rate,12.83,100,,,Fee Schedule,100% of WV Medicaid Rate,180.11,165,,,Fee Schedule,165% of CMS OPPS Rate,113.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,313.55,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,430.01,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,538.63,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,12.83,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,109.16,100,,,Fee Schedule,100% of CMS OPPS Rate,113.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1.8,14,,,percent of total billed charges,14% of total billed charges,1.8,538.63,
95863 - Needle electromyography; 3 extremities with or without related paraspinal areas,3715354,CDM,510,RC,95863,HCPCS,Outpatient,,,20.74,10.37,,15.56,75,,,percent of total billed charges,75% of total billed charges,15.56,75,,,percent of total billed charges,75% of total billed charges,136.72,100,,,Fee Schedule,100% of CMS OPPS Rate,20.74,100,,,Fee Schedule,100% of WV Medicaid Rate,225.58,165,,,Fee Schedule,165% of CMS OPPS Rate,141.69,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,392.72,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,538.59,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,674.64,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,20.74,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,136.72,100,,,Fee Schedule,100% of CMS OPPS Rate,141.69,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,2.9,14,,,percent of total billed charges,14% of total billed charges,2.9,674.64,
95864 - Needle electromyography; 4 extremities with or without related paraspinal areas,3715360,CDM,510,RC,95864,HCPCS,Outpatient,,,46.19,23.1,,34.64,75,,,percent of total billed charges,75% of total billed charges,34.64,75,,,percent of total billed charges,75% of total billed charges,136.72,100,,,Fee Schedule,100% of CMS OPPS Rate,46.19,100,,,Fee Schedule,100% of WV Medicaid Rate,225.58,165,,,Fee Schedule,165% of CMS OPPS Rate,141.69,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,392.72,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,538.59,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,674.64,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,46.19,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,136.72,100,,,Fee Schedule,100% of CMS OPPS Rate,141.69,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,6.47,14,,,percent of total billed charges,14% of total billed charges,6.47,674.64,
95869- Needle electromyograp/thor/paraspi,3435479,CDM,510,RC,95869,HCPCS,Outpatient,,,661.05,330.53,,495.79,75,,,percent of total billed charges,75% of total billed charges,495.79,75,,,percent of total billed charges,75% of total billed charges,136.72,100,,,Fee Schedule,100% of CMS OPPS Rate,64.4,100,,,Fee Schedule,100% of WV Medicaid Rate,225.6,165,,,Fee Schedule,165% of CMS OPPS Rate,141.7,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,392.73,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,538.6,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,674.65,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,64.4,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,136.72,100,,,Fee Schedule,100% of CMS OPPS Rate,141.7,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,92.55,14,,,percent of total billed charges,14% of total billed charges,64.4,674.65,
95870- Needle electromyography/lmt/1 ext,3435480,CDM,510,RC,95870,HCPCS,Outpatient,,,527.8,263.9,,395.85,75,,,percent of total billed charges,75% of total billed charges,395.85,75,,,percent of total billed charges,75% of total billed charges,109.16,100,,,Fee Schedule,100% of CMS OPPS Rate,55.8,100,,,Fee Schedule,100% of WV Medicaid Rate,180.11,165,,,Fee Schedule,165% of CMS OPPS Rate,113.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,313.55,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,430.01,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,538.63,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,55.8,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,109.16,100,,,Fee Schedule,100% of CMS OPPS Rate,113.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,73.89,14,,,percent of total billed charges,14% of total billed charges,55.8,538.63,
95873- Electric stim/w chemodenervation,3435482,CDM,510,RC,95873,HCPCS,Outpatient,,,955,477.5,,716.25,75,,,percent of total billed charges,75% of total billed charges,716.25,75,,,percent of total billed charges,75% of total billed charges,305.6,32,,,percent of total billed charges,32% of total billed charges,49.16,100,,,Fee Schedule,100% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.16,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,133.7,14,,,percent of total billed charges,14% of total billed charges,49.16,716.25,
95874- Needle EMG/chemodenervation,3435483,CDM,510,RC,95874,HCPCS,Outpatient,,,850,425,,637.5,75,,,percent of total billed charges,75% of total billed charges,637.5,75,,,percent of total billed charges,75% of total billed charges,272,32,,,percent of total billed charges,32% of total billed charges,51.62,100,,,Fee Schedule,100% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.62,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,119,14,,,percent of total billed charges,14% of total billed charges,51.62,637.5,
Clinic EMG,3435539,CDM,510,RC,95874,HCPCS,Outpatient,,,850,425,,637.5,75,,,percent of total billed charges,75% of total billed charges,637.5,75,,,percent of total billed charges,75% of total billed charges,272,32,,,percent of total billed charges,32% of total billed charges,51.62,100,,,Fee Schedule,100% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.62,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,119,14,,,percent of total billed charges,14% of total billed charges,51.62,637.5,
95885- Needle electromyography/ea ext/lmt,3435485,CDM,510,RC,95885,HCPCS,Outpatient,,,1470,735,,1102.5,75,,,percent of total billed charges,75% of total billed charges,1102.5,75,,,percent of total billed charges,75% of total billed charges,470.4,32,,,percent of total billed charges,32% of total billed charges,41.79,100,,,Fee Schedule,100% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.79,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,205.8,14,,,percent of total billed charges,14% of total billed charges,41.79,1102.5,
95886- Needle electromyography/ea ext/com,3435486,CDM,510,RC,95886,HCPCS,Outpatient,,,1674.75,837.38,,1256.06,75,,,percent of total billed charges,75% of total billed charges,1256.06,75,,,percent of total billed charges,75% of total billed charges,535.92,32,,,percent of total billed charges,32% of total billed charges,66.12,100,,,Fee Schedule,100% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.12,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,234.47,14,,,percent of total billed charges,14% of total billed charges,66.12,1256.06,
95887- Needle electromyography/non-ext,3435487,CDM,510,RC,95887,HCPCS,Outpatient,,,1310,655,,982.5,75,,,percent of total billed charges,75% of total billed charges,982.5,75,,,percent of total billed charges,75% of total billed charges,419.2,32,,,percent of total billed charges,32% of total billed charges,57.03,100,,,Fee Schedule,100% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,57.03,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,183.4,14,,,percent of total billed charges,14% of total billed charges,57.03,982.5,
95905- Motor/sensory nerve conduction/I&R,3435490,CDM,510,RC,95905,HCPCS,Outpatient,,,1716.25,858.13,,1287.19,75,,,percent of total billed charges,75% of total billed charges,1287.19,75,,,percent of total billed charges,75% of total billed charges,354.97,100,,,Fee Schedule,100% of CMS OPPS Rate,24.33,100,,,Fee Schedule,100% of WV Medicaid Rate,585.71,165,,,Fee Schedule,165% of CMS OPPS Rate,367.9,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1019.62,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1398.33,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1751.55,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,24.33,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,354.97,100,,,Fee Schedule,100% of CMS OPPS Rate,367.9,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,240.28,14,,,percent of total billed charges,14% of total billed charges,24.33,1751.55,
95907- Nerve conduction study/1-2 study,3435491,CDM,510,RC,95907,HCPCS,Outpatient,,,661.05,330.53,,495.79,75,,,percent of total billed charges,75% of total billed charges,495.79,75,,,percent of total billed charges,75% of total billed charges,136.72,100,,,Fee Schedule,100% of CMS OPPS Rate,61.2,100,,,Fee Schedule,100% of WV Medicaid Rate,225.58,165,,,Fee Schedule,165% of CMS OPPS Rate,141.69,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,392.72,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,538.59,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,674.64,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,61.2,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,136.72,100,,,Fee Schedule,100% of CMS OPPS Rate,141.69,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,92.55,14,,,percent of total billed charges,14% of total billed charges,61.2,674.64,
95908- Nerve conduction study/3-4 study,3435492,CDM,510,RC,95908,HCPCS,Outpatient,,,1273,636.5,,954.75,75,,,percent of total billed charges,75% of total billed charges,954.75,75,,,percent of total billed charges,75% of total billed charges,263.29,100,,,Fee Schedule,100% of CMS OPPS Rate,76.2,100,,,Fee Schedule,100% of WV Medicaid Rate,434.44,165,,,Fee Schedule,165% of CMS OPPS Rate,272.88,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,756.29,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1037.2,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1299.2,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,76.2,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,263.29,100,,,Fee Schedule,100% of CMS OPPS Rate,272.88,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,178.22,14,,,percent of total billed charges,14% of total billed charges,76.2,1299.2,
95909- Nerve conduction study/5-6 study,3435493,CDM,510,RC,95909,HCPCS,Outpatient,,,1273,636.5,,954.75,75,,,percent of total billed charges,75% of total billed charges,954.75,75,,,percent of total billed charges,75% of total billed charges,263.29,100,,,Fee Schedule,100% of CMS OPPS Rate,91.93,100,,,Fee Schedule,100% of WV Medicaid Rate,434.44,165,,,Fee Schedule,165% of CMS OPPS Rate,272.88,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,756.29,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1037.2,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1299.2,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,91.93,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,263.29,100,,,Fee Schedule,100% of CMS OPPS Rate,272.88,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,178.22,14,,,percent of total billed charges,14% of total billed charges,91.93,1299.2,
95910- Nerve conduction study/7-8 study,3435494,CDM,510,RC,95910,HCPCS,Outpatient,,,1273,636.5,,954.75,75,,,percent of total billed charges,75% of total billed charges,954.75,75,,,percent of total billed charges,75% of total billed charges,263.29,100,,,Fee Schedule,100% of CMS OPPS Rate,119.95,100,,,Fee Schedule,100% of WV Medicaid Rate,434.44,165,,,Fee Schedule,165% of CMS OPPS Rate,272.88,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,756.29,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1037.2,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1299.2,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,119.95,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,263.29,100,,,Fee Schedule,100% of CMS OPPS Rate,272.88,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,178.22,14,,,percent of total billed charges,14% of total billed charges,119.95,1299.2,
95911- Nerve conduction study/9-10 study,3435495,CDM,510,RC,95911,HCPCS,Outpatient,,,2197.45,1098.73,,1648.09,75,,,percent of total billed charges,75% of total billed charges,1648.09,75,,,percent of total billed charges,75% of total billed charges,454.5,100,,,Fee Schedule,100% of CMS OPPS Rate,144.53,100,,,Fee Schedule,100% of WV Medicaid Rate,749.91,165,,,Fee Schedule,165% of CMS OPPS Rate,471.04,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1305.49,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1790.39,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,2242.64,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,144.53,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,454.5,100,,,Fee Schedule,100% of CMS OPPS Rate,471.04,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,307.64,14,,,percent of total billed charges,14% of total billed charges,144.53,2242.64,
95912- Nerve conduction study/11-12 study,3435496,CDM,510,RC,95912,HCPCS,Outpatient,,,2197.45,1098.73,,1648.09,75,,,percent of total billed charges,75% of total billed charges,1648.09,75,,,percent of total billed charges,75% of total billed charges,454.5,100,,,Fee Schedule,100% of CMS OPPS Rate,168.86,100,,,Fee Schedule,100% of WV Medicaid Rate,749.91,165,,,Fee Schedule,165% of CMS OPPS Rate,471.04,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1305.49,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1790.39,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,2242.64,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,168.86,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,454.5,100,,,Fee Schedule,100% of CMS OPPS Rate,471.04,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,307.64,14,,,percent of total billed charges,14% of total billed charges,168.86,2242.64,
95913- Nerve conduction studies/13 >,3435497,CDM,510,RC,95913,HCPCS,Outpatient,,,2197.45,1098.73,,1648.09,75,,,percent of total billed charges,75% of total billed charges,1648.09,75,,,percent of total billed charges,75% of total billed charges,454.5,100,,,Fee Schedule,100% of CMS OPPS Rate,195.41,100,,,Fee Schedule,100% of WV Medicaid Rate,749.91,165,,,Fee Schedule,165% of CMS OPPS Rate,471.04,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1305.49,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1790.39,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,2242.64,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,195.41,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,454.5,100,,,Fee Schedule,100% of CMS OPPS Rate,471.04,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,307.64,14,,,percent of total billed charges,14% of total billed charges,195.41,2242.64,
95937- Neuromuscular junc test/ea nerve,3435504,CDM,510,RC,95937,HCPCS,Outpatient,,,661.05,330.53,,495.79,75,,,percent of total billed charges,75% of total billed charges,495.79,75,,,percent of total billed charges,75% of total billed charges,136.72,100,,,Fee Schedule,100% of CMS OPPS Rate,70.05,100,,,Fee Schedule,100% of WV Medicaid Rate,225.58,165,,,Fee Schedule,165% of CMS OPPS Rate,141.69,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,392.72,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,538.59,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,674.64,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,70.05,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,136.72,100,,,Fee Schedule,100% of CMS OPPS Rate,141.69,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,92.55,14,,,percent of total billed charges,14% of total billed charges,70.05,674.64,
95970- VNS evaluation,3435519,CDM,510,RC,95970,HCPCS,Outpatient,,,527.8,263.9,,395.85,75,,,percent of total billed charges,75% of total billed charges,395.85,75,,,percent of total billed charges,75% of total billed charges,109.16,100,,,Fee Schedule,100% of CMS OPPS Rate,13.27,100,,,Fee Schedule,100% of WV Medicaid Rate,180.11,165,,,Fee Schedule,165% of CMS OPPS Rate,113.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,313.55,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,430.01,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,538.63,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,13.27,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,109.16,100,,,Fee Schedule,100% of CMS OPPS Rate,113.13,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,73.89,14,,,percent of total billed charges,14% of total billed charges,13.27,538.63,
95972- Elec Anlys Implt Npgt Cplx Sp/Pn Prgrmg,4327334,CDM,510,RC,95972,HCPCS,Outpatient,,,411.5,205.75,,308.63,75,,,percent of total billed charges,75% of total billed charges,308.63,75,,,percent of total billed charges,75% of total billed charges,93.83,100,,,Fee Schedule,100% of CMS OPPS Rate,28.76,100,,,Fee Schedule,100% of WV Medicaid Rate,154.82,165,,,Fee Schedule,165% of CMS OPPS Rate,97.24,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,269.52,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,369.64,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,463.01,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,28.76,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,93.83,100,,,Fee Schedule,100% of CMS OPPS Rate,97.24,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,57.61,14,,,percent of total billed charges,14% of total billed charges,28.76,463.01,
"95976 - (PF) Electronic analysis of implanted neurostimulator pulse generator/transmitter (eg, conta",3635243,CDM,510,RC,95976,HCPCS,Outpatient,,,1.57,0.79,,1.18,75,,,percent of total billed charges,75% of total billed charges,1.18,75,,,percent of total billed charges,75% of total billed charges,32.9,100,,,Fee Schedule,100% of CMS OPPS Rate,1.57,100,,,Fee Schedule,100% of WV Medicaid Rate,54.28,165,,,Fee Schedule,165% of CMS OPPS Rate,34.1,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,94.51,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,129.62,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,162.36,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,1.57,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,32.9,100,,,Fee Schedule,100% of CMS OPPS Rate,34.1,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,1.18,162.36,
"95976- Electronic analysis of implanted neurostimulator pulse generator/transmitter (eg, contact gro",3692914,CDM,510,RC,95976,HCPCS,Outpatient,,,159.1,79.55,,119.33,75,,,percent of total billed charges,75% of total billed charges,119.33,75,,,percent of total billed charges,75% of total billed charges,32.9,100,,,Fee Schedule,100% of CMS OPPS Rate,28.02,100,,,Fee Schedule,100% of WV Medicaid Rate,54.28,165,,,Fee Schedule,165% of CMS OPPS Rate,34.1,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,94.51,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,129.62,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,162.36,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,28.02,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,32.9,100,,,Fee Schedule,100% of CMS OPPS Rate,34.1,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,22.27,14,,,percent of total billed charges,14% of total billed charges,22.27,162.36,
"95977 - Electronic analysis of implanted neurostimulator pulse generator/transmitter (eg, contact gr",3715361,CDM,510,RC,95977,HCPCS,Outpatient,,,2.36,1.18,,1.77,75,,,percent of total billed charges,75% of total billed charges,1.77,75,,,percent of total billed charges,75% of total billed charges,93.83,100,,,Fee Schedule,100% of CMS OPPS Rate,2.36,100,,,Fee Schedule,100% of WV Medicaid Rate,154.82,165,,,Fee Schedule,165% of CMS OPPS Rate,97.24,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,269.52,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,369.64,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,463.01,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,2.36,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,93.83,100,,,Fee Schedule,100% of CMS OPPS Rate,97.24,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,1.77,463.01,
"95977-  Electronic analysis of implanted neurostimulator pulse generator/transmitter (eg, contact gr",3692915,CDM,510,RC,95977,HCPCS,Outpatient,,,453.7,226.85,,340.28,75,,,percent of total billed charges,75% of total billed charges,340.28,75,,,percent of total billed charges,75% of total billed charges,93.83,100,,,Fee Schedule,100% of CMS OPPS Rate,36.61,100,,,Fee Schedule,100% of WV Medicaid Rate,154.82,165,,,Fee Schedule,165% of CMS OPPS Rate,97.24,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,269.52,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,369.64,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,463.01,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,36.61,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,93.83,100,,,Fee Schedule,100% of CMS OPPS Rate,97.24,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,63.52,14,,,percent of total billed charges,14% of total billed charges,36.61,463.01,
95983 - Elec Anlys Implnt Brn Npgt Prgrmg 1st 15 Min,4315922,CDM,920,RC,95983,HCPCS,Outpatient,,,453.7,226.85,,340.28,75,,,percent of total billed charges,75% of total billed charges,340.28,75,,,percent of total billed charges,75% of total billed charges,93.83,100,,,Fee Schedule,100% of CMS OPPS Rate,34.9,100,,,Fee Schedule,100% of WV Medicaid Rate,154.82,165,,,Fee Schedule,165% of CMS OPPS Rate,97.24,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,269.52,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,369.64,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,463.01,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,34.9,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,93.83,100,,,Fee Schedule,100% of CMS OPPS Rate,97.24,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,63.52,14,,,percent of total billed charges,14% of total billed charges,34.9,463.01,
95984 - Elec Anlys Implnt Brn Npgt Prgrmg Ea Addl 15 Min,4315923,CDM,920,RC,95984,HCPCS,Outpatient,,,595.55,297.78,,446.66,75,,,percent of total billed charges,75% of total billed charges,446.66,75,,,percent of total billed charges,75% of total billed charges,190.58,32,,,percent of total billed charges,32% of total billed charges,30.73,100,,,Fee Schedule,100% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.73,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,83.38,14,,,percent of total billed charges,14% of total billed charges,30.73,446.66,
95992 - Epley Maneuver,3575063,CDM,510,RC,95992,HCPCS,Outpatient,,,783.95,391.98,,587.96,75,,,percent of total billed charges,75% of total billed charges,587.96,75,,,percent of total billed charges,75% of total billed charges,35.29,100,,,Fee Schedule,100% of CMS OPPS Rate,25.56,100,,,Fee Schedule,100% of WV Medicaid Rate,58.23,165,,,Fee Schedule,165% of CMS OPPS Rate,34.43,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,125.12,354.54,,,Fee Schedule,354.54% of CMS OPPS Fee Schedule Rate,151.29,428.7,,,Fee Schedule,428.7% of CMS OPPS Fee Schedule Rate,159.09,450.81,,,Fee Schedule,450.81% of CMS OPPS Fee Schedule Rate,25.56,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,35.29,100,,,Fee Schedule,100% of CMS OPPS Rate,34.43,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,109.75,14,,,percent of total billed charges,14% of total billed charges,25.56,587.96,
96156 - Health Coach Assessment,3635244,CDM,510,RC,96156,HCPCS,Outpatient,,,450.13,225.07,,337.6,75,,,percent of total billed charges,75% of total billed charges,337.6,75,,,percent of total billed charges,75% of total billed charges,71.29,100,,,Fee Schedule,100% of CMS OPPS Rate,60.96,100,,,Fee Schedule,100% of WV Medicaid Rate,117.66,165,,,Fee Schedule,165% of CMS OPPS Rate,73.9,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,204.82,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,280.89,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,351.86,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,60.96,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,71.29,100,,,Fee Schedule,100% of CMS OPPS Rate,73.9,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,63.02,14,,,percent of total billed charges,14% of total billed charges,60.96,351.86,
96158 - Health Coach Initial 30 Mins,3635247,CDM,510,RC,96158,HCPCS,Outpatient,,,805.12,402.56,,603.84,75,,,percent of total billed charges,75% of total billed charges,603.84,75,,,percent of total billed charges,75% of total billed charges,71.29,100,,,Fee Schedule,100% of CMS OPPS Rate,41.79,100,,,Fee Schedule,100% of WV Medicaid Rate,117.66,165,,,Fee Schedule,165% of CMS OPPS Rate,73.9,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,204.82,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,280.89,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,351.86,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,41.79,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,71.29,100,,,Fee Schedule,100% of CMS OPPS Rate,73.9,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,112.72,14,,,percent of total billed charges,14% of total billed charges,41.79,603.84,
96372- Subq/IM Injection,3428362,CDM,761,RC,96372,HCPCS,Outpatient,,,364.11,182.06,,273.08,75,,,percent of total billed charges,75% of total billed charges,273.08,75,,,percent of total billed charges,75% of total billed charges,63.43,100,,,Fee Schedule,100% of CMS OPPS Rate,9.59,100,,,Fee Schedule,100% of WV Medicaid Rate,104.66,165,,,Fee Schedule,165% of CMS OPPS Rate,65.74,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,182.2,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,249.87,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,312.99,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,9.59,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,63.43,100,,,Fee Schedule,100% of CMS OPPS Rate,65.74,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,50.98,14,,,percent of total billed charges,14% of total billed charges,9.59,312.99,
"96374- IV Injection, single/initial",3428364,CDM,940,RC,96374,HCPCS,Outpatient,,,1082.37,541.19,,811.78,75,,,percent of total billed charges,75% of total billed charges,811.78,75,,,percent of total billed charges,75% of total billed charges,194.2,100,,,Fee Schedule,100% of CMS OPPS Rate,25.07,100,,,Fee Schedule,100% of WV Medicaid Rate,320.44,165,,,Fee Schedule,165% of CMS OPPS Rate,201.28,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,557.84,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,765.02,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,958.27,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,25.07,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,194.2,100,,,Fee Schedule,100% of CMS OPPS Rate,201.28,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,151.53,14,,,percent of total billed charges,14% of total billed charges,25.07,958.27,
96401- Chemo admin/SQ/IM/anti-neo,3431073,CDM,331,RC,96401,HCPCS,Outpatient,,,364.11,182.06,,273.08,75,,,percent of total billed charges,75% of total billed charges,273.08,75,,,percent of total billed charges,75% of total billed charges,63.43,100,,,Fee Schedule,100% of CMS OPPS Rate,48.67,100,,,Fee Schedule,100% of WV Medicaid Rate,104.66,165,,,Fee Schedule,165% of CMS OPPS Rate,65.74,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,182.2,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,249.87,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,312.99,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,48.67,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,63.43,100,,,Fee Schedule,100% of CMS OPPS Rate,65.74,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,50.98,14,,,percent of total billed charges,14% of total billed charges,48.67,312.99,
Admin leuprolide Charge:INJ Admin Charge 96401,3444231,CDM,331,RC,96401,HCPCS,Outpatient,,,364.11,182.06,,273.08,75,,,percent of total billed charges,75% of total billed charges,273.08,75,,,percent of total billed charges,75% of total billed charges,63.43,100,,,Fee Schedule,100% of CMS OPPS Rate,48.67,100,,,Fee Schedule,100% of WV Medicaid Rate,104.66,165,,,Fee Schedule,165% of CMS OPPS Rate,65.74,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,182.2,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,249.87,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,312.99,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,48.67,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,63.43,100,,,Fee Schedule,100% of CMS OPPS Rate,65.74,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,50.98,14,,,percent of total billed charges,14% of total billed charges,48.67,312.99,
"96402 - Chemotherapy administration, subcutaneous or intramu",3918947,CDM,331,RC,96402,HCPCS,Outpatient,,,327.84,163.92,,245.88,75,,,percent of total billed charges,75% of total billed charges,245.88,75,,,percent of total billed charges,75% of total billed charges,63.43,100,,,Fee Schedule,100% of CMS OPPS Rate,21.38,100,,,Fee Schedule,100% of WV Medicaid Rate,104.66,165,,,Fee Schedule,165% of CMS OPPS Rate,65.74,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,182.2,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,249.87,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,312.99,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,21.38,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,63.43,100,,,Fee Schedule,100% of CMS OPPS Rate,65.74,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,45.9,14,,,percent of total billed charges,14% of total billed charges,21.38,312.99,
INJ Nonhormonal A/Neo 96402,4297300,CDM,331,RC,96402,HCPCS,Outpatient,,,327.84,163.92,,245.88,75,,,percent of total billed charges,75% of total billed charges,245.88,75,,,percent of total billed charges,75% of total billed charges,63.43,100,,,Fee Schedule,100% of CMS OPPS Rate,21.38,100,,,Fee Schedule,100% of WV Medicaid Rate,104.66,165,,,Fee Schedule,165% of CMS OPPS Rate,65.74,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,182.2,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,249.87,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,312.99,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,21.38,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,63.43,100,,,Fee Schedule,100% of CMS OPPS Rate,65.74,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,45.9,14,,,percent of total billed charges,14% of total billed charges,21.38,312.99,
96920 Excimer lsr psriasis<250sqcm,3431074,CDM,940,RC,96920,HCPCS,Outpatient,,,1010.98,505.49,,758.24,75,,,percent of total billed charges,75% of total billed charges,758.24,75,,,percent of total billed charges,75% of total billed charges,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,43.75,100,,,Fee Schedule,100% of WV Medicaid Rate,280.12,165,,,Fee Schedule,165% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,487.65,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,668.78,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,837.71,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,43.75,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,141.54,14,,,percent of total billed charges,14% of total billed charges,43.75,837.71,
96921- Excimer lsr psriasis 250-500,3431095,CDM,940,RC,96921,HCPCS,Outpatient,,,1010.98,505.49,,758.24,75,,,percent of total billed charges,75% of total billed charges,758.24,75,,,percent of total billed charges,75% of total billed charges,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,48.91,100,,,Fee Schedule,100% of WV Medicaid Rate,280.12,165,,,Fee Schedule,165% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,487.65,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,668.78,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,837.71,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,48.91,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,141.54,14,,,percent of total billed charges,14% of total billed charges,48.91,837.71,
97010-HOT/COLD PACKS,3430549,CDM,421,RC,97010,HCPCS,Outpatient,,,38.12,19.06,,28.59,75,,,percent of total billed charges,75% of total billed charges,28.59,75,,,percent of total billed charges,75% of total billed charges,5.95,100,,,Fee Schedule,100% of CMS OPPS Rate,3.93,100,,,Fee Schedule,100% of WV Medicaid Rate,9.82,165,,,Fee Schedule,165% of CMS OPPS Rate,5.81,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,21.1,354.54,,,Fee Schedule,354.54% of CMS OPPS Fee Schedule Rate,25.51,428.7,,,Fee Schedule,428.7% of CMS OPPS Fee Schedule Rate,26.82,450.81,,,Fee Schedule,450.81% of CMS OPPS Fee Schedule Rate,3.93,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,5.95,100,,,Fee Schedule,100% of CMS OPPS Rate,5.81,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,5.34,14,,,percent of total billed charges,14% of total billed charges,3.93,28.59,
97014 Appl Modality 1/> Areas Elec Stimj Unattended,3351852,CDM,761,RC,97014,HCPCS,Outpatient,,,205,102.5,,153.75,75,,,percent of total billed charges,75% of total billed charges,153.75,75,,,percent of total billed charges,75% of total billed charges,65.6,32,,,percent of total billed charges,32% of total billed charges,8.36,100,,,Fee Schedule,100% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.36,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.7,14,,,percent of total billed charges,14% of total billed charges,8.36,153.75,
97014-PT E-STIM UNATTENDED(WOUND),3430550,CDM,421,RC,97014,HCPCS,Outpatient,,,205,102.5,,153.75,75,,,percent of total billed charges,75% of total billed charges,153.75,75,,,percent of total billed charges,75% of total billed charges,65.6,32,,,percent of total billed charges,32% of total billed charges,8.36,100,,,Fee Schedule,100% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.36,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.7,14,,,percent of total billed charges,14% of total billed charges,8.36,153.75,
97016 Appl Modality 1/> Areas Vasopneumatic Devices,3436064,CDM,761,RC,97016,HCPCS,Outpatient,,,211,105.5,,158.25,75,,,percent of total billed charges,75% of total billed charges,158.25,75,,,percent of total billed charges,75% of total billed charges,11.19,100,,,Fee Schedule,100% of CMS OPPS Rate,8.11,100,,,Fee Schedule,100% of WV Medicaid Rate,18.46,165,,,Fee Schedule,165% of CMS OPPS Rate,10.91,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,39.67,354.54,,,Fee Schedule,354.54% of CMS OPPS Fee Schedule Rate,47.97,428.7,,,Fee Schedule,428.7% of CMS OPPS Fee Schedule Rate,50.45,450.81,,,Fee Schedule,450.81% of CMS OPPS Fee Schedule Rate,8.11,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,11.19,100,,,Fee Schedule,100% of CMS OPPS Rate,10.91,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,29.54,14,,,percent of total billed charges,14% of total billed charges,8.11,158.25,
97026 Application Modality 1/> Areas Infrared,3351933,CDM,761,RC,97026,HCPCS,Outpatient,,,31.23,15.62,,23.42,75,,,percent of total billed charges,75% of total billed charges,23.42,75,,,percent of total billed charges,75% of total billed charges,6.25,100,,,Fee Schedule,100% of CMS OPPS Rate,4.18,100,,,Fee Schedule,100% of WV Medicaid Rate,10.31,165,,,Fee Schedule,165% of CMS OPPS Rate,6.09,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,22.16,354.54,,,Fee Schedule,354.54% of CMS OPPS Fee Schedule Rate,26.79,428.7,,,Fee Schedule,428.7% of CMS OPPS Fee Schedule Rate,28.18,450.81,,,Fee Schedule,450.81% of CMS OPPS Fee Schedule Rate,4.18,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,6.25,100,,,Fee Schedule,100% of CMS OPPS Rate,6.09,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,4.37,14,,,percent of total billed charges,14% of total billed charges,4.18,28.18,
97026-INFRARED,3430551,CDM,420,RC,97026,HCPCS,Outpatient,,,31.23,15.62,,23.42,75,,,percent of total billed charges,75% of total billed charges,23.42,75,,,percent of total billed charges,75% of total billed charges,6.25,100,,,Fee Schedule,100% of CMS OPPS Rate,4.18,100,,,Fee Schedule,100% of WV Medicaid Rate,10.31,165,,,Fee Schedule,165% of CMS OPPS Rate,6.09,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,22.16,354.54,,,Fee Schedule,354.54% of CMS OPPS Fee Schedule Rate,26.79,428.7,,,Fee Schedule,428.7% of CMS OPPS Fee Schedule Rate,28.18,450.81,,,Fee Schedule,450.81% of CMS OPPS Fee Schedule Rate,4.18,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,6.25,100,,,Fee Schedule,100% of CMS OPPS Rate,6.09,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,4.37,14,,,percent of total billed charges,14% of total billed charges,4.18,28.18,
97035 Appl Modality 1/> Areas Ultrasound Ea 15 Min,3351853,CDM,761,RC,97035,HCPCS,Outpatient,,,215,107.5,,161.25,75,,,percent of total billed charges,75% of total billed charges,161.25,75,,,percent of total billed charges,75% of total billed charges,13.66,100,,,Fee Schedule,100% of CMS OPPS Rate,9.59,100,,,Fee Schedule,100% of WV Medicaid Rate,22.54,165,,,Fee Schedule,165% of CMS OPPS Rate,13.33,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,48.43,354.54,,,Fee Schedule,354.54% of CMS OPPS Fee Schedule Rate,58.56,428.7,,,Fee Schedule,428.7% of CMS OPPS Fee Schedule Rate,61.58,450.81,,,Fee Schedule,450.81% of CMS OPPS Fee Schedule Rate,9.59,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,13.66,100,,,Fee Schedule,100% of CMS OPPS Rate,13.33,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,30.1,14,,,percent of total billed charges,14% of total billed charges,9.59,161.25,
97035-PT ULTRASOUND(WOUND),3430552,CDM,420,RC,97035,HCPCS,Outpatient,,,215,107.5,,161.25,75,,,percent of total billed charges,75% of total billed charges,161.25,75,,,percent of total billed charges,75% of total billed charges,13.66,100,,,Fee Schedule,100% of CMS OPPS Rate,9.59,100,,,Fee Schedule,100% of WV Medicaid Rate,22.54,165,,,Fee Schedule,165% of CMS OPPS Rate,13.33,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,48.43,354.54,,,Fee Schedule,354.54% of CMS OPPS Fee Schedule Rate,58.56,428.7,,,Fee Schedule,428.7% of CMS OPPS Fee Schedule Rate,61.58,450.81,,,Fee Schedule,450.81% of CMS OPPS Fee Schedule Rate,9.59,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,13.66,100,,,Fee Schedule,100% of CMS OPPS Rate,13.33,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,30.1,14,,,percent of total billed charges,14% of total billed charges,9.59,161.25,
97039 Unlist Modality Spec Type&Time Constant Attend,3351932,CDM,761,RC,97039,HCPCS,Outpatient,,,164.88,82.44,,123.66,75,,,percent of total billed charges,75% of total billed charges,123.66,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.08,14,,,percent of total billed charges,14% of total billed charges,23.08,123.66,
97039-LASER/OTHER,3430553,CDM,420,RC,97039,HCPCS,Outpatient,,,164.88,82.44,,123.66,75,,,percent of total billed charges,75% of total billed charges,123.66,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.08,14,,,percent of total billed charges,14% of total billed charges,23.08,123.66,
97110 Therapeutic Px 1/> Areas Each 15 Min Exercises,3436066,CDM,761,RC,97110,HCPCS,Outpatient,,,274,137,,205.5,75,,,percent of total billed charges,75% of total billed charges,205.5,75,,,percent of total billed charges,75% of total billed charges,27.91,100,,,Fee Schedule,100% of CMS OPPS Rate,19.91,100,,,Fee Schedule,100% of WV Medicaid Rate,46.05,165,,,Fee Schedule,165% of CMS OPPS Rate,27.23,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,98.95,354.54,,,Fee Schedule,354.54% of CMS OPPS Fee Schedule Rate,119.65,428.7,,,Fee Schedule,428.7% of CMS OPPS Fee Schedule Rate,125.82,450.81,,,Fee Schedule,450.81% of CMS OPPS Fee Schedule Rate,19.91,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,27.91,100,,,Fee Schedule,100% of CMS OPPS Rate,27.23,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,38.36,14,,,percent of total billed charges,14% of total billed charges,19.91,205.5,
97112 Therapeutic Px 1/> Areas Each 15 Min Neuromusc ReEd,3984924,CDM,761,RC,97112,HCPCS,Outpatient,,,203,101.5,,152.25,75,,,percent of total billed charges,75% of total billed charges,152.25,75,,,percent of total billed charges,75% of total billed charges,31.94,100,,,Fee Schedule,100% of CMS OPPS Rate,23.11,100,,,Fee Schedule,100% of WV Medicaid Rate,52.7,165,,,Fee Schedule,165% of CMS OPPS Rate,31.16,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,113.24,354.54,,,Fee Schedule,354.54% of CMS OPPS Fee Schedule Rate,136.93,428.7,,,Fee Schedule,428.7% of CMS OPPS Fee Schedule Rate,143.99,450.81,,,Fee Schedule,450.81% of CMS OPPS Fee Schedule Rate,23.11,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,31.94,100,,,Fee Schedule,100% of CMS OPPS Rate,31.16,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,28.42,14,,,percent of total billed charges,14% of total billed charges,23.11,152.25,
97140 Manual Therapy TQS 1/> Regions Each 15 Minutes - OT,3436071,CDM,761,RC,97140,HCPCS,Outpatient,,,230,115,,172.5,75,,,percent of total billed charges,75% of total billed charges,172.5,75,,,percent of total billed charges,75% of total billed charges,25.78,100,,,Fee Schedule,100% of CMS OPPS Rate,18.44,100,,,Fee Schedule,100% of WV Medicaid Rate,42.54,165,,,Fee Schedule,165% of CMS OPPS Rate,25.15,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,91.4,354.54,,,Fee Schedule,354.54% of CMS OPPS Fee Schedule Rate,110.52,428.7,,,Fee Schedule,428.7% of CMS OPPS Fee Schedule Rate,116.22,450.81,,,Fee Schedule,450.81% of CMS OPPS Fee Schedule Rate,18.44,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,25.78,100,,,Fee Schedule,100% of CMS OPPS Rate,25.15,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,32.2,14,,,percent of total billed charges,14% of total billed charges,18.44,172.5,
97165 OT Eval Low Complex 30 Minutes,3436073,CDM,761,RC,97165,HCPCS,Outpatient,,,421.5,210.75,,316.13,75,,,percent of total billed charges,75% of total billed charges,316.13,75,,,percent of total billed charges,75% of total billed charges,95.28,100,,,Fee Schedule,100% of CMS OPPS Rate,68.81,100,,,Fee Schedule,100% of WV Medicaid Rate,157.21,165,,,Fee Schedule,165% of CMS OPPS Rate,92.96,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,337.81,354.54,,,Fee Schedule,354.54% of CMS OPPS Fee Schedule Rate,408.47,428.7,,,Fee Schedule,428.7% of CMS OPPS Fee Schedule Rate,429.53,450.81,,,Fee Schedule,450.81% of CMS OPPS Fee Schedule Rate,68.81,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,95.28,100,,,Fee Schedule,100% of CMS OPPS Rate,92.96,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,59.01,14,,,percent of total billed charges,14% of total billed charges,59.01,429.53,
97166 OT Eval Mod Complex 45 Minutes,3436074,CDM,761,RC,97166,HCPCS,Outpatient,,,446,223,,334.5,75,,,percent of total billed charges,75% of total billed charges,334.5,75,,,percent of total billed charges,75% of total billed charges,95.28,100,,,Fee Schedule,100% of CMS OPPS Rate,68.81,100,,,Fee Schedule,100% of WV Medicaid Rate,157.21,165,,,Fee Schedule,165% of CMS OPPS Rate,92.96,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,337.81,354.54,,,Fee Schedule,354.54% of CMS OPPS Fee Schedule Rate,408.47,428.7,,,Fee Schedule,428.7% of CMS OPPS Fee Schedule Rate,429.53,450.81,,,Fee Schedule,450.81% of CMS OPPS Fee Schedule Rate,68.81,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,95.28,100,,,Fee Schedule,100% of CMS OPPS Rate,92.96,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,62.44,14,,,percent of total billed charges,14% of total billed charges,62.44,429.53,
97167 OT Eval High Complex 60 Minutes,3436075,CDM,761,RC,97167,HCPCS,Outpatient,,,469.5,234.75,,352.13,75,,,percent of total billed charges,75% of total billed charges,352.13,75,,,percent of total billed charges,75% of total billed charges,95.28,100,,,Fee Schedule,100% of CMS OPPS Rate,68.81,100,,,Fee Schedule,100% of WV Medicaid Rate,157.21,165,,,Fee Schedule,165% of CMS OPPS Rate,92.96,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,337.81,354.54,,,Fee Schedule,354.54% of CMS OPPS Fee Schedule Rate,408.47,428.7,,,Fee Schedule,428.7% of CMS OPPS Fee Schedule Rate,429.53,450.81,,,Fee Schedule,450.81% of CMS OPPS Fee Schedule Rate,68.81,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,95.28,100,,,Fee Schedule,100% of CMS OPPS Rate,92.96,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,65.73,14,,,percent of total billed charges,14% of total billed charges,65.73,429.53,
97168 OT Re-Eval Est Plan Care 30 Minutes,3436076,CDM,761,RC,97168,HCPCS,Outpatient,,,307,153.5,,230.25,75,,,percent of total billed charges,75% of total billed charges,230.25,75,,,percent of total billed charges,75% of total billed charges,65.43,100,,,Fee Schedule,100% of CMS OPPS Rate,46.95,100,,,Fee Schedule,100% of WV Medicaid Rate,107.96,165,,,Fee Schedule,165% of CMS OPPS Rate,63.83,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,231.98,354.54,,,Fee Schedule,354.54% of CMS OPPS Fee Schedule Rate,280.5,428.7,,,Fee Schedule,428.7% of CMS OPPS Fee Schedule Rate,294.96,450.81,,,Fee Schedule,450.81% of CMS OPPS Fee Schedule Rate,46.95,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,65.43,100,,,Fee Schedule,100% of CMS OPPS Rate,63.83,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,42.98,14,,,percent of total billed charges,14% of total billed charges,42.98,294.96,
97530 Therapeut Activity Direct  Contact Each 15 Min,3436077,CDM,761,RC,97530,HCPCS,Outpatient,,,171.5,85.75,,128.63,75,,,percent of total billed charges,75% of total billed charges,128.63,75,,,percent of total billed charges,75% of total billed charges,34.57,100,,,Fee Schedule,100% of CMS OPPS Rate,24.83,100,,,Fee Schedule,100% of WV Medicaid Rate,57.04,165,,,Fee Schedule,165% of CMS OPPS Rate,33.73,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,122.56,354.54,,,Fee Schedule,354.54% of CMS OPPS Fee Schedule Rate,148.2,428.7,,,Fee Schedule,428.7% of CMS OPPS Fee Schedule Rate,155.85,450.81,,,Fee Schedule,450.81% of CMS OPPS Fee Schedule Rate,24.83,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,34.57,100,,,Fee Schedule,100% of CMS OPPS Rate,33.73,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,24.01,14,,,percent of total billed charges,14% of total billed charges,24.01,155.85,
97535 Self Care Mngment Training,3436078,CDM,761,RC,97535,HCPCS,Outpatient,,,174,87,,130.5,75,,,percent of total billed charges,75% of total billed charges,130.5,75,,,percent of total billed charges,75% of total billed charges,30.83,100,,,Fee Schedule,100% of CMS OPPS Rate,22.12,100,,,Fee Schedule,100% of WV Medicaid Rate,50.87,165,,,Fee Schedule,165% of CMS OPPS Rate,30.08,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,109.3,354.54,,,Fee Schedule,354.54% of CMS OPPS Fee Schedule Rate,132.17,428.7,,,Fee Schedule,428.7% of CMS OPPS Fee Schedule Rate,138.98,450.81,,,Fee Schedule,450.81% of CMS OPPS Fee Schedule Rate,22.12,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,30.83,100,,,Fee Schedule,100% of CMS OPPS Rate,30.08,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,24.36,14,,,percent of total billed charges,14% of total billed charges,22.12,138.98,
97537 Community or Work Reint Training Ea 15 Min,4305641,CDM,761,RC,97537,HCPCS,Outpatient,,,131,65.5,,98.25,75,,,percent of total billed charges,75% of total billed charges,98.25,75,,,percent of total billed charges,75% of total billed charges,30.1,100,,,Fee Schedule,100% of CMS OPPS Rate,21.63,100,,,Fee Schedule,100% of WV Medicaid Rate,49.67,165,,,Fee Schedule,165% of CMS OPPS Rate,29.36,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,106.72,354.54,,,Fee Schedule,354.54% of CMS OPPS Fee Schedule Rate,129.04,428.7,,,Fee Schedule,428.7% of CMS OPPS Fee Schedule Rate,135.69,450.81,,,Fee Schedule,450.81% of CMS OPPS Fee Schedule Rate,21.63,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,30.1,100,,,Fee Schedule,100% of CMS OPPS Rate,29.36,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,18.34,14,,,percent of total billed charges,14% of total billed charges,18.34,135.69,
97597- Debrid/select/1st 20 sq cm or less,3430558,CDM,420,RC,97597,HCPCS,Outpatient,,,1010.98,505.49,,758.24,75,,,percent of total billed charges,75% of total billed charges,758.24,75,,,percent of total billed charges,75% of total billed charges,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,25.56,100,,,Fee Schedule,100% of WV Medicaid Rate,280.12,165,,,Fee Schedule,165% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,487.65,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,668.77,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,837.71,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,25.56,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,141.54,14,,,percent of total billed charges,14% of total billed charges,25.56,837.71,
97597 Debridement Open Wound 20 Sq Cm/<,3436079,CDM,761,RC,97597,HCPCS,Outpatient,,,1010.98,505.49,,758.24,75,,,percent of total billed charges,75% of total billed charges,758.24,75,,,percent of total billed charges,75% of total billed charges,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,25.56,100,,,Fee Schedule,100% of WV Medicaid Rate,280.12,165,,,Fee Schedule,165% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,487.65,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,668.77,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,837.71,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,25.56,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,141.54,14,,,percent of total billed charges,14% of total billed charges,25.56,837.71,
"97598 - Debridement (eg, high pressure waterjet with/without suction, sharp selective debridement wi",3715362,CDM,510,RC,97598,HCPCS,Outpatient,,,354.5,177.25,,265.88,75,,,percent of total billed charges,75% of total billed charges,265.88,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,17.94,100,,,Fee Schedule,100% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.94,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.63,14,,,percent of total billed charges,14% of total billed charges,17.94,265.88,
97598 Debridement Open Wound Each Addtl 20 Sq Cm,3436082,CDM,761,RC,97598,HCPCS,Outpatient,,,354.5,177.25,,265.88,75,,,percent of total billed charges,75% of total billed charges,265.88,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,17.94,100,,,Fee Schedule,100% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.94,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.63,14,,,percent of total billed charges,14% of total billed charges,17.94,265.88,
"97602 -Removal of devitalized tissue from wound(s), non-selective debridement, without anesthesia (e",3641199,CDM,510,RC,97602,HCPCS,Outpatient,,,1010.98,505.49,,758.24,75,,,percent of total billed charges,75% of total billed charges,758.24,75,,,percent of total billed charges,75% of total billed charges,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,280.12,165,,,Fee Schedule,165% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,487.65,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,668.78,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,837.71,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,141.54,14,,,percent of total billed charges,14% of total billed charges,141.54,837.71,
97602 Rmvl Devital Tiss N-Slctv Dbrdmt W/O Anes 1 Sess,3436083,CDM,761,RC,97602,HCPCS,Outpatient,,,1010.98,505.49,,758.24,75,,,percent of total billed charges,75% of total billed charges,758.24,75,,,percent of total billed charges,75% of total billed charges,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,280.12,165,,,Fee Schedule,165% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,487.65,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,668.78,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,837.71,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,141.54,14,,,percent of total billed charges,14% of total billed charges,141.54,837.71,
97605 Negative Pressure Wound Therapy DME <=50 Sq Cm,3436085,CDM,761,RC,97605,HCPCS,Outpatient,,,1010.98,505.49,,758.24,75,,,percent of total billed charges,75% of total billed charges,758.24,75,,,percent of total billed charges,75% of total billed charges,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,17.45,100,,,Fee Schedule,100% of WV Medicaid Rate,280.12,165,,,Fee Schedule,165% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,487.65,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,668.78,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,837.71,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,17.45,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,169.77,100,,,Fee Schedule,100% of CMS OPPS Rate,175.95,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,141.54,14,,,percent of total billed charges,14% of total billed charges,17.45,837.71,
97606- Neg press wound therapy/>50 sq cm,3430560,CDM,510,RC,97606,HCPCS,Outpatient,,,2013.58,1006.79,,1510.19,75,,,percent of total billed charges,75% of total billed charges,1510.19,75,,,percent of total billed charges,75% of total billed charges,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,18.93,100,,,Fee Schedule,100% of WV Medicaid Rate,578.73,165,,,Fee Schedule,165% of CMS OPPS Rate,363.52,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1007.47,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1381.67,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1730.68,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,18.93,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,363.52,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,281.9,14,,,percent of total billed charges,14% of total billed charges,18.93,1730.68,
97606 Negative Pressure Wound Therapy DME >50 Sq Cm,3436088,CDM,761,RC,97606,HCPCS,Outpatient,,,2013.58,1006.79,,1510.19,75,,,percent of total billed charges,75% of total billed charges,1510.19,75,,,percent of total billed charges,75% of total billed charges,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,18.93,100,,,Fee Schedule,100% of WV Medicaid Rate,578.73,165,,,Fee Schedule,165% of CMS OPPS Rate,363.52,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1007.47,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1381.67,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1730.68,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,18.93,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,363.52,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,281.9,14,,,percent of total billed charges,14% of total billed charges,18.93,1730.68,
97607 Negative Pressure Wound Therapy Non DME <=50 Sq Cm,3351838,CDM,761,RC,97607,HCPCS,Outpatient,,,2013.58,1006.79,,1510.19,75,,,percent of total billed charges,75% of total billed charges,1510.19,75,,,percent of total billed charges,75% of total billed charges,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,16.22,100,,,Fee Schedule,100% of WV Medicaid Rate,578.72,165,,,Fee Schedule,165% of CMS OPPS Rate,363.51,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1007.47,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1381.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1730.67,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,16.22,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,363.51,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,281.9,14,,,percent of total billed charges,14% of total billed charges,16.22,1730.67,
97608 Negative Pressure Wound Therapy Non DME >50 Sq Cm,3351843,CDM,761,RC,97608,HCPCS,Outpatient,,,2013.58,1006.79,,1510.19,75,,,percent of total billed charges,75% of total billed charges,1510.19,75,,,percent of total billed charges,75% of total billed charges,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,17.94,100,,,Fee Schedule,100% of WV Medicaid Rate,578.72,165,,,Fee Schedule,165% of CMS OPPS Rate,363.51,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1007.47,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1381.66,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1730.67,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,17.94,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,350.74,100,,,Fee Schedule,100% of CMS OPPS Rate,363.51,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,281.9,14,,,percent of total billed charges,14% of total billed charges,17.94,1730.67,
97750 Physical Perf Test/Meas w/ Reprt Ea 15 Min,4305640,CDM,761,RC,97750,HCPCS,Outpatient,,,237,118.5,,177.75,75,,,percent of total billed charges,75% of total billed charges,177.75,75,,,percent of total billed charges,75% of total billed charges,31.7,100,,,Fee Schedule,100% of CMS OPPS Rate,22.61,100,,,Fee Schedule,100% of WV Medicaid Rate,52.31,165,,,Fee Schedule,165% of CMS OPPS Rate,30.93,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,112.39,354.54,,,Fee Schedule,354.54% of CMS OPPS Fee Schedule Rate,135.9,428.7,,,Fee Schedule,428.7% of CMS OPPS Fee Schedule Rate,142.91,450.81,,,Fee Schedule,450.81% of CMS OPPS Fee Schedule Rate,22.61,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,31.7,100,,,Fee Schedule,100% of CMS OPPS Rate,30.93,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,33.18,14,,,percent of total billed charges,14% of total billed charges,22.61,177.75,
97760 Orthotics Mgmt & Traing Initial Enctr Ea 15 Mins,3436091,CDM,761,RC,97760,HCPCS,Outpatient,,,213,106.5,,159.75,75,,,percent of total billed charges,75% of total billed charges,159.75,75,,,percent of total billed charges,75% of total billed charges,44.76,100,,,Fee Schedule,100% of CMS OPPS Rate,32.2,100,,,Fee Schedule,100% of WV Medicaid Rate,73.85,165,,,Fee Schedule,165% of CMS OPPS Rate,43.67,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,158.69,354.54,,,Fee Schedule,354.54% of CMS OPPS Fee Schedule Rate,191.89,428.7,,,Fee Schedule,428.7% of CMS OPPS Fee Schedule Rate,201.78,450.81,,,Fee Schedule,450.81% of CMS OPPS Fee Schedule Rate,32.2,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,44.76,100,,,Fee Schedule,100% of CMS OPPS Rate,43.67,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,29.82,14,,,percent of total billed charges,14% of total billed charges,29.82,201.78,
97763 Orthotics/Prosth Mgmt & Traing Sbsq Enctr 15 Min,3436092,CDM,761,RC,97763,HCPCS,Outpatient,,,193.5,96.75,,145.13,75,,,percent of total billed charges,75% of total billed charges,145.13,75,,,percent of total billed charges,75% of total billed charges,48.75,100,,,Fee Schedule,100% of CMS OPPS Rate,35.4,100,,,Fee Schedule,100% of WV Medicaid Rate,80.44,165,,,Fee Schedule,165% of CMS OPPS Rate,47.56,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,172.84,354.54,,,Fee Schedule,354.54% of CMS OPPS Fee Schedule Rate,208.99,428.7,,,Fee Schedule,428.7% of CMS OPPS Fee Schedule Rate,219.77,450.81,,,Fee Schedule,450.81% of CMS OPPS Fee Schedule Rate,35.4,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,48.75,100,,,Fee Schedule,100% of CMS OPPS Rate,47.56,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,27.09,14,,,percent of total billed charges,14% of total billed charges,27.09,219.77,
98925 Osteopathic Manipulations 1-2 body regions,3438184,CDM,510,RC,98925,HCPCS,Outpatient,,,17.89,8.95,,13.42,75,,,percent of total billed charges,75% of total billed charges,13.42,75,,,percent of total billed charges,75% of total billed charges,23.48,100,,,Fee Schedule,100% of CMS OPPS Rate,16.47,100,,,Fee Schedule,100% of WV Medicaid Rate,38.75,165,,,Fee Schedule,165% of CMS OPPS Rate,24.34,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,67.45,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,92.51,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,115.88,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,16.47,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,23.48,100,,,Fee Schedule,100% of CMS OPPS Rate,24.34,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,2.5,14,,,percent of total billed charges,14% of total billed charges,2.5,115.88,
98925 Osteopathic manipulative treatment (OMT); 1-2 body regions involved,3620985,CDM,510,RC,98925,HCPCS,Outpatient,,,18.96,9.48,,14.22,75,,,percent of total billed charges,75% of total billed charges,14.22,75,,,percent of total billed charges,75% of total billed charges,23.48,100,,,Fee Schedule,100% of CMS OPPS Rate,16.47,100,,,Fee Schedule,100% of WV Medicaid Rate,38.75,165,,,Fee Schedule,165% of CMS OPPS Rate,24.34,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,67.45,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,92.51,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,115.88,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,16.47,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,23.48,100,,,Fee Schedule,100% of CMS OPPS Rate,24.34,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,2.65,14,,,percent of total billed charges,14% of total billed charges,2.65,115.88,
98926 Osteopathic Manipulations 3-4 body regions,3438185,CDM,761,RC,98926,HCPCS,Outpatient,,,27.51,13.76,,20.63,75,,,percent of total billed charges,75% of total billed charges,20.63,75,,,percent of total billed charges,75% of total billed charges,23.48,100,,,Fee Schedule,100% of CMS OPPS Rate,24.58,100,,,Fee Schedule,100% of WV Medicaid Rate,38.75,165,,,Fee Schedule,165% of CMS OPPS Rate,24.34,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,67.45,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,92.51,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,115.88,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,24.58,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,23.48,100,,,Fee Schedule,100% of CMS OPPS Rate,24.34,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,3.85,14,,,percent of total billed charges,14% of total billed charges,3.85,115.88,
98927 Osteopathic Manipulations 5-6 body regions,3438186,CDM,510,RC,98927,HCPCS,Outpatient,,,26.06,13.03,,19.55,75,,,percent of total billed charges,75% of total billed charges,19.55,75,,,percent of total billed charges,75% of total billed charges,23.48,100,,,Fee Schedule,100% of CMS OPPS Rate,26.06,100,,,Fee Schedule,100% of WV Medicaid Rate,38.75,165,,,Fee Schedule,165% of CMS OPPS Rate,24.34,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,67.45,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,92.51,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,115.88,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,26.06,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,23.48,100,,,Fee Schedule,100% of CMS OPPS Rate,24.34,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,3.65,14,,,percent of total billed charges,14% of total billed charges,3.65,115.88,
98927 Osteopathic manipulative treatment (OMT); 5-6 body regions involved,3621071,CDM,510,RC,98927,HCPCS,Outpatient,,,27.62,13.81,,20.72,75,,,percent of total billed charges,75% of total billed charges,20.72,75,,,percent of total billed charges,75% of total billed charges,23.48,100,,,Fee Schedule,100% of CMS OPPS Rate,27.62,100,,,Fee Schedule,100% of WV Medicaid Rate,38.75,165,,,Fee Schedule,165% of CMS OPPS Rate,24.34,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,67.45,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,92.51,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,115.88,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,27.62,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,23.48,100,,,Fee Schedule,100% of CMS OPPS Rate,24.34,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,3.87,14,,,percent of total billed charges,14% of total billed charges,3.87,115.88,
98928 Osteopathic Manipulations  7-8 body regions,3438187,CDM,510,RC,98928,HCPCS,Outpatient,,,28.3,14.15,,21.23,75,,,percent of total billed charges,75% of total billed charges,21.23,75,,,percent of total billed charges,75% of total billed charges,23.48,100,,,Fee Schedule,100% of CMS OPPS Rate,28.3,100,,,Fee Schedule,100% of WV Medicaid Rate,38.75,165,,,Fee Schedule,165% of CMS OPPS Rate,24.34,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,67.45,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,92.51,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,115.88,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,28.3,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,23.48,100,,,Fee Schedule,100% of CMS OPPS Rate,24.34,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,3.96,14,,,percent of total billed charges,14% of total billed charges,3.96,115.88,
98928 Osteopathic manipulative treatment (OMT); 7-8 body regions involved,3621072,CDM,510,RC,98928,HCPCS,Outpatient,,,30,15,,22.5,75,,,percent of total billed charges,75% of total billed charges,22.5,75,,,percent of total billed charges,75% of total billed charges,23.48,100,,,Fee Schedule,100% of CMS OPPS Rate,30,100,,,Fee Schedule,100% of WV Medicaid Rate,38.75,165,,,Fee Schedule,165% of CMS OPPS Rate,24.34,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,67.45,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,92.51,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,115.88,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,30,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,23.48,100,,,Fee Schedule,100% of CMS OPPS Rate,24.34,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4.2,14,,,percent of total billed charges,14% of total billed charges,4.2,115.88,
98929 Osteopathic Manipulations 9-10 body regions,3438188,CDM,510,RC,98929,HCPCS,Outpatient,,,31.28,15.64,,23.46,75,,,percent of total billed charges,75% of total billed charges,23.46,75,,,percent of total billed charges,75% of total billed charges,23.48,100,,,Fee Schedule,100% of CMS OPPS Rate,31.28,100,,,Fee Schedule,100% of WV Medicaid Rate,38.75,165,,,Fee Schedule,165% of CMS OPPS Rate,24.34,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,67.45,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,92.51,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,115.88,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,31.28,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,23.48,100,,,Fee Schedule,100% of CMS OPPS Rate,24.34,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,4.38,14,,,percent of total billed charges,14% of total billed charges,4.38,115.88,
98960 - Education Training for self-mgmt,4323185,CDM,761,RC,98960,HCPCS,Outpatient,,,165,82.5,,123.75,75,,,percent of total billed charges,75% of total billed charges,123.75,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,18.19,100,,,Fee Schedule,100% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.19,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.1,14,,,percent of total billed charges,14% of total billed charges,18.19,123.75,
99152 - MOD SED SAME PHYS/QHP 5/>YRS,3997219,CDM,370,RC,99152,HCPCS,Outpatient,,,89.99,45,,67.49,75,,,percent of total billed charges,75% of total billed charges,67.49,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,9.09,100,,,Fee Schedule,100% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.09,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.6,14,,,percent of total billed charges,14% of total billed charges,9.09,67.49,
99183 Phys/QHP Attn&Supvj Hyprbaric Oxygen Tx/Session,3436093,CDM,761,RC,99183,HCPCS,Outpatient,,,216,108,,162,75,,,percent of total billed charges,75% of total billed charges,162,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,75.7,100,,,Fee Schedule,100% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,75.7,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.24,14,,,percent of total billed charges,14% of total billed charges,30.24,162,
99202 Office Outpt visist new StrFrwd or 15 to 29 mins,3572774,CDM,510,RC,99202,HCPCS,Outpatient,,,238.27,119.14,,178.7,75,,,percent of total billed charges,75% of total billed charges,178.7,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,34.17,100,,,Fee Schedule,100% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.17,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.36,14,,,percent of total billed charges,14% of total billed charges,33.36,178.7,
99202 Office/OP New SF MDM 15-29 Minutes,3438254,CDM,761,RC,99202,HCPCS,Outpatient,,,238.27,119.14,,178.7,75,,,percent of total billed charges,75% of total billed charges,178.7,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,34.17,100,,,Fee Schedule,100% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.17,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.36,14,,,percent of total billed charges,14% of total billed charges,33.36,178.7,
99203 Office OP New Low MDM 30-44 Minutes,3436094,CDM,761,RC,99203,HCPCS,Outpatient,,,238.27,119.14,,178.7,75,,,percent of total billed charges,75% of total billed charges,178.7,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,58.25,100,,,Fee Schedule,100% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,58.25,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.36,14,,,percent of total billed charges,14% of total billed charges,33.36,178.7,
99203 Office Outpt visit new Low or 30 to 44 mins,3572775,CDM,510,RC,99203,HCPCS,Outpatient,,,238.27,119.14,,178.7,75,,,percent of total billed charges,75% of total billed charges,178.7,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,58.25,100,,,Fee Schedule,100% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,58.25,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.36,14,,,percent of total billed charges,14% of total billed charges,33.36,178.7,
99204 Office Outpt visit new Mod or 45 to 59 mins,3572776,CDM,510,RC,99204,HCPCS,Outpatient,,,238.27,119.14,,178.7,75,,,percent of total billed charges,75% of total billed charges,178.7,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,94.39,100,,,Fee Schedule,100% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,94.39,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.36,14,,,percent of total billed charges,14% of total billed charges,33.36,178.7,
99204 Office/OP New Moderate MDM 45-59 Minutes,3984931,CDM,761,RC,99204,HCPCS,Outpatient,,,238.27,119.14,,178.7,75,,,percent of total billed charges,75% of total billed charges,178.7,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,94.39,100,,,Fee Schedule,100% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,94.39,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.36,14,,,percent of total billed charges,14% of total billed charges,33.36,178.7,
99205 Office Outpt visist new High 60 to 74 mins,3572777,CDM,510,RC,99205,HCPCS,Outpatient,,,238.27,119.14,,178.7,75,,,percent of total billed charges,75% of total billed charges,178.7,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,127.82,100,,,Fee Schedule,100% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,127.82,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.36,14,,,percent of total billed charges,14% of total billed charges,33.36,178.7,
99205 Office/OP New High MDM 60-74 Minutes,3436095,CDM,761,RC,99205,HCPCS,Outpatient,,,238.27,119.14,,178.7,75,,,percent of total billed charges,75% of total billed charges,178.7,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,127.82,100,,,Fee Schedule,100% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,127.82,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.36,14,,,percent of total billed charges,14% of total billed charges,33.36,178.7,
99211 Office outpatient visit est  nursing visit only,3572778,CDM,510,RC,99211,HCPCS,Outpatient,,,238.27,119.14,,178.7,75,,,percent of total billed charges,75% of total billed charges,178.7,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.36,14,,,percent of total billed charges,14% of total billed charges,33.36,178.7,
99211 Office/OP Established  May Not Rqr Phys/QHP,3441817,CDM,761,RC,99211,HCPCS,Outpatient,,,238.27,119.14,,178.7,75,,,percent of total billed charges,75% of total billed charges,178.7,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.36,14,,,percent of total billed charges,14% of total billed charges,33.36,178.7,
99212 Office Outpt visit est Strtforward or 10 to 19 mins,3572779,CDM,510,RC,99212,HCPCS,Outpatient,,,238.27,119.14,,178.7,75,,,percent of total billed charges,75% of total billed charges,178.7,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.36,14,,,percent of total billed charges,14% of total billed charges,33.36,178.7,
99212 Office/OP Established SF MDM 10-19 Min,3435838,CDM,761,RC,99212,HCPCS,Outpatient,,,238.27,119.14,,178.7,75,,,percent of total billed charges,75% of total billed charges,178.7,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.36,14,,,percent of total billed charges,14% of total billed charges,33.36,178.7,
99213- Office/OP Est SF 20 Minutes,3572780,CDM,510,RC,99213,HCPCS,Outpatient,,,238.27,119.14,,178.7,75,,,percent of total billed charges,75% of total billed charges,178.7,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.36,14,,,percent of total billed charges,14% of total billed charges,33.36,178.7,
99213 Office/OP Established  Low MDM 20-29 Min,3436097,CDM,761,RC,99213,HCPCS,Outpatient,,,266.67,133.34,,200,75,,,percent of total billed charges,75% of total billed charges,200,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.33,14,,,percent of total billed charges,14% of total billed charges,37.33,200,
99214- Office/OP Est Mod 30 Minutes,3572781,CDM,510,RC,99214,HCPCS,Outpatient,,,238.27,119.14,,178.7,75,,,percent of total billed charges,75% of total billed charges,178.7,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.36,14,,,percent of total billed charges,14% of total billed charges,33.36,178.7,
99214 Office/OP Established Mod MDM 30-39 Min,3436098,CDM,761,RC,99214,HCPCS,Outpatient,,,238.27,119.14,,178.7,75,,,percent of total billed charges,75% of total billed charges,178.7,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.36,14,,,percent of total billed charges,14% of total billed charges,33.36,178.7,
99214-EST PATIENT LEVEL 4 (30-39 min),3537583,CDM,510,RC,99214,HCPCS,Outpatient,,,238.27,119.14,,178.7,75,,,percent of total billed charges,75% of total billed charges,178.7,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.36,14,,,percent of total billed charges,14% of total billed charges,33.36,178.7,
99214-Office outpatient visit est Moderate or 30 39 minutes,4223209,CDM,510,RC,99214,HCPCS,Outpatient,,,238.27,119.14,,178.7,75,,,percent of total billed charges,75% of total billed charges,178.7,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.36,14,,,percent of total billed charges,14% of total billed charges,33.36,178.7,
99215 Office Outpatient visit est High or 40 to 54 minutes,3572782,CDM,510,RC,99215,HCPCS,Outpatient,,,238.27,119.14,,178.7,75,,,percent of total billed charges,75% of total billed charges,178.7,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.36,14,,,percent of total billed charges,14% of total billed charges,33.36,178.7,
99215 Office/OP Established High MDM 40-54 Min,3436099,CDM,761,RC,99215,HCPCS,Outpatient,,,238.27,119.14,,178.7,75,,,percent of total billed charges,75% of total billed charges,178.7,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.36,14,,,percent of total billed charges,14% of total billed charges,33.36,178.7,
99244-Office Consult New/Est PT Mod MDM Level 4 (40 min),4355203,CDM,761,RC,99244,HCPCS,Outpatient,,,238.27,119.14,,178.7,75,,,percent of total billed charges,75% of total billed charges,178.7,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,105.69,100,,,Fee Schedule,100% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,105.69,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.36,14,,,percent of total billed charges,14% of total billed charges,33.36,178.7,
99245-Office Consult New/Est PT High MDM Level 5 (55 min),4355205,CDM,761,RC,99245,HCPCS,Outpatient,,,238.27,119.14,,178.7,75,,,percent of total billed charges,75% of total billed charges,178.7,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,130.77,100,,,Fee Schedule,100% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,130.77,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.36,14,,,percent of total billed charges,14% of total billed charges,33.36,178.7,
99253- Initl IP/OBV Consult New/Est Pt Low MDM (45 min),3437947,CDM,510,RC,99253,HCPCS,Outpatient,,,358.4,179.2,,268.8,75,,,percent of total billed charges,75% of total billed charges,268.8,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,79.39,100,,,Fee Schedule,100% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,79.39,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50.18,14,,,percent of total billed charges,14% of total billed charges,50.18,268.8,
99291- Critical care first hour,3437957,CDM,983,RC,99291,HCPCS,Outpatient,,,136.33,68.17,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
99292- Critical care addl 30 min,3437958,CDM,983,RC,99292,HCPCS,Outpatient,,,28.3,14.15,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
99406 Tobacco Counseling (as part of MWV),3428377,CDM,983,RC,99406,HCPCS,Outpatient,,,7.45,3.73,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
99406- Tobacco Use Cessation Intermediate 3-10 Minutes,3438055,CDM,983,RC,99406,HCPCS,Outpatient,,,7.45,3.73,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
99406-BEHAV CHNG SMOKING 3-10 MIN,3400474,CDM,510,RC,99406,HCPCS,Outpatient,,,148.4,74.2,,111.3,75,,,percent of total billed charges,75% of total billed charges,111.3,75,,,percent of total billed charges,75% of total billed charges,27.89,100,,,Fee Schedule,100% of CMS OPPS Rate,8.36,100,,,Fee Schedule,100% of WV Medicaid Rate,46.03,165,,,Fee Schedule,165% of CMS OPPS Rate,28.91,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,80.14,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,109.91,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,137.68,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,8.36,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,27.89,100,,,Fee Schedule,100% of CMS OPPS Rate,28.91,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,20.78,14,,,percent of total billed charges,14% of total billed charges,8.36,137.68,
99407- Behav chng smoking > 10 min,3438056,CDM,983,RC,99407,HCPCS,Outpatient,,,6.7,3.35,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
99407- Tobacco Use Cessation Intensive >10 Minutes,3438057,CDM,983,RC,99407,HCPCS,Outpatient,,,6.7,3.35,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
99407-BEHAV CHNG SMOKING > 10 MIN,3537585,CDM,983,RC,99407,HCPCS,Outpatient,,,7.1,3.55,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
99441 Phone E/M Phys/QHP 5-10 Min,3991169,CDM,761,RC,99441,HCPCS,Outpatient,,,140.2,70.1,,105.15,75,,,percent of total billed charges,75% of total billed charges,105.15,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,24.83,100,,,Fee Schedule,100% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.83,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.63,14,,,percent of total billed charges,14% of total billed charges,19.63,105.15,
99442 Phone E/M Phys/QHP 11-20 Min,3991175,CDM,761,RC,99442,HCPCS,Outpatient,,,140.2,70.1,,105.15,75,,,percent of total billed charges,75% of total billed charges,105.15,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,46.21,100,,,Fee Schedule,100% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.21,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.63,14,,,percent of total billed charges,14% of total billed charges,19.63,105.15,
99443 Phone E/M Phys/QHP 21-30 Min,3993118,CDM,761,RC,99443,HCPCS,Outpatient,,,324.95,162.48,,243.71,75,,,percent of total billed charges,75% of total billed charges,243.71,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,67.84,100,,,Fee Schedule,100% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.84,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.49,14,,,percent of total billed charges,14% of total billed charges,45.49,243.71,
99495- Trans care mgmt 14 day disch,3438135,CDM,510,RC,99495,HCPCS,Outpatient,,,138.57,69.29,,103.93,75,,,percent of total billed charges,75% of total billed charges,103.93,75,,,percent of total billed charges,75% of total billed charges,113.62,100,,,Fee Schedule,100% of CMS OPPS Rate,99.55,100,,,Fee Schedule,100% of WV Medicaid Rate,187.47,165,,,Fee Schedule,165% of CMS OPPS Rate,117.76,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,326.38,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,447.6,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,560.66,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,99.55,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,113.62,100,,,Fee Schedule,100% of CMS OPPS Rate,117.76,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,19.4,14,,,percent of total billed charges,14% of total billed charges,19.4,560.66,
99496- Trans care mgmt 7 day disch,3438136,CDM,510,RC,99496,HCPCS,Outpatient,,,184.72,92.36,,138.54,75,,,percent of total billed charges,75% of total billed charges,138.54,75,,,percent of total billed charges,75% of total billed charges,113.62,100,,,Fee Schedule,100% of CMS OPPS Rate,134.69,100,,,Fee Schedule,100% of WV Medicaid Rate,187.47,165,,,Fee Schedule,165% of CMS OPPS Rate,117.76,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,326.38,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,447.6,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,560.66,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,134.69,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,113.62,100,,,Fee Schedule,100% of CMS OPPS Rate,117.76,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,25.86,14,,,percent of total billed charges,14% of total billed charges,25.86,560.66,
99497 Advanced Directives Counseling (as part of MWV),3428378,CDM,983,RC,99497,HCPCS,Outpatient,,,16.39,8.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
99498 - Advanced care plan addl 30 min,3678905,CDM,983,RC,99498,HCPCS,Outpatient,,,1.48,0.74,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
0094A - ADM SARSCOV2 50MCG/0.5 MLBST,4113121,CDM,771,RC,0094A,HCPCS,Outpatient,,,96.62,48.31,,72.47,75,,,percent of total billed charges,75% of total billed charges,72.47,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.53,14,,,percent of total billed charges,14% of total billed charges,13.53,72.47,
A4465- Circ Aid Reduction Kit,3726897,CDM,279,RC,A4465,HCPCS,Outpatient,,,1296.9,648.45,,972.68,75,,,percent of total billed charges,75% of total billed charges,972.68,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,181.57,14,,,percent of total billed charges,14% of total billed charges,181.57,972.68,
A4648-IMPLANTABLE TISSUE MARKER,3435845,CDM,278,RC,A4648,HCPCS,Outpatient,,,884.8,442.4,,663.6,75,,,percent of total billed charges,75% of total billed charges,663.6,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,123.87,14,,,percent of total billed charges,14% of total billed charges,123.87,663.6,
Fiducial Marker - Gold - Pelvic,3880988,CDM,278,RC,A4648,HCPCS,Outpatient,,,884.8,442.4,,663.6,75,,,percent of total billed charges,75% of total billed charges,663.6,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,123.87,14,,,percent of total billed charges,14% of total billed charges,123.87,663.6,
A6021-PRISMA 4.34 IN SQUARED,3436110,CDM,279,RC,A6021,HCPCS,Outpatient,,,90.63,45.32,,67.97,75,,,percent of total billed charges,75% of total billed charges,67.97,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.69,14,,,percent of total billed charges,14% of total billed charges,12.69,67.97,
A6021-PROMOGRAN 4.23 IN SQUARED,3436111,CDM,279,RC,A6021,HCPCS,Outpatient,,,76.84,38.42,,57.63,75,,,percent of total billed charges,75% of total billed charges,57.63,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.76,14,,,percent of total billed charges,14% of total billed charges,10.76,57.63,
A6196-ALGINATE AG TEGADERM < 16 SQ IN,3436112,CDM,279,RC,A6196,HCPCS,Outpatient,,,23.24,11.62,,17.43,75,,,percent of total billed charges,75% of total billed charges,17.43,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,7.35,102,,,Fee Schedule,102% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.21,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.25,14,,,percent of total billed charges,14% of total billed charges,3.25,17.43,
A6196-ALGISITE M CALCIUM ALG. 3/4X12IN,3436114,CDM,279,RC,A6196,HCPCS,Outpatient,,,34.16,17.08,,25.62,75,,,percent of total billed charges,75% of total billed charges,25.62,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,7.35,102,,,Fee Schedule,102% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.21,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.78,14,,,percent of total billed charges,14% of total billed charges,4.78,25.62,
A6196-CALCIUM ALGINATE 4X4IN,3436115,CDM,279,RC,A6196,HCPCS,Outpatient,,,23.24,11.62,,17.43,75,,,percent of total billed charges,75% of total billed charges,17.43,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,7.35,102,,,Fee Schedule,102% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.21,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.25,14,,,percent of total billed charges,14% of total billed charges,3.25,17.43,
A6196-DRAWTEX 4X4IN,3436116,CDM,279,RC,A6196,HCPCS,Outpatient,,,85.5,42.75,,64.13,75,,,percent of total billed charges,75% of total billed charges,64.13,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,7.35,102,,,Fee Schedule,102% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.21,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.97,14,,,percent of total billed charges,14% of total billed charges,7.21,64.13,
A6197-AQUACEL  4X5IN,3436118,CDM,279,RC,A6197,HCPCS,Outpatient,,,35.98,17.99,,26.99,75,,,percent of total billed charges,75% of total billed charges,26.99,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,16.42,102,,,Fee Schedule,102% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.1,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.04,14,,,percent of total billed charges,14% of total billed charges,5.04,26.99,
A6197-SILVERCEL 4.25X4.25IN,3436120,CDM,279,RC,A6197,HCPCS,Outpatient,,,63.62,31.81,,47.72,75,,,percent of total billed charges,75% of total billed charges,47.72,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,16.42,102,,,Fee Schedule,102% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.1,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.91,14,,,percent of total billed charges,14% of total billed charges,8.91,47.72,
A6206-MEPITEL ONE 3X4IN,3436121,CDM,279,RC,A6206,HCPCS,Outpatient,,,44.41,22.21,,33.31,75,,,percent of total billed charges,75% of total billed charges,33.31,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,5.46,102,,,Fee Schedule,102% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.35,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.22,14,,,percent of total billed charges,14% of total billed charges,5.35,33.31,
A6206-WOUND VEIL,3436122,CDM,279,RC,A6206,HCPCS,Outpatient,,,5.65,2.83,,4.24,75,,,percent of total billed charges,75% of total billed charges,4.24,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,5.46,102,,,Fee Schedule,102% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.35,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.24,5.46,
A6206-XEROFORM 1X8IN,3436123,CDM,279,RC,A6206,HCPCS,Outpatient,,,3.73,1.87,,2.8,75,,,percent of total billed charges,75% of total billed charges,2.8,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,5.46,102,,,Fee Schedule,102% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.35,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.8,5.46,
A6207-XEROFORM 5X9IN,3436124,CDM,279,RC,A6207,HCPCS,Outpatient,,,5.2,2.6,,3.9,75,,,percent of total billed charges,75% of total billed charges,3.9,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,7.33,102,,,Fee Schedule,102% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.19,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.9,7.33,
A6209-ALLEVYN 4X4IN,3436125,CDM,279,RC,A6209,HCPCS,Outpatient,,,25.13,12.57,,18.85,75,,,percent of total billed charges,75% of total billed charges,18.85,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,7.46,102,,,Fee Schedule,102% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.31,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.52,14,,,percent of total billed charges,14% of total billed charges,3.52,18.85,
A6209-ALLEVYN HEEL 4 1/8X5 1/16IN,3436126,CDM,279,RC,A6209,HCPCS,Outpatient,,,74.58,37.29,,55.94,75,,,percent of total billed charges,75% of total billed charges,55.94,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,7.46,102,,,Fee Schedule,102% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.31,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.44,14,,,percent of total billed charges,14% of total billed charges,7.31,55.94,
A6222-THERAHONEY SHEET 4X5IN,3436127,CDM,279,RC,A6222,HCPCS,Outpatient,,,68.59,34.3,,51.44,75,,,percent of total billed charges,75% of total billed charges,51.44,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,2.13,102,,,Fee Schedule,102% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.09,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.6,14,,,percent of total billed charges,14% of total billed charges,2.09,51.44,
A6234-DUODERM XTHIN 4X4IN,3436128,CDM,279,RC,A6234,HCPCS,Outpatient,,,111.37,55.69,,83.53,75,,,percent of total billed charges,75% of total billed charges,83.53,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,6.54,102,,,Fee Schedule,102% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.41,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.59,14,,,percent of total billed charges,14% of total billed charges,6.41,83.53,
A6252-EXUDRY 4X6IN,3436130,CDM,279,RC,A6252,HCPCS,Outpatient,,,14.69,7.35,,11.02,75,,,percent of total billed charges,75% of total billed charges,11.02,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,3.24,102,,,Fee Schedule,102% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.18,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.06,14,,,percent of total billed charges,14% of total billed charges,2.06,11.02,
A6252-EXUDRY 6X9IN,3436131,CDM,279,RC,A6252,HCPCS,Outpatient,,,20.57,10.29,,15.43,75,,,percent of total billed charges,75% of total billed charges,15.43,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,3.24,102,,,Fee Schedule,102% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.18,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.88,14,,,percent of total billed charges,14% of total billed charges,2.88,15.43,
A6253-ABD PAD,3436132,CDM,279,RC,A6253,HCPCS,Outpatient,,,1.24,0.62,,0.93,75,,,percent of total billed charges,75% of total billed charges,0.93,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,6.32,102,,,Fee Schedule,102% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.2,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.93,6.32,
A6448-ROSIDAL K 6CMX5M (5.47yds),3436134,CDM,279,RC,A6448,HCPCS,Outpatient,,,53.34,26.67,,40.01,75,,,percent of total billed charges,75% of total billed charges,40.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,1.15,102,,,Fee Schedule,102% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.47,14,,,percent of total billed charges,14% of total billed charges,1.13,40.01,
A6449-ROSIDAL K 10CMX5M (5.47yds),3436135,CDM,279,RC,A6449,HCPCS,Outpatient,,,81.02,40.51,,60.77,75,,,percent of total billed charges,75% of total billed charges,60.77,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,1.74,102,,,Fee Schedule,102% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.71,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.34,14,,,percent of total billed charges,14% of total billed charges,1.71,60.77,
A6449-ROSIDAL K 12CMX5M (5.47yds),3991163,CDM,279,RC,A6449,HCPCS,Outpatient,,,92.1,46.05,,69.08,75,,,percent of total billed charges,75% of total billed charges,69.08,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,1.74,102,,,Fee Schedule,102% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.71,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.89,14,,,percent of total billed charges,14% of total billed charges,1.71,69.08,
A6449-ROSIDAL K 8CMX5M (5.47yds),3436136,CDM,279,RC,A6449,HCPCS,Outpatient,,,66.56,33.28,,49.92,75,,,percent of total billed charges,75% of total billed charges,49.92,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,1.74,102,,,Fee Schedule,102% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.71,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.32,14,,,percent of total billed charges,14% of total billed charges,1.71,49.92,
A6456-UNNA 3 IN X 10 YARDS,3436137,CDM,279,RC,A6456,HCPCS,Outpatient,,,49.38,24.69,,37.04,75,,,percent of total billed charges,75% of total billed charges,37.04,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,1.25,102,,,Fee Schedule,102% of WV Medicaid Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.23,100,,,Fee Schedule,Pays based on 100% of WV Medicaid OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.91,14,,,percent of total billed charges,14% of total billed charges,1.23,37.04,
A6459 - Circ Aid Reduction Kit Knee,4023159,CDM,272,RC,A6549,HCPCS,Outpatient,,,1296.9,648.45,,972.68,75,,,percent of total billed charges,75% of total billed charges,972.68,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,181.57,14,,,percent of total billed charges,14% of total billed charges,181.57,972.68,
A6459 - Circ Aid Reduction Kit Upper Leg,4023158,CDM,272,RC,A6549,HCPCS,Outpatient,,,1296.9,648.45,,972.68,75,,,percent of total billed charges,75% of total billed charges,972.68,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,181.57,14,,,percent of total billed charges,14% of total billed charges,181.57,972.68,
A6549 - Circ Aid Reduction Kit Arm,4023156,CDM,272,RC,A6549,HCPCS,Outpatient,,,1296.9,648.45,,972.68,75,,,percent of total billed charges,75% of total billed charges,972.68,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,181.57,14,,,percent of total billed charges,14% of total billed charges,181.57,972.68,
A6549 - Circ Aid Reduction Kit Lower Leg,4023157,CDM,272,RC,A6549,HCPCS,Outpatient,,,1296.9,648.45,,972.68,75,,,percent of total billed charges,75% of total billed charges,972.68,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,181.57,14,,,percent of total billed charges,14% of total billed charges,181.57,972.68,
"C1717-Brachytx, Non-Str, HDR IR-192",4169516,CDM,278,RC,C1717,HCPCS,Outpatient,,,765.45,382.73,,574.09,75,,,percent of total billed charges,75% of total billed charges,574.09,75,,,percent of total billed charges,75% of total billed charges,335.71,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,553.91,165,,,Fee Schedule,165% of CMS OPPS Rate,372.63,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,1032.74,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1416.32,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1774.09,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,335.71,100,,,Fee Schedule,100% of CMS OPPS Rate,372.63,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,107.16,14,,,percent of total billed charges,14% of total billed charges,107.16,1774.09,
"C1897- lead, neurostimulator test kit, implanted",3690951,CDM,278,RC,C1897,HCPCS,Outpatient,,,1781,890.5,,1335.75,75,,,percent of total billed charges,75% of total billed charges,1335.75,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,249.34,14,,,percent of total billed charges,14% of total billed charges,249.34,1335.75,
G0101- Cervical Or Vaginal Cancer Screening,3431440,CDM,510,RC,G0101,HCPCS,Outpatient,,,64.59,32.3,,48.44,75,,,percent of total billed charges,75% of total billed charges,48.44,75,,,percent of total billed charges,75% of total billed charges,71.29,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,117.66,165,,,Fee Schedule,165% of CMS OPPS Rate,73.9,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,204.82,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,280.89,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,351.86,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,71.29,100,,,Fee Schedule,100% of CMS OPPS Rate,73.9,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,9.04,14,,,percent of total billed charges,14% of total billed charges,9.04,351.86,
G0270 - MNT subs tx for change dx,4037466,CDM,983,RC,G0270,HCPCS,Outpatient,,,10.27,5.14,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,
"G0277 HBOT, Full Body Chamber, 30 Minutes",3436143,CDM,761,RC,G0277,HCPCS,Outpatient,,,700.71,350.36,,525.53,75,,,percent of total billed charges,75% of total billed charges,525.53,75,,,percent of total billed charges,75% of total billed charges,117.58,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,194.01,165,,,Fee Schedule,165% of CMS OPPS Rate,121.86,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,337.74,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,463.19,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,580.2,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,117.58,100,,,Fee Schedule,100% of CMS OPPS Rate,121.86,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,98.1,14,,,percent of total billed charges,14% of total billed charges,98.1,580.2,
MA TOMO Mammogram Diagnostic Rt,3332563,CDM,401,RC,G0279,HCPCS,Outpatient,,,117.01,58.51,,87.76,75,,,percent of total billed charges,75% of total billed charges,87.76,75,,,percent of total billed charges,75% of total billed charges,20.98,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,34.62,165,,,Fee Schedule,165% of CMS OPPS Rate,48.23,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,74.38,354.54,,,Fee Schedule,354.54% of CMS OPPS Fee Schedule Rate,89.94,428.7,,,Fee Schedule,428.7% of CMS OPPS Fee Schedule Rate,94.58,450.81,,,Fee Schedule,450.81% of CMS OPPS Fee Schedule Rate,,,,,Other,Not Separately reimbursable,20.98,100,,,Fee Schedule,100% of CMS OPPS Rate,48.23,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,16.38,14,,,percent of total billed charges,14% of total billed charges,16.38,94.58,
G0399- Home Sleep Test 3,3430575,CDM,920,RC,G0399,HCPCS,Outpatient,,,788.8,394.4,,591.6,75,,,percent of total billed charges,75% of total billed charges,591.6,75,,,percent of total billed charges,75% of total billed charges,136.72,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,225.58,165,,,Fee Schedule,165% of CMS OPPS Rate,141.69,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,392.72,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,538.59,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,674.64,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,136.72,100,,,Fee Schedule,100% of CMS OPPS Rate,141.69,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,110.43,14,,,percent of total billed charges,14% of total billed charges,110.43,674.64,
G0400 - Home Sleep Test/Type 4 Portable-Unattended,4347086,CDM,510,RC,G0400,HCPCS,Outpatient,,,1414.42,707.21,,1060.82,75,,,percent of total billed charges,75% of total billed charges,1060.82,75,,,percent of total billed charges,75% of total billed charges,263.29,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,434.44,165,,,Fee Schedule,165% of CMS OPPS Rate,272.88,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,756.29,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,1037.2,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,1299.2,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,263.29,100,,,Fee Schedule,100% of CMS OPPS Rate,272.88,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,198.02,14,,,percent of total billed charges,14% of total billed charges,198.02,1299.2,
G0463-EST PATIENT ( formerly LEVEL 3),3400467,CDM,510,RC,G0463,HCPCS,Outpatient,,,238.27,119.14,,178.7,75,,,percent of total billed charges,75% of total billed charges,178.7,75,,,percent of total billed charges,75% of total billed charges,113.62,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,187.47,165,,,Fee Schedule,165% of CMS OPPS Rate,117.76,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,326.38,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,447.6,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,560.66,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,113.62,100,,,Fee Schedule,100% of CMS OPPS Rate,117.76,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,33.36,14,,,percent of total billed charges,14% of total billed charges,33.36,560.66,
G0463-EST PATIENT (formerly LEVEL 1),3400465,CDM,510,RC,G0463,HCPCS,Outpatient,,,238.27,119.14,,178.7,75,,,percent of total billed charges,75% of total billed charges,178.7,75,,,percent of total billed charges,75% of total billed charges,113.62,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,187.47,165,,,Fee Schedule,165% of CMS OPPS Rate,117.76,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,326.38,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,447.6,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,560.66,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,113.62,100,,,Fee Schedule,100% of CMS OPPS Rate,117.76,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,33.36,14,,,percent of total billed charges,14% of total billed charges,33.36,560.66,
G0463-EST PATIENT (formerly LEVEL 2),3400466,CDM,510,RC,G0463,HCPCS,Outpatient,,,238.27,119.14,,178.7,75,,,percent of total billed charges,75% of total billed charges,178.7,75,,,percent of total billed charges,75% of total billed charges,113.62,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,187.47,165,,,Fee Schedule,165% of CMS OPPS Rate,117.76,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,326.38,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,447.6,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,560.66,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,113.62,100,,,Fee Schedule,100% of CMS OPPS Rate,117.76,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,33.36,14,,,percent of total billed charges,14% of total billed charges,33.36,560.66,
G0463-EST PATIENT (formerly LEVEL 4),3400468,CDM,510,RC,G0463,HCPCS,Outpatient,,,238.27,119.14,,178.7,75,,,percent of total billed charges,75% of total billed charges,178.7,75,,,percent of total billed charges,75% of total billed charges,113.62,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,187.47,165,,,Fee Schedule,165% of CMS OPPS Rate,117.76,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,326.38,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,447.6,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,560.66,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,113.62,100,,,Fee Schedule,100% of CMS OPPS Rate,117.76,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,33.36,14,,,percent of total billed charges,14% of total billed charges,33.36,560.66,
G0463-EST PATIENT (formerly LEVEL 5),3400469,CDM,510,RC,G0463,HCPCS,Outpatient,,,238.27,119.14,,178.7,75,,,percent of total billed charges,75% of total billed charges,178.7,75,,,percent of total billed charges,75% of total billed charges,113.62,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,187.47,165,,,Fee Schedule,165% of CMS OPPS Rate,117.76,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,326.38,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,447.6,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,560.66,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,113.62,100,,,Fee Schedule,100% of CMS OPPS Rate,117.76,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,33.36,14,,,percent of total billed charges,14% of total billed charges,33.36,560.66,
G0500 - MOD SEDAT ENDO SERVICE >5YRS,3999154,CDM,370,RC,G0500,HCPCS,Outpatient,,,119.22,59.61,,89.42,75,,,percent of total billed charges,75% of total billed charges,89.42,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.69,14,,,percent of total billed charges,14% of total billed charges,16.69,89.42,
G6012-RAD TREATMENT DELIVERY 6-10 MEV,3400470,CDM,333,RC,G6012,HCPCS,Outpatient,,,700.45,350.23,,525.34,75,,,percent of total billed charges,75% of total billed charges,525.34,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,98.06,14,,,percent of total billed charges,14% of total billed charges,98.06,525.34,
G6013-RAD TREATMENT DELIVERY 11-19 MEV,3400471,CDM,333,RC,G6013,HCPCS,Outpatient,,,700.45,350.23,,525.34,75,,,percent of total billed charges,75% of total billed charges,525.34,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,98.06,14,,,percent of total billed charges,14% of total billed charges,98.06,525.34,
G6014-RAD TREATMENT DELIVERY >20 MEV,3400472,CDM,333,RC,G6014,HCPCS,Outpatient,,,701.64,350.82,,526.23,75,,,percent of total billed charges,75% of total billed charges,526.23,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,98.23,14,,,percent of total billed charges,14% of total billed charges,98.23,526.23,
AMB alprostadil Charge:2.5 mcg  alprostadil  Inj,3444238,CDM,636,RC,J0270,HCPCS,Outpatient,,,359.08,179.54,,269.31,75,,,percent of total billed charges,75% of total billed charges,269.31,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50.27,14,,,percent of total billed charges,14% of total billed charges,50.27,269.31,
"J0585 - Injection, onabotulinumtoxinA, 1 unit",3430587,CDM,636,RC,J0585,HCPCS,Outpatient,,,38.04,19.02,,28.53,75,,,percent of total billed charges,75% of total billed charges,28.53,75,,,percent of total billed charges,75% of total billed charges,6.33,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,10.44,165,,,Fee Schedule,165% of CMS OPPS Rate,7.02,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,19.47,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,26.7,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,33.45,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,6.33,100,,,Fee Schedule,100% of CMS OPPS Rate,7.02,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,5.33,14,,,percent of total billed charges,14% of total billed charges,5.33,33.45,
J1212-MUA DIMETHYL SULFOXIDE 50% 50 ML,3430595,CDM,636,RC,J1212,HCPCS,Outpatient,,,269.92,134.96,,202.44,75,,,percent of total billed charges,75% of total billed charges,202.44,75,,,percent of total billed charges,75% of total billed charges,681.74,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1124.85,165,,,Fee Schedule,165% of CMS OPPS Rate,756.73,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,2097.23,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,2876.19,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,3602.72,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,681.74,100,,,Fee Schedule,100% of CMS OPPS Rate,756.73,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,37.79,14,,,percent of total billed charges,14% of total billed charges,37.79,3602.72,
J1580-MUA GARAMYCIN GENTAMICIN INJ,3430596,CDM,636,RC,J1580,HCPCS,Outpatient,,,13.44,6.72,,10.08,75,,,percent of total billed charges,75% of total billed charges,10.08,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.88,14,,,percent of total billed charges,14% of total billed charges,1.88,10.08,
"J9030 - Bcg live intravesical instillation, 1 mg",4257722,CDM,636,RC,J9030,HCPCS,Outpatient,,,7.54,3.77,,5.66,75,,,percent of total billed charges,75% of total billed charges,5.66,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.06,14,,,percent of total billed charges,14% of total billed charges,1.06,5.66,
"Q0091- Screening Pap Smear,Specimen Prep",3431441,CDM,510,RC,Q0091,HCPCS,Outpatient,,,46.38,23.19,,34.79,75,,,percent of total billed charges,75% of total billed charges,34.79,75,,,percent of total billed charges,75% of total billed charges,23.46,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,38.71,165,,,Fee Schedule,165% of CMS OPPS Rate,24.31,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,67.4,307.63,,,Fee Schedule,307.63% of CMS APC Fee Schedule Rate,92.43,421.89,,,Fee Schedule,421.89% of CMS APC Fee Schedule Rate,115.78,528.46,,,Fee Schedule,528.46% of CMS APC Fee Schedule Rate,,,,,Other,Not Separately reimbursable,23.46,100,,,Fee Schedule,100% of CMS OPPS Rate,24.31,111,,,Fee Schedule,111% of CMS APC Fee Schedule Rate,6.49,14,,,percent of total billed charges,14% of total billed charges,6.49,115.78,
Q0111 Wet mounts w preparations,3428512,CDM,510,RC,Q0111,HCPCS,Outpatient,,,83.24,41.62,,62.43,75,,,percent of total billed charges,75% of total billed charges,62.43,75,,,percent of total billed charges,75% of total billed charges,17.3,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,17.3,100,,,Fee Schedule,100% of CMS OPPS Rate,15.92,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,61.37,354.54,,,Fee Schedule,354.54% of CMS OPPS Fee Schedule Rate,74.2,428.7,,,Fee Schedule,428.7% of CMS OPPS Fee Schedule Rate,78.03,450.81,,,Fee Schedule,450.81% of CMS OPPS Fee Schedule Rate,,,,,Other,Not Separately reimbursable,17.3,100,,,Fee Schedule,100% of CMS OPPS Rate,15.92,100,,,Fee Schedule,Pays based on 100% of PEIA Fee Schedule Rate,11.65,14,,,percent of total billed charges,14% of total billed charges,11.65,78.03,
"Q4101 Apligraf (44), Per sq cm",3436158,CDM,278,RC,Q4101,HCPCS,Outpatient,,,208.64,104.32,,156.48,75,,,percent of total billed charges,75% of total billed charges,156.48,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.21,14,,,percent of total billed charges,14% of total billed charges,29.21,156.48,
"Q4121 Theraskin 7.6cm x 15.2cm (116), Per sq cm",3984944,CDM,278,RC,Q4121,HCPCS,Outpatient,,,156.33,78.17,,117.25,75,,,percent of total billed charges,75% of total billed charges,117.25,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.89,14,,,percent of total billed charges,14% of total billed charges,21.89,117.25,
Q4124 Oasis Ultra Tri-Layer Wound Matrix 3 x 7 (21) Per sq c,3592974,CDM,278,RC,Q4124,HCPCS,Outpatient,,,523.95,261.98,,392.96,75,,,percent of total billed charges,75% of total billed charges,392.96,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,73.35,14,,,percent of total billed charges,14% of total billed charges,73.35,392.96,
"Q4124 Oasis Ultra Tri-Layer Wound Matrix 5 x 7 (35), Per sq",3592966,CDM,278,RC,Q4124,HCPCS,Outpatient,,,285.77,142.89,,214.33,75,,,percent of total billed charges,75% of total billed charges,214.33,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.01,14,,,percent of total billed charges,14% of total billed charges,40.01,214.33,
"Q4159 Affinity fresh amniotic 1.5x1.5cm (3), Per sq cm",4223262,CDM,278,RC,Q4159,HCPCS,Outpatient,,,4320,2160,,3240,75,,,percent of total billed charges,75% of total billed charges,3240,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,604.8,14,,,percent of total billed charges,14% of total billed charges,604.8,3240,
Q4196 Puraply AM 3.02 x 3.02 (10) per sq cm,4363618,CDM,278,RC,Q4196,HCPCS,Outpatient,,,989,494.5,,741.75,75,,,percent of total billed charges,75% of total billed charges,741.75,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,138.46,14,,,percent of total billed charges,14% of total billed charges,138.46,741.75,
Q4197 Puraply XT 4.91x4.91 (25) per sq cm,4363619,CDM,278,RC,Q4197,HCPCS,Outpatient,,,1064,532,,798,75,,,percent of total billed charges,75% of total billed charges,798,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,148.96,14,,,percent of total billed charges,14% of total billed charges,148.96,798,
HEART TRANSPLANT OR IMPLANT OF HEART ASSIST SYSTEM WITH MCC,1,MS-DRG,,,,,Inpatient,,,,,,724713.88,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,724713.88,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,263532.32,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,125437.88,102,,,case rate,102% WV Medicaid DRG rate,434828.328,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,114638.78,100,,,case rate,100% PEIA with CHIP DRG base rate,510618.92,100,,,case rate,100% Highmark ACA DRG rate,645705.44,100,,,case rate,100% Highmark PPO DRG rate,645705.44,100,,,case rate,100% Highmark Trad DRG rate,122978.19,100,,,case rate,100% WV Medicaid DRG rate,263532.32,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,97511.6,100,,,case rate,100% PEIA DRG rate,480192.34,100,,,case rate,100% The Health Plan DRG rate,97511.6,724713.88,
HEART TRANSPLANT OR IMPLANT OF HEART ASSIST SYSTEM WITHOUT MCC,2,MS-DRG,,,,,Inpatient,,,,,,346909.255,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,346909.255,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,126148.82,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,60045.16,102,,,case rate,102% WV Medicaid DRG rate,208145.553,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,54875.8,100,,,case rate,100% PEIA with CHIP DRG base rate,230715.58,100,,,case rate,100% Highmark ACA DRG rate,291752.41,100,,,case rate,100% Highmark PPO DRG rate,291752.41,100,,,case rate,100% Highmark Trad DRG rate,58867.75,100,,,case rate,100% WV Medicaid DRG rate,126148.82,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,46677.29,100,,,case rate,100% PEIA DRG rate,216967.78,100,,,case rate,100% The Health Plan DRG rate,46677.29,346909.255,
"ECMO OR TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE, MOUTH AND NECK WITH MAJOR O.R. PROCEDURES",3,MS-DRG,,,,,Inpatient,,,,,,521070.6875,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,521070.6875,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,189480.25,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,66402.15,102,,,case rate,102% WV Medicaid DRG rate,312642.4125,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,60685.51,100,,,case rate,100% PEIA with CHIP DRG base rate,401738.41,100,,,case rate,100% Highmark ACA DRG rate,508020.11,100,,,case rate,100% Highmark PPO DRG rate,508020.11,100,,,case rate,100% Highmark Trad DRG rate,65100.09,100,,,case rate,100% WV Medicaid DRG rate,189480.25,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,51619.02,100,,,case rate,100% PEIA DRG rate,377799.77,100,,,case rate,100% The Health Plan DRG rate,51619.02,521070.6875,
"TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE, MOUTH AND NECK WITHOUT MAJOR O.R. PROCEDURES",4,MS-DRG,,,,,Inpatient,,,,,,353567.775,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,353567.775,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,128570.1,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,48861.15,102,,,case rate,102% WV Medicaid DRG rate,212140.665,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,44654.63,100,,,case rate,100% PEIA with CHIP DRG base rate,276992.1,100,,,case rate,100% Highmark ACA DRG rate,350271.6,100,,,case rate,100% Highmark PPO DRG rate,350271.6,100,,,case rate,100% Highmark Trad DRG rate,47903.04,100,,,case rate,100% WV Medicaid DRG rate,128570.1,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,37983.17,100,,,case rate,100% PEIA DRG rate,260486.79,100,,,case rate,100% The Health Plan DRG rate,37983.17,353567.775,
LIVER TRANSPLANT WITH MCC OR INTESTINAL TRANSPLANT,5,MS-DRG,,,,,Inpatient,,,,,,293710.7525,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,293710.7525,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,106803.91,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,50837.23,102,,,case rate,102% WV Medicaid DRG rate,176226.4515,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,46460.6,100,,,case rate,100% PEIA with CHIP DRG base rate,195025.05,100,,,case rate,100% Highmark ACA DRG rate,246619.8,100,,,case rate,100% Highmark PPO DRG rate,246619.8,100,,,case rate,100% Highmark Trad DRG rate,49840.38,100,,,case rate,100% WV Medicaid DRG rate,106803.91,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,39519.32,100,,,case rate,100% PEIA DRG rate,183403.97,100,,,case rate,100% The Health Plan DRG rate,39519.32,293710.7525,
LIVER TRANSPLANT WITHOUT MCC,6,MS-DRG,,,,,Inpatient,,,,,,123831.235,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,123831.235,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,45029.54,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,21433.46,102,,,case rate,102% WV Medicaid DRG rate,74298.741,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,19588.23,100,,,case rate,100% PEIA with CHIP DRG base rate,91141.71,100,,,case rate,100% Highmark ACA DRG rate,115253.65,100,,,case rate,100% Highmark PPO DRG rate,115253.65,100,,,case rate,100% Highmark Trad DRG rate,21013.18,100,,,case rate,100% WV Medicaid DRG rate,45029.54,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,16661.72,100,,,case rate,100% PEIA DRG rate,85710.79,100,,,case rate,100% The Health Plan DRG rate,16661.72,123831.235,
LUNG TRANSPLANT,7,MS-DRG,,,,,Inpatient,,,,,,314317.08,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,314317.08,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,114297.12,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,54403.91,102,,,case rate,102% WV Medicaid DRG rate,188590.248,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,49720.21,100,,,case rate,100% PEIA with CHIP DRG base rate,231135.78,100,,,case rate,100% Highmark ACA DRG rate,292283.78,100,,,case rate,100% Highmark PPO DRG rate,292283.78,100,,,case rate,100% Highmark Trad DRG rate,53337.11,100,,,case rate,100% WV Medicaid DRG rate,114297.12,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,42291.95,100,,,case rate,100% PEIA DRG rate,217362.94,100,,,case rate,100% The Health Plan DRG rate,42291.95,314317.08,
SIMULTANEOUS PANCREAS AND KIDNEY TRANSPLANT,8,MS-DRG,,,,,Inpatient,,,,,,143961.235,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,143961.235,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,52349.54,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,24917.69,102,,,case rate,102% WV Medicaid DRG rate,86376.741,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,22772.49,100,,,case rate,100% PEIA with CHIP DRG base rate,99146.21,100,,,case rate,100% Highmark ACA DRG rate,125375.79,100,,,case rate,100% Highmark PPO DRG rate,125375.79,100,,,case rate,100% Highmark Trad DRG rate,24429.08,100,,,case rate,100% WV Medicaid DRG rate,52349.54,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,19370.25,100,,,case rate,100% PEIA DRG rate,93238.32,100,,,case rate,100% The Health Plan DRG rate,19370.25,143961.235,
PANCREAS TRANSPLANT,10,MS-DRG,,,,,Inpatient,,,,,,106773.0125,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,106773.0125,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,38826.55,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,18480.92,102,,,case rate,102% WV Medicaid DRG rate,64063.8075,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,16889.87,100,,,case rate,100% PEIA with CHIP DRG base rate,90702.66,100,,,case rate,100% Highmark ACA DRG rate,114698.46,100,,,case rate,100% Highmark PPO DRG rate,114698.46,100,,,case rate,100% Highmark Trad DRG rate,18118.53,100,,,case rate,100% WV Medicaid DRG rate,38826.55,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,14366.51,100,,,case rate,100% PEIA DRG rate,85297.91,100,,,case rate,100% The Health Plan DRG rate,14366.51,114698.46,
"TRACHEOSTOMY FOR FACE, MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITH MCC",11,MS-DRG,,,,,Inpatient,,,,,,132995.06,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,132995.06,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,48361.84,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,33380.01,102,,,case rate,102% WV Medicaid DRG rate,79797.036,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,30506.29,100,,,case rate,100% PEIA with CHIP DRG base rate,97160.16,100,,,case rate,100% Highmark ACA DRG rate,122864.32,100,,,case rate,100% Highmark PPO DRG rate,122864.32,100,,,case rate,100% Highmark Trad DRG rate,32725.47,100,,,case rate,100% WV Medicaid DRG rate,48361.84,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,25948.61,100,,,case rate,100% PEIA DRG rate,91370.62,100,,,case rate,100% The Health Plan DRG rate,25948.61,132995.06,
"TRACHEOSTOMY FOR FACE, MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITH CC",12,MS-DRG,,,,,Inpatient,,,,,,100662.925,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,100662.925,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,36604.7,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,20780.56,102,,,case rate,102% WV Medicaid DRG rate,60397.755,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,18991.54,100,,,case rate,100% PEIA with CHIP DRG base rate,75464.33,100,,,case rate,100% Highmark ACA DRG rate,95428.76,100,,,case rate,100% Highmark PPO DRG rate,95428.76,100,,,case rate,100% Highmark Trad DRG rate,20373.08,100,,,case rate,100% WV Medicaid DRG rate,36604.7,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,16154.18,100,,,case rate,100% PEIA DRG rate,70967.59,100,,,case rate,100% The Health Plan DRG rate,16154.18,100662.925,
"TRACHEOSTOMY FOR FACE, MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITHOUT CC/MCC",13,MS-DRG,,,,,Inpatient,,,,,,72823.905,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,72823.905,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,26481.42,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,17034.73,102,,,case rate,102% WV Medicaid DRG rate,43694.343,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,15568.19,100,,,case rate,100% PEIA with CHIP DRG base rate,50606.65,100,,,case rate,100% Highmark ACA DRG rate,63994.86,100,,,case rate,100% Highmark PPO DRG rate,63994.86,100,,,case rate,100% Highmark Trad DRG rate,16700.7,100,,,case rate,100% WV Medicaid DRG rate,26481.42,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,13242.28,100,,,case rate,100% PEIA DRG rate,47591.11,100,,,case rate,100% The Health Plan DRG rate,13242.28,72823.905,
ALLOGENEIC BONE MARROW TRANSPLANT,14,MS-DRG,,,,,Inpatient,,,,,,288200.605,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,288200.605,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,104800.22,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,49883.51,102,,,case rate,102% WV Medicaid DRG rate,172920.363,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,45588.98,100,,,case rate,100% PEIA with CHIP DRG base rate,215957.74,100,,,case rate,100% Highmark ACA DRG rate,273090.33,100,,,case rate,100% Highmark PPO DRG rate,273090.33,100,,,case rate,100% Highmark Trad DRG rate,48905.35,100,,,case rate,100% WV Medicaid DRG rate,104800.22,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,38777.92,100,,,case rate,100% PEIA DRG rate,203089.33,100,,,case rate,100% The Health Plan DRG rate,38777.92,288200.605,
AUTOLOGOUS BONE MARROW TRANSPLANT WITH CC/MCC,16,MS-DRG,,,,,Inpatient,,,,,,156662.8525,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,156662.8525,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,56968.31,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,27116.16,102,,,case rate,102% WV Medicaid DRG rate,93997.7115,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,24781.7,100,,,case rate,100% PEIA with CHIP DRG base rate,116393.21,100,,,case rate,100% Highmark ACA DRG rate,147185.56,100,,,case rate,100% Highmark PPO DRG rate,147185.56,100,,,case rate,100% Highmark Trad DRG rate,26584.45,100,,,case rate,100% WV Medicaid DRG rate,56968.31,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,21079.28,100,,,case rate,100% PEIA DRG rate,109457.61,100,,,case rate,100% The Health Plan DRG rate,21079.28,156662.8525,
AUTOLOGOUS BONE MARROW TRANSPLANT WITHOUT CC/MCC,17,MS-DRG,,,,,Inpatient,,,,,,112522.575,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,112522.575,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,40917.3,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,19476.09,102,,,case rate,102% WV Medicaid DRG rate,67513.545,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,17799.37,100,,,case rate,100% PEIA with CHIP DRG base rate,116393.21,100,,,case rate,100% Highmark ACA DRG rate,147185.56,100,,,case rate,100% Highmark PPO DRG rate,147185.56,100,,,case rate,100% Highmark Trad DRG rate,19094.19,100,,,case rate,100% WV Medicaid DRG rate,40917.3,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,15140.12,100,,,case rate,100% PEIA DRG rate,109457.61,100,,,case rate,100% The Health Plan DRG rate,15140.12,147185.56,
CHIMERIC ANTIGEN RECEPTOR (CAR) T-CELL AND OTHER IMMUNOTHERAPIES,18,MS-DRG,,,,,Inpatient,,,,,,930677.0825,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,930677.0825,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,338428.03,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,232111.4,102,,,case rate,102% WV Medicaid DRG rate,558406.2495,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,212128.65,100,,,case rate,100% PEIA with CHIP DRG base rate,694227,100,,,case rate,100% Highmark ACA DRG rate,877887.86,100,,,case rate,100% Highmark PPO DRG rate,877887.86,100,,,case rate,100% Highmark Trad DRG rate,227559.97,100,,,case rate,100% WV Medicaid DRG rate,338428.03,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,180436.35,100,,,case rate,100% PEIA DRG rate,652859.64,100,,,case rate,100% The Health Plan DRG rate,180436.35,930677.0825,
SIMULTANEOUS PANCREAS AND KIDNEY TRANSPLANT WITH HEMODIALYSIS,19,MS-DRG,,,,,Inpatient,,,,,,183703.7125,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,183703.7125,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,66801.35,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,31796.56,102,,,case rate,102% WV Medicaid DRG rate,110222.2275,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,29059.15,100,,,case rate,100% PEIA with CHIP DRG base rate,150621.52,100,,,case rate,100% Highmark ACA DRG rate,190469.12,100,,,case rate,100% Highmark PPO DRG rate,190469.12,100,,,case rate,100% Highmark Trad DRG rate,31173.07,100,,,case rate,100% WV Medicaid DRG rate,66801.35,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,24717.68,100,,,case rate,100% PEIA DRG rate,141646.34,100,,,case rate,100% The Health Plan DRG rate,24717.68,190469.12,
INTRACRANIAL VASCULAR PROCEDURES WITH PRINCIPAL DIAGNOSIS HEMORRHAGE WITH MCC,20,MS-DRG,,,,,Inpatient,,,,,,239544.0575,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,239544.0575,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,87106.93,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,42729.21,102,,,case rate,102% WV Medicaid DRG rate,143726.4345,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,39050.61,100,,,case rate,100% PEIA with CHIP DRG base rate,159268.57,100,,,case rate,100% Highmark ACA DRG rate,201403.79,100,,,case rate,100% Highmark PPO DRG rate,201403.79,100,,,case rate,100% Highmark Trad DRG rate,41891.35,100,,,case rate,100% WV Medicaid DRG rate,87106.93,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,33216.39,100,,,case rate,100% PEIA DRG rate,149778.13,100,,,case rate,100% The Health Plan DRG rate,33216.39,239544.0575,
INTRACRANIAL VASCULAR PROCEDURES WITH PRINCIPAL DIAGNOSIS HEMORRHAGE WITH CC,21,MS-DRG,,,,,Inpatient,,,,,,174810.2675,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,174810.2675,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,63567.37,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,32782.82,102,,,case rate,102% WV Medicaid DRG rate,104886.1605,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,29960.51,100,,,case rate,100% PEIA with CHIP DRG base rate,115722.4,100,,,case rate,100% Highmark ACA DRG rate,146337.28,100,,,case rate,100% Highmark PPO DRG rate,146337.28,100,,,case rate,100% Highmark Trad DRG rate,32139.99,100,,,case rate,100% WV Medicaid DRG rate,63567.37,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,25484.37,100,,,case rate,100% PEIA DRG rate,108826.77,100,,,case rate,100% The Health Plan DRG rate,25484.37,174810.2675,
INTRACRANIAL VASCULAR PROCEDURES WITH PRINCIPAL DIAGNOSIS HEMORRHAGE WITHOUT CC/MCC,22,MS-DRG,,,,,Inpatient,,,,,,112223.925,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,112223.925,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,40808.7,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,28947.41,102,,,case rate,102% WV Medicaid DRG rate,67334.355,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,26455.29,100,,,case rate,100% PEIA with CHIP DRG base rate,65511.46,100,,,case rate,100% Highmark ACA DRG rate,82842.81,100,,,case rate,100% Highmark PPO DRG rate,82842.81,100,,,case rate,100% Highmark Trad DRG rate,28379.78,100,,,case rate,100% WV Medicaid DRG rate,40808.7,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,22502.84,100,,,case rate,100% PEIA DRG rate,61607.78,100,,,case rate,100% The Health Plan DRG rate,22502.84,112223.925,
CRANIOTOMY WITH MAJOR DEVICE IMPLANT OR ACUTE COMPLEX CNS PRINCIPAL DIAGNOSIS WITH MCC OR CHEMOTHERAPY IMPLANT OR EPILEPSY WITH NEUROSTIMULATOR,23,MS-DRG,,,,,Inpatient,,,,,,147573.7175,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,147573.7175,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,53663.17,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,28072.12,102,,,case rate,102% WV Medicaid DRG rate,88544.2305,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,25655.36,100,,,case rate,100% PEIA with CHIP DRG base rate,106817.2,100,,,case rate,100% Highmark ACA DRG rate,135076.17,100,,,case rate,100% Highmark PPO DRG rate,135076.17,100,,,case rate,100% Highmark Trad DRG rate,27521.66,100,,,case rate,100% WV Medicaid DRG rate,53663.17,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,21822.41,100,,,case rate,100% PEIA DRG rate,100452.21,100,,,case rate,100% The Health Plan DRG rate,21822.41,147573.7175,
CRANIOTOMY WITH MAJOR DEVICE IMPLANT OR ACUTE COMPLEX CNS PRINCIPAL DIAGNOSIS WITHOUT MCC,24,MS-DRG,,,,,Inpatient,,,,,,101674.815,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,101674.815,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,36972.66,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,15276.13,102,,,case rate,102% WV Medicaid DRG rate,61004.889,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,13960.99,100,,,case rate,100% PEIA with CHIP DRG base rate,71392.36,100,,,case rate,100% Highmark ACA DRG rate,90279.53,100,,,case rate,100% Highmark PPO DRG rate,90279.53,100,,,case rate,100% Highmark Trad DRG rate,14976.58,100,,,case rate,100% WV Medicaid DRG rate,36972.66,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,11875.2,100,,,case rate,100% PEIA DRG rate,67138.26,100,,,case rate,100% The Health Plan DRG rate,11875.2,101674.815,
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH MCC,25,MS-DRG,,,,,Inpatient,,,,,,116910.09,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,116910.09,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,42512.76,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,24544.22,102,,,case rate,102% WV Medicaid DRG rate,70146.054,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,22431.18,100,,,case rate,100% PEIA with CHIP DRG base rate,83210.69,100,,,case rate,100% Highmark ACA DRG rate,105224.45,100,,,case rate,100% Highmark PPO DRG rate,105224.45,100,,,case rate,100% Highmark Trad DRG rate,24062.94,100,,,case rate,100% WV Medicaid DRG rate,42512.76,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,19079.93,100,,,case rate,100% PEIA DRG rate,78252.36,100,,,case rate,100% The Health Plan DRG rate,19079.93,116910.09,
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH CC,26,MS-DRG,,,,,Inpatient,,,,,,77849.9425,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,77849.9425,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,28309.07,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,14912.91,102,,,case rate,102% WV Medicaid DRG rate,46709.9655,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,13629.04,100,,,case rate,100% PEIA with CHIP DRG base rate,55645.26,100,,,case rate,100% Highmark ACA DRG rate,70366.47,100,,,case rate,100% Highmark PPO DRG rate,70366.47,100,,,case rate,100% Highmark Trad DRG rate,14620.48,100,,,case rate,100% WV Medicaid DRG rate,28309.07,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,11592.84,100,,,case rate,100% PEIA DRG rate,52329.49,100,,,case rate,100% The Health Plan DRG rate,11592.84,77849.9425,
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITHOUT CC/MCC,27,MS-DRG,,,,,Inpatient,,,,,,64252.2375,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,64252.2375,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,23364.45,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,13239.43,102,,,case rate,102% WV Medicaid DRG rate,38551.3425,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,12099.63,100,,,case rate,100% PEIA with CHIP DRG base rate,45843.13,100,,,case rate,100% Highmark ACA DRG rate,57971.14,100,,,case rate,100% Highmark PPO DRG rate,57971.14,100,,,case rate,100% Highmark Trad DRG rate,12979.82,100,,,case rate,100% WV Medicaid DRG rate,23364.45,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,10291.93,100,,,case rate,100% PEIA DRG rate,43111.45,100,,,case rate,100% The Health Plan DRG rate,10291.93,64252.2375,
SPINAL PROCEDURES WITH MCC,28,MS-DRG,,,,,Inpatient,,,,,,151335.5525,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,151335.5525,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,55031.11,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,27590.35,102,,,case rate,102% WV Medicaid DRG rate,90801.3315,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,25215.07,100,,,case rate,100% PEIA with CHIP DRG base rate,113549.8,100,,,case rate,100% Highmark ACA DRG rate,143589.91,100,,,case rate,100% Highmark PPO DRG rate,143589.91,100,,,case rate,100% Highmark Trad DRG rate,27049.34,100,,,case rate,100% WV Medicaid DRG rate,55031.11,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,21447.9,100,,,case rate,100% PEIA DRG rate,106783.64,100,,,case rate,100% The Health Plan DRG rate,21447.9,151335.5525,
SPINAL PROCEDURES WITH CC OR SPINAL NEUROSTIMULATORS,29,MS-DRG,,,,,Inpatient,,,,,,87997.36,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,87997.36,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,31999.04,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,15444.14,102,,,case rate,102% WV Medicaid DRG rate,52798.416,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,14114.54,100,,,case rate,100% PEIA with CHIP DRG base rate,64597.57,100,,,case rate,100% Highmark ACA DRG rate,81687.15,100,,,case rate,100% Highmark PPO DRG rate,81687.15,100,,,case rate,100% Highmark Trad DRG rate,15141.3,100,,,case rate,100% WV Medicaid DRG rate,31999.04,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,12005.81,100,,,case rate,100% PEIA DRG rate,60748.36,100,,,case rate,100% The Health Plan DRG rate,12005.81,87997.36,
SPINAL PROCEDURES WITHOUT CC/MCC,30,MS-DRG,,,,,Inpatient,,,,,,60281.87,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,60281.87,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,21920.68,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,13079.44,102,,,case rate,102% WV Medicaid DRG rate,36169.122,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,11953.41,100,,,case rate,100% PEIA with CHIP DRG base rate,43696.92,100,,,case rate,100% Highmark ACA DRG rate,55257.13,100,,,case rate,100% Highmark PPO DRG rate,55257.13,100,,,case rate,100% Highmark Trad DRG rate,12822.96,100,,,case rate,100% WV Medicaid DRG rate,21920.68,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,10167.56,100,,,case rate,100% PEIA DRG rate,41093.12,100,,,case rate,100% The Health Plan DRG rate,10167.56,60281.87,
VENTRICULAR SHUNT PROCEDURES WITH MCC,31,MS-DRG,,,,,Inpatient,,,,,,106108.695,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,106108.695,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,38584.98,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,27369.75,102,,,case rate,102% WV Medicaid DRG rate,63665.217,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,25013.45,100,,,case rate,100% PEIA with CHIP DRG base rate,77569.09,100,,,case rate,100% Highmark ACA DRG rate,98090.34,100,,,case rate,100% Highmark PPO DRG rate,98090.34,100,,,case rate,100% Highmark Trad DRG rate,26833.06,100,,,case rate,100% WV Medicaid DRG rate,38584.98,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,21276.41,100,,,case rate,100% PEIA DRG rate,72946.93,100,,,case rate,100% The Health Plan DRG rate,21276.41,106108.695,
VENTRICULAR SHUNT PROCEDURES WITH CC,32,MS-DRG,,,,,Inpatient,,,,,,52899.825,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,52899.825,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,19236.3,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,11518.71,102,,,case rate,102% WV Medicaid DRG rate,31739.895,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,10527.05,100,,,case rate,100% PEIA with CHIP DRG base rate,40584.05,100,,,case rate,100% Highmark ACA DRG rate,51320.75,100,,,case rate,100% Highmark PPO DRG rate,51320.75,100,,,case rate,100% Highmark Trad DRG rate,11292.84,100,,,case rate,100% WV Medicaid DRG rate,19236.3,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,8954.3,100,,,case rate,100% PEIA DRG rate,38165.75,100,,,case rate,100% The Health Plan DRG rate,8954.3,52899.825,
VENTRICULAR SHUNT PROCEDURES WITHOUT CC/MCC,33,MS-DRG,,,,,Inpatient,,,,,,43733.47,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,43733.47,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,15903.08,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,8280.49,102,,,case rate,102% WV Medicaid DRG rate,26240.082,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,7567.62,100,,,case rate,100% PEIA with CHIP DRG base rate,30580.3,100,,,case rate,100% Highmark ACA DRG rate,38670.46,100,,,case rate,100% Highmark PPO DRG rate,38670.46,100,,,case rate,100% Highmark Trad DRG rate,8118.12,100,,,case rate,100% WV Medicaid DRG rate,15903.08,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,6437,100,,,case rate,100% PEIA DRG rate,28758.1,100,,,case rate,100% The Health Plan DRG rate,6437,43733.47,
CAROTID ARTERY STENT PROCEDURES WITH MCC,34,MS-DRG,,,,,Inpatient,,,,,,102977.765,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,102977.765,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,37446.46,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,26562.2,102,,,case rate,102% WV Medicaid DRG rate,61786.659,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,24275.43,100,,,case rate,100% PEIA with CHIP DRG base rate,73514.08,100,,,case rate,100% Highmark ACA DRG rate,92962.56,100,,,case rate,100% Highmark PPO DRG rate,92962.56,100,,,case rate,100% Highmark Trad DRG rate,26041.35,100,,,case rate,100% WV Medicaid DRG rate,37446.46,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,20648.65,100,,,case rate,100% PEIA DRG rate,69133.55,100,,,case rate,100% The Health Plan DRG rate,20648.65,102977.765,
CAROTID ARTERY STENT PROCEDURES WITH CC,35,MS-DRG,,,,,Inpatient,,,,,,58803.91,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,58803.91,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,21383.24,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,14487.3,102,,,case rate,102% WV Medicaid DRG rate,35282.346,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,13240.07,100,,,case rate,100% PEIA with CHIP DRG base rate,43329.48,100,,,case rate,100% Highmark ACA DRG rate,54792.49,100,,,case rate,100% Highmark PPO DRG rate,54792.49,100,,,case rate,100% Highmark Trad DRG rate,14203.22,100,,,case rate,100% WV Medicaid DRG rate,21383.24,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,11261.99,100,,,case rate,100% PEIA DRG rate,40747.58,100,,,case rate,100% The Health Plan DRG rate,11261.99,58803.91,
CAROTID ARTERY STENT PROCEDURES WITHOUT CC/MCC,36,MS-DRG,,,,,Inpatient,,,,,,48424.8325,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,48424.8325,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,17609.03,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,9030.1,102,,,case rate,102% WV Medicaid DRG rate,29054.8995,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,8252.69,100,,,case rate,100% PEIA with CHIP DRG base rate,34071.91,100,,,case rate,100% Highmark ACA DRG rate,43085.79,100,,,case rate,100% Highmark PPO DRG rate,43085.79,100,,,case rate,100% Highmark Trad DRG rate,8853.04,100,,,case rate,100% WV Medicaid DRG rate,17609.03,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,7019.73,100,,,case rate,100% PEIA DRG rate,32041.65,100,,,case rate,100% The Health Plan DRG rate,7019.73,48424.8325,
EXTRACRANIAL PROCEDURES WITH MCC,37,MS-DRG,,,,,Inpatient,,,,,,86848.9875,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,86848.9875,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,31581.45,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,15613.94,102,,,case rate,102% WV Medicaid DRG rate,52109.3925,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,14269.72,100,,,case rate,100% PEIA with CHIP DRG base rate,63606.43,100,,,case rate,100% Highmark ACA DRG rate,80433.8,100,,,case rate,100% Highmark PPO DRG rate,80433.8,100,,,case rate,100% Highmark Trad DRG rate,15307.77,100,,,case rate,100% WV Medicaid DRG rate,31581.45,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,12137.81,100,,,case rate,100% PEIA DRG rate,59816.27,100,,,case rate,100% The Health Plan DRG rate,12137.81,86848.9875,
EXTRACRANIAL PROCEDURES WITH CC,38,MS-DRG,,,,,Inpatient,,,,,,42111.355,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,42111.355,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,15313.22,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,12409.6,102,,,case rate,102% WV Medicaid DRG rate,25266.813,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,11341.24,100,,,case rate,100% PEIA with CHIP DRG base rate,30146.92,100,,,case rate,100% Highmark ACA DRG rate,38122.42,100,,,case rate,100% Highmark PPO DRG rate,38122.42,100,,,case rate,100% Highmark Trad DRG rate,12166.26,100,,,case rate,100% WV Medicaid DRG rate,15313.22,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,9646.84,100,,,case rate,100% PEIA DRG rate,28350.53,100,,,case rate,100% The Health Plan DRG rate,9646.84,42111.355,
EXTRACRANIAL PROCEDURES WITHOUT CC/MCC,39,MS-DRG,,,,,Inpatient,,,,,,29680.0625,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,29680.0625,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,10792.75,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,9424.97,102,,,case rate,102% WV Medicaid DRG rate,17808.0375,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,8613.56,100,,,case rate,100% PEIA with CHIP DRG base rate,21499.86,100,,,case rate,100% Highmark ACA DRG rate,27187.75,100,,,case rate,100% Highmark PPO DRG rate,27187.75,100,,,case rate,100% Highmark Trad DRG rate,9240.15,100,,,case rate,100% WV Medicaid DRG rate,10792.75,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,7326.68,100,,,case rate,100% PEIA DRG rate,20218.74,100,,,case rate,100% The Health Plan DRG rate,7326.68,29680.0625,
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH MCC",40,MS-DRG,,,,,Inpatient,,,,,,97544.8375,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,97544.8375,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,35470.85,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,13853.56,102,,,case rate,102% WV Medicaid DRG rate,58526.9025,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,12660.89,100,,,case rate,100% PEIA with CHIP DRG base rate,72554.97,100,,,case rate,100% Highmark ACA DRG rate,91749.71,100,,,case rate,100% Highmark PPO DRG rate,91749.71,100,,,case rate,100% Highmark Trad DRG rate,13581.91,100,,,case rate,100% WV Medicaid DRG rate,35470.85,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,10769.34,100,,,case rate,100% PEIA DRG rate,68231.59,100,,,case rate,100% The Health Plan DRG rate,10769.34,97544.8375,
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH CC OR PERIPHERAL NEUROSTIMULATOR",41,MS-DRG,,,,,Inpatient,,,,,,60202.065,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,60202.065,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,21891.66,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,12592.32,102,,,case rate,102% WV Medicaid DRG rate,36121.239,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,11508.23,100,,,case rate,100% PEIA with CHIP DRG base rate,42033.08,100,,,case rate,100% Highmark ACA DRG rate,53153.12,100,,,case rate,100% Highmark PPO DRG rate,53153.12,100,,,case rate,100% Highmark Trad DRG rate,12345.4,100,,,case rate,100% WV Medicaid DRG rate,21891.66,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,9788.89,100,,,case rate,100% PEIA DRG rate,39528.43,100,,,case rate,100% The Health Plan DRG rate,9788.89,60202.065,
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITHOUT CC/MCC",42,MS-DRG,,,,,Inpatient,,,,,,47626.645,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,47626.645,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,17318.78,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,9395.11,102,,,case rate,102% WV Medicaid DRG rate,28575.987,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,8586.27,100,,,case rate,100% PEIA with CHIP DRG base rate,32783.05,100,,,case rate,100% Highmark ACA DRG rate,41455.95,100,,,case rate,100% Highmark PPO DRG rate,41455.95,100,,,case rate,100% Highmark Trad DRG rate,9210.88,100,,,case rate,100% WV Medicaid DRG rate,17318.78,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,7303.47,100,,,case rate,100% PEIA DRG rate,30829.59,100,,,case rate,100% The Health Plan DRG rate,7303.47,47626.645,
SPINAL DISORDERS AND INJURIES WITH CC/MCC,52,MS-DRG,,,,,Inpatient,,,,,,45839.695,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,45839.695,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,16668.98,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,11824.44,102,,,case rate,102% WV Medicaid DRG rate,27503.817,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,10806.46,100,,,case rate,100% PEIA with CHIP DRG base rate,36640.21,100,,,case rate,100% Highmark ACA DRG rate,46333.55,100,,,case rate,100% Highmark PPO DRG rate,46333.55,100,,,case rate,100% Highmark Trad DRG rate,11592.57,100,,,case rate,100% WV Medicaid DRG rate,16668.98,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,9191.96,100,,,case rate,100% PEIA DRG rate,34456.91,100,,,case rate,100% The Health Plan DRG rate,9191.96,46333.55,
SPINAL DISORDERS AND INJURIES WITHOUT CC/MCC,53,MS-DRG,,,,,Inpatient,,,,,,26335.3475,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,26335.3475,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,9576.49,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,6792.86,102,,,case rate,102% WV Medicaid DRG rate,15801.2085,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,6208.05,100,,,case rate,100% PEIA with CHIP DRG base rate,18537.74,100,,,case rate,100% Highmark ACA DRG rate,23441.99,100,,,case rate,100% Highmark PPO DRG rate,23441.99,100,,,case rate,100% Highmark Trad DRG rate,6659.66,100,,,case rate,100% WV Medicaid DRG rate,9576.49,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,5280.56,100,,,case rate,100% PEIA DRG rate,17433.12,100,,,case rate,100% The Health Plan DRG rate,5280.56,26335.3475,
NERVOUS SYSTEM NEOPLASMS WITH MCC,54,MS-DRG,,,,,Inpatient,,,,,,35712.875,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,35712.875,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,12986.5,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,9087.6,102,,,case rate,102% WV Medicaid DRG rate,21427.725,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,8305.23,100,,,case rate,100% PEIA with CHIP DRG base rate,27765.16,100,,,case rate,100% Highmark ACA DRG rate,35110.56,100,,,case rate,100% Highmark PPO DRG rate,35110.56,100,,,case rate,100% Highmark Trad DRG rate,8909.4,100,,,case rate,100% WV Medicaid DRG rate,12986.5,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,7064.42,100,,,case rate,100% PEIA DRG rate,26110.7,100,,,case rate,100% The Health Plan DRG rate,7064.42,35712.875,
NERVOUS SYSTEM NEOPLASMS WITHOUT MCC,55,MS-DRG,,,,,Inpatient,,,,,,25962.0075,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,25962.0075,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,9440.73,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,5337.31,102,,,case rate,102% WV Medicaid DRG rate,15577.2045,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,4877.81,100,,,case rate,100% PEIA with CHIP DRG base rate,20222.31,100,,,case rate,100% Highmark ACA DRG rate,25572.21,100,,,case rate,100% Highmark PPO DRG rate,25572.21,100,,,case rate,100% Highmark Trad DRG rate,5232.65,100,,,case rate,100% WV Medicaid DRG rate,9440.73,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,4149.06,100,,,case rate,100% PEIA DRG rate,19017.31,100,,,case rate,100% The Health Plan DRG rate,4149.06,25962.0075,
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITH MCC,56,MS-DRG,,,,,Inpatient,,,,,,57439.305,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,57439.305,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,20887.02,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,13390.96,102,,,case rate,102% WV Medicaid DRG rate,34463.583,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,12238.11,100,,,case rate,100% PEIA with CHIP DRG base rate,45110.14,100,,,case rate,100% Highmark ACA DRG rate,57044.23,100,,,case rate,100% Highmark PPO DRG rate,57044.23,100,,,case rate,100% Highmark Trad DRG rate,13128.38,100,,,case rate,100% WV Medicaid DRG rate,20887.02,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,10409.72,100,,,case rate,100% PEIA DRG rate,42422.13,100,,,case rate,100% The Health Plan DRG rate,10409.72,57439.305,
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITHOUT MCC,57,MS-DRG,,,,,Inpatient,,,,,,33511.445,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,33511.445,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,12185.98,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,8332.64,102,,,case rate,102% WV Medicaid DRG rate,20106.867,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,7615.27,100,,,case rate,100% PEIA with CHIP DRG base rate,25686.78,100,,,case rate,100% Highmark ACA DRG rate,32482.33,100,,,case rate,100% Highmark PPO DRG rate,32482.33,100,,,case rate,100% Highmark Trad DRG rate,8169.24,100,,,case rate,100% WV Medicaid DRG rate,12185.98,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,6477.54,100,,,case rate,100% PEIA DRG rate,24156.16,100,,,case rate,100% The Health Plan DRG rate,6477.54,33511.445,
MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH MCC,58,MS-DRG,,,,,Inpatient,,,,,,44423.555,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,44423.555,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,16154.02,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,11458.54,102,,,case rate,102% WV Medicaid DRG rate,26654.133,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,10472.06,100,,,case rate,100% PEIA with CHIP DRG base rate,32558.82,100,,,case rate,100% Highmark ACA DRG rate,41172.4,100,,,case rate,100% Highmark PPO DRG rate,41172.4,100,,,case rate,100% Highmark Trad DRG rate,11233.86,100,,,case rate,100% WV Medicaid DRG rate,16154.02,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,8907.52,100,,,case rate,100% PEIA DRG rate,30618.72,100,,,case rate,100% The Health Plan DRG rate,8907.52,44423.555,
MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH CC,59,MS-DRG,,,,,Inpatient,,,,,,29443.1775,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,29443.1775,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,10706.61,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,6488.02,102,,,case rate,102% WV Medicaid DRG rate,17665.9065,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,5929.46,100,,,case rate,100% PEIA with CHIP DRG base rate,22370.41,100,,,case rate,100% Highmark ACA DRG rate,28288.6,100,,,case rate,100% Highmark PPO DRG rate,28288.6,100,,,case rate,100% Highmark Trad DRG rate,6360.8,100,,,case rate,100% WV Medicaid DRG rate,10706.61,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,5043.59,100,,,case rate,100% PEIA DRG rate,21037.41,100,,,case rate,100% The Health Plan DRG rate,5043.59,29443.1775,
MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITHOUT CC/MCC,60,MS-DRG,,,,,Inpatient,,,,,,23335.675,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,23335.675,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,8485.7,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,4663.91,102,,,case rate,102% WV Medicaid DRG rate,14001.405,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,4262.38,100,,,case rate,100% PEIA with CHIP DRG base rate,16909.71,100,,,case rate,100% Highmark ACA DRG rate,21383.25,100,,,case rate,100% Highmark PPO DRG rate,21383.25,100,,,case rate,100% Highmark Trad DRG rate,4572.45,100,,,case rate,100% WV Medicaid DRG rate,8485.7,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,3625.58,100,,,case rate,100% PEIA DRG rate,15902.1,100,,,case rate,100% The Health Plan DRG rate,3625.58,23335.675,
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH MCC",61,MS-DRG,,,,,Inpatient,,,,,,75509.4175,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,75509.4175,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,27457.97,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,13658.36,102,,,case rate,102% WV Medicaid DRG rate,45305.6505,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,12482.49,100,,,case rate,100% PEIA with CHIP DRG base rate,52813.16,100,,,case rate,100% Highmark ACA DRG rate,66785.12,100,,,case rate,100% Highmark PPO DRG rate,66785.12,100,,,case rate,100% Highmark Trad DRG rate,13390.53,100,,,case rate,100% WV Medicaid DRG rate,27457.97,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,10617.59,100,,,case rate,100% PEIA DRG rate,49666.15,100,,,case rate,100% The Health Plan DRG rate,10617.59,75509.4175,
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH CC",62,MS-DRG,,,,,Inpatient,,,,,,49364.645,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,49364.645,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,17950.78,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,11183.12,102,,,case rate,102% WV Medicaid DRG rate,29618.787,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,10220.35,100,,,case rate,100% PEIA with CHIP DRG base rate,35268.44,100,,,case rate,100% Highmark ACA DRG rate,44598.87,100,,,case rate,100% Highmark PPO DRG rate,44598.87,100,,,case rate,100% Highmark Trad DRG rate,10963.83,100,,,case rate,100% WV Medicaid DRG rate,17950.78,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,8693.42,100,,,case rate,100% PEIA DRG rate,33166.88,100,,,case rate,100% The Health Plan DRG rate,8693.42,49364.645,
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITHOUT CC/MCC",63,MS-DRG,,,,,Inpatient,,,,,,40708.0025,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,40708.0025,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,14802.91,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,8038.5,102,,,case rate,102% WV Medicaid DRG rate,24424.8015,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,7346.45,100,,,case rate,100% PEIA with CHIP DRG base rate,28015.77,100,,,case rate,100% Highmark ACA DRG rate,35427.47,100,,,case rate,100% Highmark PPO DRG rate,35427.47,100,,,case rate,100% Highmark Trad DRG rate,7880.87,100,,,case rate,100% WV Medicaid DRG rate,14802.91,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,6248.88,100,,,case rate,100% PEIA DRG rate,26346.38,100,,,case rate,100% The Health Plan DRG rate,6248.88,40708.0025,
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH MCC,64,MS-DRG,,,,,Inpatient,,,,,,50775.5875,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,50775.5875,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,18463.85,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,11114.04,102,,,case rate,102% WV Medicaid DRG rate,30465.3525,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,10157.22,100,,,case rate,100% PEIA with CHIP DRG base rate,37742.53,100,,,case rate,100% Highmark ACA DRG rate,47727.48,100,,,case rate,100% Highmark PPO DRG rate,47727.48,100,,,case rate,100% Highmark Trad DRG rate,10896.11,100,,,case rate,100% WV Medicaid DRG rate,18463.85,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,8639.72,100,,,case rate,100% PEIA DRG rate,35493.54,100,,,case rate,100% The Health Plan DRG rate,8639.72,50775.5875,
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH CC OR TPA IN 24 HOURS,65,MS-DRG,,,,,Inpatient,,,,,,26170.5675,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,26170.5675,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,9516.57,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,6033.89,102,,,case rate,102% WV Medicaid DRG rate,15702.3405,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,5514.42,100,,,case rate,100% PEIA with CHIP DRG base rate,19152.03,100,,,case rate,100% Highmark ACA DRG rate,24218.78,100,,,case rate,100% Highmark PPO DRG rate,24218.78,100,,,case rate,100% Highmark Trad DRG rate,5915.57,100,,,case rate,100% WV Medicaid DRG rate,9516.57,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,4690.56,100,,,case rate,100% PEIA DRG rate,18010.8,100,,,case rate,100% The Health Plan DRG rate,4690.56,26170.5675,
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITHOUT CC/MCC,66,MS-DRG,,,,,Inpatient,,,,,,17985.1925,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,17985.1925,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,6540.07,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,5704.98,102,,,case rate,102% WV Medicaid DRG rate,10791.1155,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,5213.83,100,,,case rate,100% PEIA with CHIP DRG base rate,12954.56,100,,,case rate,100% Highmark ACA DRG rate,16381.75,100,,,case rate,100% Highmark PPO DRG rate,16381.75,100,,,case rate,100% Highmark Trad DRG rate,5593.12,100,,,case rate,100% WV Medicaid DRG rate,6540.07,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,4434.88,100,,,case rate,100% PEIA DRG rate,12182.63,100,,,case rate,100% The Health Plan DRG rate,4434.88,17985.1925,
NONSPECIFIC CVA AND PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITH MCC,67,MS-DRG,,,,,Inpatient,,,,,,36410.66,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,36410.66,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,13240.24,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,9391.99,102,,,case rate,102% WV Medicaid DRG rate,21846.396,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,8583.42,100,,,case rate,100% PEIA with CHIP DRG base rate,26698.65,100,,,case rate,100% Highmark ACA DRG rate,33761.89,100,,,case rate,100% Highmark PPO DRG rate,33761.89,100,,,case rate,100% Highmark Trad DRG rate,9207.82,100,,,case rate,100% WV Medicaid DRG rate,13240.24,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,7301.05,100,,,case rate,100% PEIA DRG rate,25107.74,100,,,case rate,100% The Health Plan DRG rate,7301.05,36410.66,
NONSPECIFIC CVA AND PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITHOUT MCC,68,MS-DRG,,,,,Inpatient,,,,,,23268.7675,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,23268.7675,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,8461.37,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,5509.78,102,,,case rate,102% WV Medicaid DRG rate,13961.2605,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,5035.44,100,,,case rate,100% PEIA with CHIP DRG base rate,16412.25,100,,,case rate,100% Highmark ACA DRG rate,20754.19,100,,,case rate,100% Highmark PPO DRG rate,20754.19,100,,,case rate,100% Highmark Trad DRG rate,5401.74,100,,,case rate,100% WV Medicaid DRG rate,8461.37,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,4283.14,100,,,case rate,100% PEIA DRG rate,15434.29,100,,,case rate,100% The Health Plan DRG rate,4283.14,23268.7675,
TRANSIENT ISCHEMIA WITHOUT THROMBOLYTIC,69,MS-DRG,,,,,Inpatient,,,,,,20544.59,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,20544.59,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,7470.76,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,5314.58,102,,,case rate,102% WV Medicaid DRG rate,12326.754,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,4857.04,100,,,case rate,100% PEIA with CHIP DRG base rate,15049.9,100,,,case rate,100% Highmark ACA DRG rate,19031.42,100,,,case rate,100% Highmark PPO DRG rate,19031.42,100,,,case rate,100% Highmark Trad DRG rate,5210.37,100,,,case rate,100% WV Medicaid DRG rate,7470.76,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,4131.39,100,,,case rate,100% PEIA DRG rate,14153.12,100,,,case rate,100% The Health Plan DRG rate,4131.39,20544.59,
NONSPECIFIC CEREBROVASCULAR DISORDERS WITH MCC,70,MS-DRG,,,,,Inpatient,,,,,,44395.2025,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,44395.2025,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,16143.71,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,8828.22,102,,,case rate,102% WV Medicaid DRG rate,26637.1215,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,8068.19,100,,,case rate,100% PEIA with CHIP DRG base rate,33719.55,100,,,case rate,100% Highmark ACA DRG rate,42640.21,100,,,case rate,100% Highmark PPO DRG rate,42640.21,100,,,case rate,100% Highmark Trad DRG rate,8655.11,100,,,case rate,100% WV Medicaid DRG rate,16143.71,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,6862.79,100,,,case rate,100% PEIA DRG rate,31710.28,100,,,case rate,100% The Health Plan DRG rate,6862.79,44395.2025,
NONSPECIFIC CEREBROVASCULAR DISORDERS WITH CC,71,MS-DRG,,,,,Inpatient,,,,,,27524.9425,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,27524.9425,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,10009.07,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,5320.82,102,,,case rate,102% WV Medicaid DRG rate,16514.9655,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,4862.74,100,,,case rate,100% PEIA with CHIP DRG base rate,20007.5,100,,,case rate,100% Highmark ACA DRG rate,25300.57,100,,,case rate,100% Highmark PPO DRG rate,25300.57,100,,,case rate,100% Highmark Trad DRG rate,5216.48,100,,,case rate,100% WV Medicaid DRG rate,10009.07,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,4136.24,100,,,case rate,100% PEIA DRG rate,18815.3,100,,,case rate,100% The Health Plan DRG rate,4136.24,27524.9425,
NONSPECIFIC CEREBROVASCULAR DISORDERS WITHOUT CC/MCC,72,MS-DRG,,,,,Inpatient,,,,,,19877.66,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,19877.66,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,7228.24,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,4212.44,102,,,case rate,102% WV Medicaid DRG rate,11926.596,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,3849.79,100,,,case rate,100% PEIA with CHIP DRG base rate,14754.07,100,,,case rate,100% Highmark ACA DRG rate,18657.32,100,,,case rate,100% Highmark PPO DRG rate,18657.32,100,,,case rate,100% Highmark Trad DRG rate,4129.84,100,,,case rate,100% WV Medicaid DRG rate,7228.24,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,3274.63,100,,,case rate,100% PEIA DRG rate,13874.91,100,,,case rate,100% The Health Plan DRG rate,3274.63,19877.66,
CRANIAL AND PERIPHERAL NERVE DISORDERS WITH MCC,73,MS-DRG,,,,,Inpatient,,,,,,38604.445,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,38604.445,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,14037.98,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,7999.28,102,,,case rate,102% WV Medicaid DRG rate,23162.667,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,7310.61,100,,,case rate,100% PEIA with CHIP DRG base rate,28509.46,100,,,case rate,100% Highmark ACA DRG rate,36051.76,100,,,case rate,100% Highmark PPO DRG rate,36051.76,100,,,case rate,100% Highmark Trad DRG rate,7842.42,100,,,case rate,100% WV Medicaid DRG rate,14037.98,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,6218.4,100,,,case rate,100% PEIA DRG rate,26810.65,100,,,case rate,100% The Health Plan DRG rate,6218.4,38604.445,
CRANIAL AND PERIPHERAL NERVE DISORDERS WITHOUT MCC,74,MS-DRG,,,,,Inpatient,,,,,,26355.945,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,26355.945,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,9583.98,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,4728.08,102,,,case rate,102% WV Medicaid DRG rate,15813.567,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,4321.04,100,,,case rate,100% PEIA with CHIP DRG base rate,19336.69,100,,,case rate,100% Highmark ACA DRG rate,24452.29,100,,,case rate,100% Highmark PPO DRG rate,24452.29,100,,,case rate,100% Highmark Trad DRG rate,4635.37,100,,,case rate,100% WV Medicaid DRG rate,9583.98,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,3675.47,100,,,case rate,100% PEIA DRG rate,18184.46,100,,,case rate,100% The Health Plan DRG rate,3675.47,26355.945,
VIRAL MENINGITIS WITH CC/MCC,75,MS-DRG,,,,,Inpatient,,,,,,46990.5975,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,46990.5975,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,17087.49,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,12120.81,102,,,case rate,102% WV Medicaid DRG rate,28194.3585,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,11077.31,100,,,case rate,100% PEIA with CHIP DRG base rate,36061.73,100,,,case rate,100% Highmark ACA DRG rate,45602.03,100,,,case rate,100% Highmark PPO DRG rate,45602.03,100,,,case rate,100% Highmark Trad DRG rate,11883.13,100,,,case rate,100% WV Medicaid DRG rate,17087.49,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,9422.35,100,,,case rate,100% PEIA DRG rate,33912.9,100,,,case rate,100% The Health Plan DRG rate,9422.35,46990.5975,
VIRAL MENINGITIS WITHOUT CC/MCC,76,MS-DRG,,,,,Inpatient,,,,,,25421.275,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,25421.275,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,9244.1,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,4848.41,102,,,case rate,102% WV Medicaid DRG rate,15252.765,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,4431.01,100,,,case rate,100% PEIA with CHIP DRG base rate,17382.67,100,,,case rate,100% Highmark ACA DRG rate,21981.33,100,,,case rate,100% Highmark PPO DRG rate,21981.33,100,,,case rate,100% Highmark Trad DRG rate,4753.34,100,,,case rate,100% WV Medicaid DRG rate,9244.1,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,3769.01,100,,,case rate,100% PEIA DRG rate,16346.88,100,,,case rate,100% The Health Plan DRG rate,3769.01,25421.275,
HYPERTENSIVE ENCEPHALOPATHY WITH MCC,77,MS-DRG,,,,,Inpatient,,,,,,40275.4825,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,40275.4825,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,14645.63,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,10388.94,102,,,case rate,102% WV Medicaid DRG rate,24165.2895,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,9494.55,100,,,case rate,100% PEIA with CHIP DRG base rate,28469.89,100,,,case rate,100% Highmark ACA DRG rate,36001.73,100,,,case rate,100% Highmark PPO DRG rate,36001.73,100,,,case rate,100% Highmark Trad DRG rate,10185.23,100,,,case rate,100% WV Medicaid DRG rate,14645.63,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,8076.05,100,,,case rate,100% PEIA DRG rate,26773.44,100,,,case rate,100% The Health Plan DRG rate,8076.05,40275.4825,
HYPERTENSIVE ENCEPHALOPATHY WITH CC,78,MS-DRG,,,,,Inpatient,,,,,,25562.8725,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,25562.8725,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,9295.59,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,6593.2,102,,,case rate,102% WV Medicaid DRG rate,15337.7235,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,6025.58,100,,,case rate,100% PEIA with CHIP DRG base rate,19161.45,100,,,case rate,100% Highmark ACA DRG rate,24230.69,100,,,case rate,100% Highmark PPO DRG rate,24230.69,100,,,case rate,100% Highmark Trad DRG rate,6463.91,100,,,case rate,100% WV Medicaid DRG rate,9295.59,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,5125.35,100,,,case rate,100% PEIA DRG rate,18019.66,100,,,case rate,100% The Health Plan DRG rate,5125.35,25562.8725,
HYPERTENSIVE ENCEPHALOPATHY WITHOUT CC/MCC,79,MS-DRG,,,,,Inpatient,,,,,,18896.7075,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,18896.7075,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,6871.53,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,4873.81,102,,,case rate,102% WV Medicaid DRG rate,11338.0245,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,4454.22,100,,,case rate,100% PEIA with CHIP DRG base rate,13958.89,100,,,case rate,100% Highmark ACA DRG rate,17651.78,100,,,case rate,100% Highmark PPO DRG rate,17651.78,100,,,case rate,100% Highmark Trad DRG rate,4778.24,100,,,case rate,100% WV Medicaid DRG rate,6871.53,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,3788.76,100,,,case rate,100% PEIA DRG rate,13127.12,100,,,case rate,100% The Health Plan DRG rate,3788.76,18896.7075,
NONTRAUMATIC STUPOR AND COMA WITH MCC,80,MS-DRG,,,,,Inpatient,,,,,,52521.3425,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,52521.3425,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,19098.67,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,13547.83,102,,,case rate,102% WV Medicaid DRG rate,31512.8055,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,12381.48,100,,,case rate,100% PEIA with CHIP DRG base rate,41618.53,100,,,case rate,100% Highmark ACA DRG rate,52628.9,100,,,case rate,100% Highmark PPO DRG rate,52628.9,100,,,case rate,100% Highmark Trad DRG rate,13282.17,100,,,case rate,100% WV Medicaid DRG rate,19098.67,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,10531.67,100,,,case rate,100% PEIA DRG rate,39138.58,100,,,case rate,100% The Health Plan DRG rate,10531.67,52628.9,
NONTRAUMATIC STUPOR AND COMA WITHOUT MCC,81,MS-DRG,,,,,Inpatient,,,,,,23134.815,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,23134.815,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,8412.66,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,6506.29,102,,,case rate,102% WV Medicaid DRG rate,13880.889,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,5946.16,100,,,case rate,100% PEIA with CHIP DRG base rate,17137.71,100,,,case rate,100% Highmark ACA DRG rate,21671.57,100,,,case rate,100% Highmark PPO DRG rate,21671.57,100,,,case rate,100% Highmark Trad DRG rate,6378.71,100,,,case rate,100% WV Medicaid DRG rate,8412.66,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,5057.79,100,,,case rate,100% PEIA DRG rate,16116.51,100,,,case rate,100% The Health Plan DRG rate,5057.79,23134.815,
TRAUMATIC STUPOR AND COMA >1 HOUR WITH MCC,82,MS-DRG,,,,,Inpatient,,,,,,58327.61,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,58327.61,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,21210.04,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,9797.1,102,,,case rate,102% WV Medicaid DRG rate,34996.566,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,8953.65,100,,,case rate,100% PEIA with CHIP DRG base rate,42930.01,100,,,case rate,100% Highmark ACA DRG rate,54287.33,100,,,case rate,100% Highmark PPO DRG rate,54287.33,100,,,case rate,100% Highmark Trad DRG rate,9604.99,100,,,case rate,100% WV Medicaid DRG rate,21210.04,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,7615.97,100,,,case rate,100% PEIA DRG rate,40371.91,100,,,case rate,100% The Health Plan DRG rate,7615.97,58327.61,
TRAUMATIC STUPOR AND COMA >1 HOUR WITH CC,83,MS-DRG,,,,,Inpatient,,,,,,34713.855,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,34713.855,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,12623.22,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,5590.45,102,,,case rate,102% WV Medicaid DRG rate,20828.313,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,5109.16,100,,,case rate,100% PEIA with CHIP DRG base rate,25558.65,100,,,case rate,100% Highmark ACA DRG rate,32320.3,100,,,case rate,100% Highmark PPO DRG rate,32320.3,100,,,case rate,100% Highmark Trad DRG rate,5480.82,100,,,case rate,100% WV Medicaid DRG rate,12623.22,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,4345.84,100,,,case rate,100% PEIA DRG rate,24035.67,100,,,case rate,100% The Health Plan DRG rate,4345.84,34713.855,
TRAUMATIC STUPOR AND COMA >1 HOUR WITHOUT CC/MCC,84,MS-DRG,,,,,Inpatient,,,,,,23598.3275,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,23598.3275,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,8581.21,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,3480.21,102,,,case rate,102% WV Medicaid DRG rate,14158.9965,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,3180.6,100,,,case rate,100% PEIA with CHIP DRG base rate,17329.91,100,,,case rate,100% Highmark ACA DRG rate,21914.61,100,,,case rate,100% Highmark PPO DRG rate,21914.61,100,,,case rate,100% Highmark Trad DRG rate,3411.97,100,,,case rate,100% WV Medicaid DRG rate,8581.21,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,2705.41,100,,,case rate,100% PEIA DRG rate,16297.26,100,,,case rate,100% The Health Plan DRG rate,2705.41,23598.3275,
TRAUMATIC STUPOR AND COMA <1 HOUR WITH MCC,85,MS-DRG,,,,,Inpatient,,,,,,60140.3,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,60140.3,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,21869.2,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,9064.87,102,,,case rate,102% WV Medicaid DRG rate,36084.18,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,8284.46,100,,,case rate,100% PEIA with CHIP DRG base rate,42826.37,100,,,case rate,100% Highmark ACA DRG rate,54156.28,100,,,case rate,100% Highmark PPO DRG rate,54156.28,100,,,case rate,100% Highmark Trad DRG rate,8887.12,100,,,case rate,100% WV Medicaid DRG rate,21869.2,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,7046.75,100,,,case rate,100% PEIA DRG rate,40274.45,100,,,case rate,100% The Health Plan DRG rate,7046.75,60140.3,
TRAUMATIC STUPOR AND COMA <1 HOUR WITH CC,86,MS-DRG,,,,,Inpatient,,,,,,33465.025,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,33465.025,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,12169.1,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,4729.86,102,,,case rate,102% WV Medicaid DRG rate,20079.015,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,4322.66,100,,,case rate,100% PEIA with CHIP DRG base rate,24818.12,100,,,case rate,100% Highmark ACA DRG rate,31383.86,100,,,case rate,100% Highmark PPO DRG rate,31383.86,100,,,case rate,100% Highmark Trad DRG rate,4637.12,100,,,case rate,100% WV Medicaid DRG rate,12169.1,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,3676.85,100,,,case rate,100% PEIA DRG rate,23339.26,100,,,case rate,100% The Health Plan DRG rate,3676.85,33465.025,
TRAUMATIC STUPOR AND COMA <1 HOUR WITHOUT CC/MCC,87,MS-DRG,,,,,Inpatient,,,,,,22462.825,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,22462.825,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,8168.3,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,2738.62,102,,,case rate,102% WV Medicaid DRG rate,13477.695,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,2502.85,100,,,case rate,100% PEIA with CHIP DRG base rate,16698.67,100,,,case rate,100% Highmark ACA DRG rate,21116.37,100,,,case rate,100% Highmark PPO DRG rate,21116.37,100,,,case rate,100% Highmark Trad DRG rate,2684.92,100,,,case rate,100% WV Medicaid DRG rate,8168.3,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,2128.92,100,,,case rate,100% PEIA DRG rate,15703.63,100,,,case rate,100% The Health Plan DRG rate,2128.92,22462.825,
CONCUSSION WITH MCC,88,MS-DRG,,,,,Inpatient,,,,,,40587.0025,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,40587.0025,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,14758.91,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,10469.61,102,,,case rate,102% WV Medicaid DRG rate,24352.2015,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,9568.27,100,,,case rate,100% PEIA with CHIP DRG base rate,28901.39,100,,,case rate,100% Highmark ACA DRG rate,36547.39,100,,,case rate,100% Highmark PPO DRG rate,36547.39,100,,,case rate,100% Highmark Trad DRG rate,10264.31,100,,,case rate,100% WV Medicaid DRG rate,14758.91,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,8138.76,100,,,case rate,100% PEIA DRG rate,27179.23,100,,,case rate,100% The Health Plan DRG rate,8138.76,40587.0025,
CONCUSSION WITH CC,89,MS-DRG,,,,,Inpatient,,,,,,30066.2725,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,30066.2725,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,10933.19,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,5930.05,102,,,case rate,102% WV Medicaid DRG rate,18039.7635,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,5419.52,100,,,case rate,100% PEIA with CHIP DRG base rate,21667.57,100,,,case rate,100% Highmark ACA DRG rate,27399.82,100,,,case rate,100% Highmark PPO DRG rate,27399.82,100,,,case rate,100% Highmark Trad DRG rate,5813.76,100,,,case rate,100% WV Medicaid DRG rate,10933.19,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,4609.84,100,,,case rate,100% PEIA DRG rate,20376.45,100,,,case rate,100% The Health Plan DRG rate,4609.84,30066.2725,
CONCUSSION WITHOUT CC/MCC,90,MS-DRG,,,,,Inpatient,,,,,,21193.48,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,21193.48,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,7706.72,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,4262.36,102,,,case rate,102% WV Medicaid DRG rate,12716.088,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,3895.41,100,,,case rate,100% PEIA with CHIP DRG base rate,17614.44,100,,,case rate,100% Highmark ACA DRG rate,22274.41,100,,,case rate,100% Highmark PPO DRG rate,22274.41,100,,,case rate,100% Highmark Trad DRG rate,4178.78,100,,,case rate,100% WV Medicaid DRG rate,7706.72,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,3313.43,100,,,case rate,100% PEIA DRG rate,16564.83,100,,,case rate,100% The Health Plan DRG rate,3313.43,22274.41,
OTHER DISORDERS OF NERVOUS SYSTEM WITH MCC,91,MS-DRG,,,,,Inpatient,,,,,,44477.565,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,44477.565,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,16173.66,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,8327.29,102,,,case rate,102% WV Medicaid DRG rate,26686.539,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,7610.38,100,,,case rate,100% PEIA with CHIP DRG base rate,33713.9,100,,,case rate,100% Highmark ACA DRG rate,42633.06,100,,,case rate,100% Highmark PPO DRG rate,42633.06,100,,,case rate,100% Highmark Trad DRG rate,8164,100,,,case rate,100% WV Medicaid DRG rate,16173.66,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,6473.38,100,,,case rate,100% PEIA DRG rate,31704.96,100,,,case rate,100% The Health Plan DRG rate,6473.38,44477.565,
OTHER DISORDERS OF NERVOUS SYSTEM WITH CC,92,MS-DRG,,,,,Inpatient,,,,,,25601.5375,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,25601.5375,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,9309.65,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,5472.35,102,,,case rate,102% WV Medicaid DRG rate,15360.9225,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,5001.22,100,,,case rate,100% PEIA with CHIP DRG base rate,19334.8,100,,,case rate,100% Highmark ACA DRG rate,24449.91,100,,,case rate,100% Highmark PPO DRG rate,24449.91,100,,,case rate,100% Highmark Trad DRG rate,5365.04,100,,,case rate,100% WV Medicaid DRG rate,9309.65,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,4254.03,100,,,case rate,100% PEIA DRG rate,18182.69,100,,,case rate,100% The Health Plan DRG rate,4254.03,25601.5375,
OTHER DISORDERS OF NERVOUS SYSTEM WITHOUT CC/MCC,93,MS-DRG,,,,,Inpatient,,,,,,19692.31,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,19692.31,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,7160.84,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,4749.03,102,,,case rate,102% WV Medicaid DRG rate,11815.386,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,4340.18,100,,,case rate,100% PEIA with CHIP DRG base rate,14592.02,100,,,case rate,100% Highmark ACA DRG rate,18452.4,100,,,case rate,100% Highmark PPO DRG rate,18452.4,100,,,case rate,100% Highmark Trad DRG rate,4655.9,100,,,case rate,100% WV Medicaid DRG rate,7160.84,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,3691.75,100,,,case rate,100% PEIA DRG rate,13722.52,100,,,case rate,100% The Health Plan DRG rate,3691.75,19692.31,
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH MCC,94,MS-DRG,,,,,Inpatient,,,,,,92011.4525,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,92011.4525,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,33458.71,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,15693.27,102,,,case rate,102% WV Medicaid DRG rate,55206.8715,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,14342.22,100,,,case rate,100% PEIA with CHIP DRG base rate,68262.54,100,,,case rate,100% Highmark ACA DRG rate,86321.7,100,,,case rate,100% Highmark PPO DRG rate,86321.7,100,,,case rate,100% Highmark Trad DRG rate,15385.55,100,,,case rate,100% WV Medicaid DRG rate,33458.71,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,12199.47,100,,,case rate,100% PEIA DRG rate,64194.93,100,,,case rate,100% The Health Plan DRG rate,12199.47,92011.4525,
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH CC,95,MS-DRG,,,,,Inpatient,,,,,,65833.2125,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,65833.2125,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,23939.35,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,12730.03,102,,,case rate,102% WV Medicaid DRG rate,39499.9275,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,11634.09,100,,,case rate,100% PEIA with CHIP DRG base rate,44925.48,100,,,case rate,100% Highmark ACA DRG rate,56810.72,100,,,case rate,100% Highmark PPO DRG rate,56810.72,100,,,case rate,100% Highmark Trad DRG rate,12480.41,100,,,case rate,100% WV Medicaid DRG rate,23939.35,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,9895.94,100,,,case rate,100% PEIA DRG rate,42248.48,100,,,case rate,100% The Health Plan DRG rate,9895.94,65833.2125,
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITHOUT CC/MCC,96,MS-DRG,,,,,Inpatient,,,,,,58816.835,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,58816.835,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,21387.94,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,9151.33,102,,,case rate,102% WV Medicaid DRG rate,35290.101,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,8363.48,100,,,case rate,100% PEIA with CHIP DRG base rate,41072.09,100,,,case rate,100% Highmark ACA DRG rate,51937.89,100,,,case rate,100% Highmark PPO DRG rate,51937.89,100,,,case rate,100% Highmark Trad DRG rate,8971.88,100,,,case rate,100% WV Medicaid DRG rate,21387.94,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,7113.96,100,,,case rate,100% PEIA DRG rate,38624.7,100,,,case rate,100% The Health Plan DRG rate,7113.96,58816.835,
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH MCC,97,MS-DRG,,,,,Inpatient,,,,,,100114.4925,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,100114.4925,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,36405.27,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,10618.46,102,,,case rate,102% WV Medicaid DRG rate,60068.6955,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,9704.31,100,,,case rate,100% PEIA with CHIP DRG base rate,68530.11,100,,,case rate,100% Highmark ACA DRG rate,86660.05,100,,,case rate,100% Highmark PPO DRG rate,86660.05,100,,,case rate,100% Highmark Trad DRG rate,10410.25,100,,,case rate,100% WV Medicaid DRG rate,36405.27,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,8254.47,100,,,case rate,100% PEIA DRG rate,64446.56,100,,,case rate,100% The Health Plan DRG rate,8254.47,100114.4925,
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH CC,98,MS-DRG,,,,,Inpatient,,,,,,53664.5725,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,53664.5725,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,19514.39,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,7959.17,102,,,case rate,102% WV Medicaid DRG rate,32198.7435,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,7273.95,100,,,case rate,100% PEIA with CHIP DRG base rate,40597.24,100,,,case rate,100% Highmark ACA DRG rate,51337.43,100,,,case rate,100% Highmark PPO DRG rate,51337.43,100,,,case rate,100% Highmark Trad DRG rate,7803.1,100,,,case rate,100% WV Medicaid DRG rate,19514.39,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,6187.21,100,,,case rate,100% PEIA DRG rate,38178.15,100,,,case rate,100% The Health Plan DRG rate,6187.21,53664.5725,
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITHOUT CC/MCC,99,MS-DRG,,,,,Inpatient,,,,,,36008.995,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,36008.995,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,13094.18,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,6682.33,102,,,case rate,102% WV Medicaid DRG rate,21605.397,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,6107.04,100,,,case rate,100% PEIA with CHIP DRG base rate,24876.53,100,,,case rate,100% Highmark ACA DRG rate,31457.73,100,,,case rate,100% Highmark PPO DRG rate,31457.73,100,,,case rate,100% Highmark Trad DRG rate,6551.3,100,,,case rate,100% WV Medicaid DRG rate,13094.18,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,5194.64,100,,,case rate,100% PEIA DRG rate,23394.19,100,,,case rate,100% The Health Plan DRG rate,5194.64,36008.995,
SEIZURES WITH MCC,100,MS-DRG,,,,,Inpatient,,,,,,49462.4625,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,49462.4625,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,17986.35,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,7473.84,102,,,case rate,102% WV Medicaid DRG rate,29677.4775,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,6830.4,100,,,case rate,100% PEIA with CHIP DRG base rate,37356.25,100,,,case rate,100% Highmark ACA DRG rate,47239.01,100,,,case rate,100% Highmark PPO DRG rate,47239.01,100,,,case rate,100% Highmark Trad DRG rate,7327.28,100,,,case rate,100% WV Medicaid DRG rate,17986.35,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,5809.93,100,,,case rate,100% PEIA DRG rate,35130.28,100,,,case rate,100% The Health Plan DRG rate,5809.93,49462.4625,
SEIZURES WITHOUT MCC,101,MS-DRG,,,,,Inpatient,,,,,,23212.09,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,23212.09,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,8440.76,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,3051.48,102,,,case rate,102% WV Medicaid DRG rate,13927.254,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,2788.78,100,,,case rate,100% PEIA with CHIP DRG base rate,17139.59,100,,,case rate,100% Highmark ACA DRG rate,21673.95,100,,,case rate,100% Highmark PPO DRG rate,21673.95,100,,,case rate,100% Highmark Trad DRG rate,2991.65,100,,,case rate,100% WV Medicaid DRG rate,8440.76,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,2372.13,100,,,case rate,100% PEIA DRG rate,16118.28,100,,,case rate,100% The Health Plan DRG rate,2372.13,23212.09,
HEADACHES WITH MCC,102,MS-DRG,,,,,Inpatient,,,,,,29607.9575,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,29607.9575,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,10766.53,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,6131.49,102,,,case rate,102% WV Medicaid DRG rate,17764.7745,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,5603.62,100,,,case rate,100% PEIA with CHIP DRG base rate,22735.96,100,,,case rate,100% Highmark ACA DRG rate,28750.86,100,,,case rate,100% Highmark PPO DRG rate,28750.86,100,,,case rate,100% Highmark Trad DRG rate,6011.26,100,,,case rate,100% WV Medicaid DRG rate,10766.53,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,4766.43,100,,,case rate,100% PEIA DRG rate,21381.18,100,,,case rate,100% The Health Plan DRG rate,4766.43,29607.9575,
HEADACHES WITHOUT MCC,103,MS-DRG,,,,,Inpatient,,,,,,21435.4525,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,21435.4525,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,7794.71,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,3624.61,102,,,case rate,102% WV Medicaid DRG rate,12861.2715,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,3312.56,100,,,case rate,100% PEIA with CHIP DRG base rate,15873.34,100,,,case rate,100% Highmark ACA DRG rate,20072.71,100,,,case rate,100% Highmark PPO DRG rate,20072.71,100,,,case rate,100% Highmark Trad DRG rate,3553.54,100,,,case rate,100% WV Medicaid DRG rate,7794.71,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,2817.66,100,,,case rate,100% PEIA DRG rate,14927.49,100,,,case rate,100% The Health Plan DRG rate,2817.66,21435.4525,
ORBITAL PROCEDURES WITH CC/MCC,113,MS-DRG,,,,,Inpatient,,,,,,57812.645,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,57812.645,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,21022.78,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,17081.97,102,,,case rate,102% WV Medicaid DRG rate,34687.587,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,15611.36,100,,,case rate,100% PEIA with CHIP DRG base rate,47245.05,100,,,case rate,100% Highmark ACA DRG rate,59743.94,100,,,case rate,100% Highmark PPO DRG rate,59743.94,100,,,case rate,100% Highmark Trad DRG rate,16747.01,100,,,case rate,100% WV Medicaid DRG rate,21022.78,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,13279.01,100,,,case rate,100% PEIA DRG rate,44429.83,100,,,case rate,100% The Health Plan DRG rate,13279.01,59743.94,
ORBITAL PROCEDURES WITHOUT CC/MCC,114,MS-DRG,,,,,Inpatient,,,,,,33544.8575,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,33544.8575,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,12198.13,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,8653.07,102,,,case rate,102% WV Medicaid DRG rate,20126.9145,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,7908.12,100,,,case rate,100% PEIA with CHIP DRG base rate,23210.81,100,,,case rate,100% Highmark ACA DRG rate,29351.33,100,,,case rate,100% Highmark PPO DRG rate,29351.33,100,,,case rate,100% Highmark Trad DRG rate,8483.39,100,,,case rate,100% WV Medicaid DRG rate,12198.13,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,6726.63,100,,,case rate,100% PEIA DRG rate,21827.73,100,,,case rate,100% The Health Plan DRG rate,6726.63,33544.8575,
EXTRAOCULAR PROCEDURES EXCEPT ORBIT,115,MS-DRG,,,,,Inpatient,,,,,,39114.24,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,39114.24,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,14223.36,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,9590.75,102,,,case rate,102% WV Medicaid DRG rate,23468.544,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,8765.07,100,,,case rate,100% PEIA with CHIP DRG base rate,29477.99,100,,,case rate,100% Highmark ACA DRG rate,37276.52,100,,,case rate,100% Highmark PPO DRG rate,37276.52,100,,,case rate,100% Highmark Trad DRG rate,9402.69,100,,,case rate,100% WV Medicaid DRG rate,14223.36,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,7455.56,100,,,case rate,100% PEIA DRG rate,27721.47,100,,,case rate,100% The Health Plan DRG rate,7455.56,39114.24,
INTRAOCULAR PROCEDURES WITH CC/MCC,116,MS-DRG,,,,,Inpatient,,,,,,48574.1575,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,48574.1575,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,17663.33,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,8499.76,102,,,case rate,102% WV Medicaid DRG rate,29144.4945,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,7768.01,100,,,case rate,100% PEIA with CHIP DRG base rate,34497.76,100,,,case rate,100% Highmark ACA DRG rate,43624.3,100,,,case rate,100% Highmark PPO DRG rate,43624.3,100,,,case rate,100% Highmark Trad DRG rate,8333.09,100,,,case rate,100% WV Medicaid DRG rate,17663.33,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,6607.46,100,,,case rate,100% PEIA DRG rate,32442.12,100,,,case rate,100% The Health Plan DRG rate,6607.46,48574.1575,
INTRAOCULAR PROCEDURES WITHOUT CC/MCC,117,MS-DRG,,,,,Inpatient,,,,,,25562.8725,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,25562.8725,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,9295.59,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,6593.2,102,,,case rate,102% WV Medicaid DRG rate,15337.7235,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,6025.58,100,,,case rate,100% PEIA with CHIP DRG base rate,22581.45,100,,,case rate,100% Highmark ACA DRG rate,28555.48,100,,,case rate,100% Highmark PPO DRG rate,28555.48,100,,,case rate,100% Highmark Trad DRG rate,6463.91,100,,,case rate,100% WV Medicaid DRG rate,9295.59,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,5125.35,100,,,case rate,100% PEIA DRG rate,21235.88,100,,,case rate,100% The Health Plan DRG rate,5125.35,28555.48,
ACUTE MAJOR EYE INFECTIONS WITH CC/MCC,121,MS-DRG,,,,,Inpatient,,,,,,31549.4025,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,31549.4025,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,11472.51,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,4403.64,102,,,case rate,102% WV Medicaid DRG rate,18929.6415,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,4024.52,100,,,case rate,100% PEIA with CHIP DRG base rate,24141.65,100,,,case rate,100% Highmark ACA DRG rate,30528.43,100,,,case rate,100% Highmark PPO DRG rate,30528.43,100,,,case rate,100% Highmark Trad DRG rate,4317.29,100,,,case rate,100% WV Medicaid DRG rate,11472.51,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,3423.25,100,,,case rate,100% PEIA DRG rate,22703.11,100,,,case rate,100% The Health Plan DRG rate,3423.25,31549.4025,
ACUTE MAJOR EYE INFECTIONS WITHOUT CC/MCC,122,MS-DRG,,,,,Inpatient,,,,,,17786.945,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,17786.945,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,6467.98,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,2675.78,102,,,case rate,102% WV Medicaid DRG rate,10672.167,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,2445.42,100,,,case rate,100% PEIA with CHIP DRG base rate,14028.61,100,,,case rate,100% Highmark ACA DRG rate,17739.95,100,,,case rate,100% Highmark PPO DRG rate,17739.95,100,,,case rate,100% Highmark Trad DRG rate,2623.32,100,,,case rate,100% WV Medicaid DRG rate,6467.98,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,2080.07,100,,,case rate,100% PEIA DRG rate,13192.68,100,,,case rate,100% The Health Plan DRG rate,2080.07,17786.945,
NEUROLOGICAL EYE DISORDERS,123,MS-DRG,,,,,Inpatient,,,,,,20438.99,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,20438.99,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,7432.36,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,6012.49,102,,,case rate,102% WV Medicaid DRG rate,12263.394,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,5494.87,100,,,case rate,100% PEIA with CHIP DRG base rate,15149.77,100,,,case rate,100% Highmark ACA DRG rate,19157.71,100,,,case rate,100% Highmark PPO DRG rate,19157.71,100,,,case rate,100% Highmark Trad DRG rate,5894.6,100,,,case rate,100% WV Medicaid DRG rate,7432.36,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,4673.93,100,,,case rate,100% PEIA DRG rate,14247.03,100,,,case rate,100% The Health Plan DRG rate,4673.93,20438.99,
OTHER DISORDERS OF THE EYE WITH MCC OR THROMBOLYTIC AGENT,124,MS-DRG,,,,,Inpatient,,,,,,36065.59,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,36065.59,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,13114.76,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,4935.76,102,,,case rate,102% WV Medicaid DRG rate,21639.354,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,4510.84,100,,,case rate,100% PEIA with CHIP DRG base rate,24908.56,100,,,case rate,100% Highmark ACA DRG rate,31498.23,100,,,case rate,100% Highmark PPO DRG rate,31498.23,100,,,case rate,100% Highmark Trad DRG rate,4838.98,100,,,case rate,100% WV Medicaid DRG rate,13114.76,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,3836.91,100,,,case rate,100% PEIA DRG rate,23424.32,100,,,case rate,100% The Health Plan DRG rate,3836.91,36065.59,
OTHER DISORDERS OF THE EYE WITHOUT MCC,125,MS-DRG,,,,,Inpatient,,,,,,22197.615,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,22197.615,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,8071.86,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,3970,102,,,case rate,102% WV Medicaid DRG rate,13318.569,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,3628.22,100,,,case rate,100% PEIA with CHIP DRG base rate,15027.29,100,,,case rate,100% Highmark ACA DRG rate,19002.83,100,,,case rate,100% Highmark PPO DRG rate,19002.83,100,,,case rate,100% Highmark Trad DRG rate,3892.15,100,,,case rate,100% WV Medicaid DRG rate,8071.86,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,3086.16,100,,,case rate,100% PEIA DRG rate,14131.85,100,,,case rate,100% The Health Plan DRG rate,3086.16,22197.615,
SINUS AND MASTOID PROCEDURES WITH CC/MCC,135,MS-DRG,,,,,Inpatient,,,,,,63101.335,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,63101.335,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,22945.94,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,16276.65,102,,,case rate,102% WV Medicaid DRG rate,37860.801,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,14875.37,100,,,case rate,100% PEIA with CHIP DRG base rate,49973.52,100,,,case rate,100% Highmark ACA DRG rate,63194.24,100,,,case rate,100% Highmark PPO DRG rate,63194.24,100,,,case rate,100% Highmark Trad DRG rate,15957.48,100,,,case rate,100% WV Medicaid DRG rate,22945.94,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,12652.97,100,,,case rate,100% PEIA DRG rate,46995.72,100,,,case rate,100% The Health Plan DRG rate,12652.97,63194.24,
SINUS AND MASTOID PROCEDURES WITHOUT CC/MCC,136,MS-DRG,,,,,Inpatient,,,,,,29875.6975,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,29875.6975,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,10863.89,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,7705.58,102,,,case rate,102% WV Medicaid DRG rate,17925.4185,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,7042.2,100,,,case rate,100% PEIA with CHIP DRG base rate,17695.46,100,,,case rate,100% Highmark ACA DRG rate,22376.87,100,,,case rate,100% Highmark PPO DRG rate,22376.87,100,,,case rate,100% Highmark Trad DRG rate,7554.49,100,,,case rate,100% WV Medicaid DRG rate,10863.89,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,5990.09,100,,,case rate,100% PEIA DRG rate,16641.03,100,,,case rate,100% The Health Plan DRG rate,5990.09,29875.6975,
MOUTH PROCEDURES WITH CC/MCC,137,MS-DRG,,,,,Inpatient,,,,,,38612.145,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,38612.145,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,14040.78,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,5988.43,102,,,case rate,102% WV Medicaid DRG rate,23167.287,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,5472.88,100,,,case rate,100% PEIA with CHIP DRG base rate,28353.06,100,,,case rate,100% Highmark ACA DRG rate,35853.99,100,,,case rate,100% Highmark PPO DRG rate,35853.99,100,,,case rate,100% Highmark Trad DRG rate,5871,100,,,case rate,100% WV Medicaid DRG rate,14040.78,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,4655.22,100,,,case rate,100% PEIA DRG rate,26663.57,100,,,case rate,100% The Health Plan DRG rate,4655.22,38612.145,
MOUTH PROCEDURES WITHOUT CC/MCC,138,MS-DRG,,,,,Inpatient,,,,,,22769.175,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,22769.175,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,8279.7,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,3638.87,102,,,case rate,102% WV Medicaid DRG rate,13661.505,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,3325.6,100,,,case rate,100% PEIA with CHIP DRG base rate,16312.39,100,,,case rate,100% Highmark ACA DRG rate,20627.9,100,,,case rate,100% Highmark PPO DRG rate,20627.9,100,,,case rate,100% Highmark Trad DRG rate,3567.52,100,,,case rate,100% WV Medicaid DRG rate,8279.7,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,2828.75,100,,,case rate,100% PEIA DRG rate,15340.37,100,,,case rate,100% The Health Plan DRG rate,2828.75,22769.175,
SALIVARY GLAND PROCEDURES,139,MS-DRG,,,,,Inpatient,,,,,,32378.445,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,32378.445,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,11773.98,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,8351.35,102,,,case rate,102% WV Medicaid DRG rate,19427.067,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,7632.38,100,,,case rate,100% PEIA with CHIP DRG base rate,22379.83,100,,,case rate,100% Highmark ACA DRG rate,28300.52,100,,,case rate,100% Highmark PPO DRG rate,28300.52,100,,,case rate,100% Highmark Trad DRG rate,8187.59,100,,,case rate,100% WV Medicaid DRG rate,11773.98,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,6492.09,100,,,case rate,100% PEIA DRG rate,21046.27,100,,,case rate,100% The Health Plan DRG rate,6492.09,32378.445,
MAJOR HEAD AND NECK PROCEDURES WITH MCC,140,MS-DRG,,,,,Inpatient,,,,,,107017.5975,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,107017.5975,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,38915.49,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,18825.87,102,,,case rate,102% WV Medicaid DRG rate,64210.5585,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,17205.12,100,,,case rate,100% PEIA with CHIP DRG base rate,71190.74,100,,,case rate,100% Highmark ACA DRG rate,90024.57,100,,,case rate,100% Highmark PPO DRG rate,90024.57,100,,,case rate,100% Highmark Trad DRG rate,18456.71,100,,,case rate,100% WV Medicaid DRG rate,38915.49,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,14634.66,100,,,case rate,100% PEIA DRG rate,66948.65,100,,,case rate,100% The Health Plan DRG rate,14634.66,107017.5975,
MAJOR HEAD AND NECK PROCEDURES WITH CC,141,MS-DRG,,,,,Inpatient,,,,,,57485.6425,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,57485.6425,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,20903.87,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,14054.11,102,,,case rate,102% WV Medicaid DRG rate,34491.3855,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,12844.17,100,,,case rate,100% PEIA with CHIP DRG base rate,39037.04,100,,,case rate,100% Highmark ACA DRG rate,49364.47,100,,,case rate,100% Highmark PPO DRG rate,49364.47,100,,,case rate,100% Highmark Trad DRG rate,13778.52,100,,,case rate,100% WV Medicaid DRG rate,20903.87,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,10925.24,100,,,case rate,100% PEIA DRG rate,36710.92,100,,,case rate,100% The Health Plan DRG rate,10925.24,57485.6425,
MAJOR HEAD AND NECK PROCEDURES WITHOUT CC/MCC,142,MS-DRG,,,,,Inpatient,,,,,,43815.86,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,43815.86,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,15933.04,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,10818.57,102,,,case rate,102% WV Medicaid DRG rate,26289.516,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,9887.18,100,,,case rate,100% PEIA with CHIP DRG base rate,29112.44,100,,,case rate,100% Highmark ACA DRG rate,36814.26,100,,,case rate,100% Highmark PPO DRG rate,36814.26,100,,,case rate,100% Highmark Trad DRG rate,10606.43,100,,,case rate,100% WV Medicaid DRG rate,15933.04,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,8410.03,100,,,case rate,100% PEIA DRG rate,27377.69,100,,,case rate,100% The Health Plan DRG rate,8410.03,43815.86,
"OTHER EAR, NOSE, MOUTH AND THROAT O.R. PROCEDURES WITH MCC",143,MS-DRG,,,,,Inpatient,,,,,,81689.025,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,81689.025,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,29705.1,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,10372.01,102,,,case rate,102% WV Medicaid DRG rate,49013.415,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,9479.07,100,,,case rate,100% PEIA with CHIP DRG base rate,62664.28,100,,,case rate,100% Highmark ACA DRG rate,79242.4,100,,,case rate,100% Highmark PPO DRG rate,79242.4,100,,,case rate,100% Highmark Trad DRG rate,10168.63,100,,,case rate,100% WV Medicaid DRG rate,29705.1,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,8062.88,100,,,case rate,100% PEIA DRG rate,58930.26,100,,,case rate,100% The Health Plan DRG rate,8062.88,81689.025,
"OTHER EAR, NOSE, MOUTH AND THROAT O.R. PROCEDURES WITH CC",144,MS-DRG,,,,,Inpatient,,,,,,46586.3475,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,46586.3475,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,16940.49,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,6726.9,102,,,case rate,102% WV Medicaid DRG rate,27951.8085,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,6147.77,100,,,case rate,100% PEIA with CHIP DRG base rate,32607.81,100,,,case rate,100% Highmark ACA DRG rate,41234.35,100,,,case rate,100% Highmark PPO DRG rate,41234.35,100,,,case rate,100% Highmark Trad DRG rate,6594.99,100,,,case rate,100% WV Medicaid DRG rate,16940.49,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,5229.29,100,,,case rate,100% PEIA DRG rate,30664.79,100,,,case rate,100% The Health Plan DRG rate,5229.29,46586.3475,
"OTHER EAR, NOSE, MOUTH AND THROAT O.R. PROCEDURES WITHOUT CC/MCC",145,MS-DRG,,,,,Inpatient,,,,,,31098.815,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,31098.815,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,11308.66,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,4570.32,102,,,case rate,102% WV Medicaid DRG rate,18659.289,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,4176.85,100,,,case rate,100% PEIA with CHIP DRG base rate,23009.19,100,,,case rate,100% Highmark ACA DRG rate,29096.37,100,,,case rate,100% Highmark PPO DRG rate,29096.37,100,,,case rate,100% Highmark Trad DRG rate,4480.7,100,,,case rate,100% WV Medicaid DRG rate,11308.66,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,3552.82,100,,,case rate,100% PEIA DRG rate,21638.12,100,,,case rate,100% The Health Plan DRG rate,3552.82,31098.815,
"EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITH MCC",146,MS-DRG,,,,,Inpatient,,,,,,51862.195,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,51862.195,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,18858.98,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,16614.91,102,,,case rate,102% WV Medicaid DRG rate,31117.317,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,15184.51,100,,,case rate,100% PEIA with CHIP DRG base rate,39777.57,100,,,case rate,100% Highmark ACA DRG rate,50300.91,100,,,case rate,100% Highmark PPO DRG rate,50300.91,100,,,case rate,100% Highmark Trad DRG rate,16289.11,100,,,case rate,100% WV Medicaid DRG rate,18858.98,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,12915.93,100,,,case rate,100% PEIA DRG rate,37407.32,100,,,case rate,100% The Health Plan DRG rate,12915.93,51862.195,
"EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITH CC",147,MS-DRG,,,,,Inpatient,,,,,,31183.7625,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,31183.7625,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,11339.55,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,5815.06,102,,,case rate,102% WV Medicaid DRG rate,18710.2575,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,5314.44,100,,,case rate,100% PEIA with CHIP DRG base rate,23286.18,100,,,case rate,100% Highmark ACA DRG rate,29446.64,100,,,case rate,100% Highmark PPO DRG rate,29446.64,100,,,case rate,100% Highmark Trad DRG rate,5701.04,100,,,case rate,100% WV Medicaid DRG rate,11339.55,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,4520.45,100,,,case rate,100% PEIA DRG rate,21898.61,100,,,case rate,100% The Health Plan DRG rate,4520.45,31183.7625,
"EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITHOUT CC/MCC",148,MS-DRG,,,,,Inpatient,,,,,,21051.8,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,21051.8,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,7655.2,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,5430.01,102,,,case rate,102% WV Medicaid DRG rate,12631.08,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,4962.53,100,,,case rate,100% PEIA with CHIP DRG base rate,16764.62,100,,,case rate,100% Highmark ACA DRG rate,21199.77,100,,,case rate,100% Highmark PPO DRG rate,21199.77,100,,,case rate,100% Highmark Trad DRG rate,5323.53,100,,,case rate,100% WV Medicaid DRG rate,7655.2,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,4221.12,100,,,case rate,100% PEIA DRG rate,15765.65,100,,,case rate,100% The Health Plan DRG rate,4221.12,21199.77,
DYSEQUILIBRIUM,149,MS-DRG,,,,,Inpatient,,,,,,19439.9975,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,19439.9975,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,7069.09,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,4187.49,102,,,case rate,102% WV Medicaid DRG rate,11663.9985,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,3826.98,100,,,case rate,100% PEIA with CHIP DRG base rate,14032.38,100,,,case rate,100% Highmark ACA DRG rate,17744.71,100,,,case rate,100% Highmark PPO DRG rate,17744.71,100,,,case rate,100% Highmark Trad DRG rate,4105.38,100,,,case rate,100% WV Medicaid DRG rate,7069.09,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,3255.23,100,,,case rate,100% PEIA DRG rate,13196.23,100,,,case rate,100% The Health Plan DRG rate,3255.23,19439.9975,
EPISTAXIS WITH MCC,150,MS-DRG,,,,,Inpatient,,,,,,35514.6275,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,35514.6275,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,12914.41,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,9161.13,102,,,case rate,102% WV Medicaid DRG rate,21308.7765,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,8372.44,100,,,case rate,100% PEIA with CHIP DRG base rate,24769.12,100,,,case rate,100% Highmark ACA DRG rate,31321.91,100,,,case rate,100% Highmark PPO DRG rate,31321.91,100,,,case rate,100% Highmark Trad DRG rate,8981.49,100,,,case rate,100% WV Medicaid DRG rate,12914.41,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,7121.59,100,,,case rate,100% PEIA DRG rate,23293.19,100,,,case rate,100% The Health Plan DRG rate,7121.59,35514.6275,
EPISTAXIS WITHOUT MCC,151,MS-DRG,,,,,Inpatient,,,,,,19851.9475,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,19851.9475,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,7218.89,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,5121.16,102,,,case rate,102% WV Medicaid DRG rate,11911.1685,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,4680.27,100,,,case rate,100% PEIA with CHIP DRG base rate,14522.3,100,,,case rate,100% Highmark ACA DRG rate,18364.24,100,,,case rate,100% Highmark PPO DRG rate,18364.24,100,,,case rate,100% Highmark Trad DRG rate,5020.74,100,,,case rate,100% WV Medicaid DRG rate,7218.89,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,3981.03,100,,,case rate,100% PEIA DRG rate,13656.95,100,,,case rate,100% The Health Plan DRG rate,3981.03,19851.9475,
OTITIS MEDIA AND URI WITH MCC,152,MS-DRG,,,,,Inpatient,,,,,,30838.72,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,30838.72,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,11214.08,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,6451.48,102,,,case rate,102% WV Medicaid DRG rate,18503.232,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,5896.06,100,,,case rate,100% PEIA with CHIP DRG base rate,22389.25,100,,,case rate,100% Highmark ACA DRG rate,28312.43,100,,,case rate,100% Highmark PPO DRG rate,28312.43,100,,,case rate,100% Highmark Trad DRG rate,6324.97,100,,,case rate,100% WV Medicaid DRG rate,11214.08,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,5015.18,100,,,case rate,100% PEIA DRG rate,21055.13,100,,,case rate,100% The Health Plan DRG rate,5015.18,30838.72,
OTITIS MEDIA AND URI WITHOUT MCC,153,MS-DRG,,,,,Inpatient,,,,,,17779.245,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,17779.245,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,6465.18,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,2388.33,102,,,case rate,102% WV Medicaid DRG rate,10667.547,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,2182.72,100,,,case rate,100% PEIA with CHIP DRG base rate,13845.84,100,,,case rate,100% Highmark ACA DRG rate,17508.81,100,,,case rate,100% Highmark PPO DRG rate,17508.81,100,,,case rate,100% Highmark Trad DRG rate,2341.5,100,,,case rate,100% WV Medicaid DRG rate,6465.18,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,1856.61,100,,,case rate,100% PEIA DRG rate,13020.8,100,,,case rate,100% The Health Plan DRG rate,1856.61,17779.245,
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH MCC",154,MS-DRG,,,,,Inpatient,,,,,,38697.12,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,38697.12,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,14071.68,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,9981.6,102,,,case rate,102% WV Medicaid DRG rate,23218.272,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,9122.28,100,,,case rate,100% PEIA with CHIP DRG base rate,28984.3,100,,,case rate,100% Highmark ACA DRG rate,36652.23,100,,,case rate,100% Highmark PPO DRG rate,36652.23,100,,,case rate,100% Highmark Trad DRG rate,9785.88,100,,,case rate,100% WV Medicaid DRG rate,14071.68,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,7759.4,100,,,case rate,100% PEIA DRG rate,27257.2,100,,,case rate,100% The Health Plan DRG rate,7759.4,38697.12,
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH CC",155,MS-DRG,,,,,Inpatient,,,,,,23670.3775,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,23670.3775,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,8607.41,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,4904.57,102,,,case rate,102% WV Medicaid DRG rate,14202.2265,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,4482.33,100,,,case rate,100% PEIA with CHIP DRG base rate,17836.78,100,,,case rate,100% Highmark ACA DRG rate,22555.58,100,,,case rate,100% Highmark PPO DRG rate,22555.58,100,,,case rate,100% Highmark Trad DRG rate,4808.39,100,,,case rate,100% WV Medicaid DRG rate,8607.41,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,3812.66,100,,,case rate,100% PEIA DRG rate,16773.93,100,,,case rate,100% The Health Plan DRG rate,3812.66,23670.3775,
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITHOUT CC/MCC",156,MS-DRG,,,,,Inpatient,,,,,,17552.59,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,17552.59,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,6382.76,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,2716.34,102,,,case rate,102% WV Medicaid DRG rate,10531.554,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,2482.49,100,,,case rate,100% PEIA with CHIP DRG base rate,12351.59,100,,,case rate,100% Highmark ACA DRG rate,15619.25,100,,,case rate,100% Highmark PPO DRG rate,15619.25,100,,,case rate,100% Highmark Trad DRG rate,2663.08,100,,,case rate,100% WV Medicaid DRG rate,6382.76,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,2111.6,100,,,case rate,100% PEIA DRG rate,11615.58,100,,,case rate,100% The Health Plan DRG rate,2111.6,17552.59,
DENTAL AND ORAL DISEASES WITH MCC,157,MS-DRG,,,,,Inpatient,,,,,,43045.97,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,43045.97,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,15653.08,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,6527.24,102,,,case rate,102% WV Medicaid DRG rate,25827.582,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,5965.3,100,,,case rate,100% PEIA with CHIP DRG base rate,32165,100,,,case rate,100% Highmark ACA DRG rate,40674.4,100,,,case rate,100% Highmark PPO DRG rate,40674.4,100,,,case rate,100% Highmark Trad DRG rate,6399.25,100,,,case rate,100% WV Medicaid DRG rate,15653.08,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,5074.08,100,,,case rate,100% PEIA DRG rate,30248.36,100,,,case rate,100% The Health Plan DRG rate,5074.08,43045.97,
DENTAL AND ORAL DISEASES WITH CC,158,MS-DRG,,,,,Inpatient,,,,,,23922.745,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,23922.745,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,8699.18,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,4006.1,102,,,case rate,102% WV Medicaid DRG rate,14353.647,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,3661.21,100,,,case rate,100% PEIA with CHIP DRG base rate,17684.16,100,,,case rate,100% Highmark ACA DRG rate,22362.58,100,,,case rate,100% Highmark PPO DRG rate,22362.58,100,,,case rate,100% Highmark Trad DRG rate,3927.55,100,,,case rate,100% WV Medicaid DRG rate,8699.18,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,3114.22,100,,,case rate,100% PEIA DRG rate,16630.4,100,,,case rate,100% The Health Plan DRG rate,3114.22,23922.745,
DENTAL AND ORAL DISEASES WITHOUT CC/MCC,159,MS-DRG,,,,,Inpatient,,,,,,19308.63,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,19308.63,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,7021.32,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,3667.84,102,,,case rate,102% WV Medicaid DRG rate,11585.178,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,3352.07,100,,,case rate,100% PEIA with CHIP DRG base rate,12722.79,100,,,case rate,100% Highmark ACA DRG rate,16088.67,100,,,case rate,100% Highmark PPO DRG rate,16088.67,100,,,case rate,100% Highmark Trad DRG rate,3595.92,100,,,case rate,100% WV Medicaid DRG rate,7021.32,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,2851.27,100,,,case rate,100% PEIA DRG rate,11964.67,100,,,case rate,100% The Health Plan DRG rate,2851.27,19308.63,
MAJOR CHEST PROCEDURES WITH MCC,163,MS-DRG,,,,,Inpatient,,,,,,124717.01,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,124717.01,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,45351.64,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,18727.37,102,,,case rate,102% WV Medicaid DRG rate,74830.206,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,17115.11,100,,,case rate,100% PEIA with CHIP DRG base rate,88818.36,100,,,case rate,100% Highmark ACA DRG rate,112315.66,100,,,case rate,100% Highmark PPO DRG rate,112315.66,100,,,case rate,100% Highmark Trad DRG rate,18360.15,100,,,case rate,100% WV Medicaid DRG rate,45351.64,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,14558.09,100,,,case rate,100% PEIA DRG rate,83525.89,100,,,case rate,100% The Health Plan DRG rate,14558.09,124717.01,
MAJOR CHEST PROCEDURES WITH CC,164,MS-DRG,,,,,Inpatient,,,,,,66500.06,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,66500.06,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,24181.84,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,14823.78,102,,,case rate,102% WV Medicaid DRG rate,39900.036,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,13547.58,100,,,case rate,100% PEIA with CHIP DRG base rate,48057.19,100,,,case rate,100% Highmark ACA DRG rate,60770.93,100,,,case rate,100% Highmark PPO DRG rate,60770.93,100,,,case rate,100% Highmark Trad DRG rate,14533.1,100,,,case rate,100% WV Medicaid DRG rate,24181.84,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,11523.55,100,,,case rate,100% PEIA DRG rate,45193.57,100,,,case rate,100% The Health Plan DRG rate,11523.55,66500.06,
MAJOR CHEST PROCEDURES WITHOUT CC/MCC,165,MS-DRG,,,,,Inpatient,,,,,,49614.345,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,49614.345,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,18041.58,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,10240.09,102,,,case rate,102% WV Medicaid DRG rate,29768.607,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,9358.51,100,,,case rate,100% PEIA with CHIP DRG base rate,35357.01,100,,,case rate,100% Highmark ACA DRG rate,44710.86,100,,,case rate,100% Highmark PPO DRG rate,44710.86,100,,,case rate,100% Highmark Trad DRG rate,10039.29,100,,,case rate,100% WV Medicaid DRG rate,18041.58,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,7960.34,100,,,case rate,100% PEIA DRG rate,33250.16,100,,,case rate,100% The Health Plan DRG rate,7960.34,49614.345,
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH MCC,166,MS-DRG,,,,,Inpatient,,,,,,94388.0575,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,94388.0575,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,34322.93,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,18781.74,102,,,case rate,102% WV Medicaid DRG rate,56632.8345,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,17164.8,100,,,case rate,100% PEIA with CHIP DRG base rate,76461.13,100,,,case rate,100% Highmark ACA DRG rate,96689.26,100,,,case rate,100% Highmark PPO DRG rate,96689.26,100,,,case rate,100% Highmark Trad DRG rate,18413.46,100,,,case rate,100% WV Medicaid DRG rate,34322.93,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,14600.36,100,,,case rate,100% PEIA DRG rate,71904.99,100,,,case rate,100% The Health Plan DRG rate,14600.36,96689.26,
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH CC,167,MS-DRG,,,,,Inpatient,,,,,,48950.055,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,48950.055,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,17800.02,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,10351.95,102,,,case rate,102% WV Medicaid DRG rate,29370.033,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,9460.74,100,,,case rate,100% PEIA with CHIP DRG base rate,34290.49,100,,,case rate,100% Highmark ACA DRG rate,43362.19,100,,,case rate,100% Highmark PPO DRG rate,43362.19,100,,,case rate,100% Highmark Trad DRG rate,10148.96,100,,,case rate,100% WV Medicaid DRG rate,17800.02,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,8047.29,100,,,case rate,100% PEIA DRG rate,32247.2,100,,,case rate,100% The Health Plan DRG rate,8047.29,48950.055,
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITHOUT CC/MCC,168,MS-DRG,,,,,Inpatient,,,,,,36500.7775,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,36500.7775,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,13273.01,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,8469.46,102,,,case rate,102% WV Medicaid DRG rate,21900.4665,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,7740.31,100,,,case rate,100% PEIA with CHIP DRG base rate,25545.46,100,,,case rate,100% Highmark ACA DRG rate,32303.62,100,,,case rate,100% Highmark PPO DRG rate,32303.62,100,,,case rate,100% Highmark Trad DRG rate,8303.38,100,,,case rate,100% WV Medicaid DRG rate,13273.01,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,6583.9,100,,,case rate,100% PEIA DRG rate,24023.26,100,,,case rate,100% The Health Plan DRG rate,6583.9,36500.7775,
ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS WITH PRINCIPAL DIAGNOSIS PULMONARY EMBOLISM,173,MS-DRG,,,,,Inpatient,,,,,,35965.1875,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,35965.1875,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,13078.25,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,,,,,other,Not Separately reimbursable,21579.1125,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,,,,,other,Not Separately reimbursable,57942.23,100,,,case rate,100% Highmark ACA DRG rate,73271.1,100,,,case rate,100% Highmark PPO DRG rate,73271.1,100,,,case rate,100% Highmark Trad DRG rate,,,,,other,Not Separately reimbursable,13078.25,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,,,,,other,Not Separately reimbursable,54489.58,100,,,case rate,100% The Health Plan DRG rate,13078.25,73271.1,
PULMONARY EMBOLISM WITH MCC OR ACUTE COR PULMONALE,175,MS-DRG,,,,,Inpatient,,,,,,21051.8,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,21051.8,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,7655.2,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,7245.21,102,,,case rate,102% WV Medicaid DRG rate,12631.08,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,6621.46,100,,,case rate,100% PEIA with CHIP DRG base rate,26436.73,100,,,case rate,100% Highmark ACA DRG rate,33430.68,100,,,case rate,100% Highmark PPO DRG rate,33430.68,100,,,case rate,100% Highmark Trad DRG rate,7103.14,100,,,case rate,100% WV Medicaid DRG rate,7655.2,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,5632.21,100,,,case rate,100% PEIA DRG rate,24861.43,100,,,case rate,100% The Health Plan DRG rate,5632.21,33430.68,
PULMONARY EMBOLISM WITHOUT MCC,176,MS-DRG,,,,,Inpatient,,,,,,45829.3825,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,45829.3825,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,16665.23,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,5584.21,102,,,case rate,102% WV Medicaid DRG rate,27497.6295,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,5103.46,100,,,case rate,100% PEIA with CHIP DRG base rate,15368.35,100,,,case rate,100% Highmark ACA DRG rate,19434.12,100,,,case rate,100% Highmark PPO DRG rate,19434.12,100,,,case rate,100% Highmark Trad DRG rate,5474.71,100,,,case rate,100% WV Medicaid DRG rate,16665.23,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,4340.99,100,,,case rate,100% PEIA DRG rate,14452.59,100,,,case rate,100% The Health Plan DRG rate,4340.99,45829.3825,
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH MCC,177,MS-DRG,,,,,Inpatient,,,,,,27988.3725,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,27988.3725,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,10177.59,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,8573.74,102,,,case rate,102% WV Medicaid DRG rate,16793.0235,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,7835.62,100,,,case rate,100% PEIA with CHIP DRG base rate,31965.27,100,,,case rate,100% Highmark ACA DRG rate,40421.82,100,,,case rate,100% Highmark PPO DRG rate,40421.82,100,,,case rate,100% Highmark Trad DRG rate,8405.62,100,,,case rate,100% WV Medicaid DRG rate,10177.59,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,6664.97,100,,,case rate,100% PEIA DRG rate,30060.53,100,,,case rate,100% The Health Plan DRG rate,6664.97,40421.82,
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH CC,178,MS-DRG,,,,,Inpatient,,,,,,20222.73,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,20222.73,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,7353.72,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,5993.78,102,,,case rate,102% WV Medicaid DRG rate,12133.638,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,5477.76,100,,,case rate,100% PEIA with CHIP DRG base rate,18592.39,100,,,case rate,100% Highmark ACA DRG rate,23511.09,100,,,case rate,100% Highmark PPO DRG rate,23511.09,100,,,case rate,100% Highmark Trad DRG rate,5876.24,100,,,case rate,100% WV Medicaid DRG rate,7353.72,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,4659.38,100,,,case rate,100% PEIA DRG rate,17484.51,100,,,case rate,100% The Health Plan DRG rate,4659.38,23511.09,
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITHOUT CC/MCC,179,MS-DRG,,,,,Inpatient,,,,,,43615,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,43615,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,15860,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,5444.71,102,,,case rate,102% WV Medicaid DRG rate,26169,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,4975.97,100,,,case rate,100% PEIA with CHIP DRG base rate,14382.86,100,,,case rate,100% Highmark ACA DRG rate,18187.91,100,,,case rate,100% Highmark PPO DRG rate,18187.91,100,,,case rate,100% Highmark Trad DRG rate,5337.95,100,,,case rate,100% WV Medicaid DRG rate,15860,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,4232.56,100,,,case rate,100% PEIA DRG rate,13525.82,100,,,case rate,100% The Health Plan DRG rate,4232.56,43615,
RESPIRATORY NEOPLASMS WITH MCC,180,MS-DRG,,,,,Inpatient,,,,,,29190.8375,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,29190.8375,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,10614.85,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,9112.11,102,,,case rate,102% WV Medicaid DRG rate,17514.5025,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,8327.64,100,,,case rate,100% PEIA with CHIP DRG base rate,32752.9,100,,,case rate,100% Highmark ACA DRG rate,41417.83,100,,,case rate,100% Highmark PPO DRG rate,41417.83,100,,,case rate,100% Highmark Trad DRG rate,8933.43,100,,,case rate,100% WV Medicaid DRG rate,10614.85,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,7083.48,100,,,case rate,100% PEIA DRG rate,30801.23,100,,,case rate,100% The Health Plan DRG rate,7083.48,41417.83,
RESPIRATORY NEOPLASMS WITH CC,181,MS-DRG,,,,,Inpatient,,,,,,22851.565,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,22851.565,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,8309.66,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,6564.23,102,,,case rate,102% WV Medicaid DRG rate,13710.939,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,5999.11,100,,,case rate,100% PEIA with CHIP DRG base rate,20748.03,100,,,case rate,100% Highmark ACA DRG rate,26237.01,100,,,case rate,100% Highmark PPO DRG rate,26237.01,100,,,case rate,100% Highmark Trad DRG rate,6435.51,100,,,case rate,100% WV Medicaid DRG rate,8309.66,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,5102.83,100,,,case rate,100% PEIA DRG rate,19511.7,100,,,case rate,100% The Health Plan DRG rate,5102.83,26237.01,
RESPIRATORY NEOPLASMS WITHOUT CC/MCC,182,MS-DRG,,,,,Inpatient,,,,,,38679.1075,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,38679.1075,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,14065.13,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,5894.39,102,,,case rate,102% WV Medicaid DRG rate,23207.4645,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,5386.94,100,,,case rate,100% PEIA with CHIP DRG base rate,14301.84,100,,,case rate,100% Highmark ACA DRG rate,18085.45,100,,,case rate,100% Highmark PPO DRG rate,18085.45,100,,,case rate,100% Highmark Trad DRG rate,5778.81,100,,,case rate,100% WV Medicaid DRG rate,14065.13,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,4582.12,100,,,case rate,100% PEIA DRG rate,13449.62,100,,,case rate,100% The Health Plan DRG rate,4582.12,38679.1075,
MAJOR CHEST TRAUMA WITH MCC,183,MS-DRG,,,,,Inpatient,,,,,,26912.1325,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,26912.1325,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,9786.23,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,6110.09,102,,,case rate,102% WV Medicaid DRG rate,16147.2795,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,5584.07,100,,,case rate,100% PEIA with CHIP DRG base rate,29668.3,100,,,case rate,100% Highmark ACA DRG rate,37517.19,100,,,case rate,100% Highmark PPO DRG rate,37517.19,100,,,case rate,100% Highmark Trad DRG rate,5990.28,100,,,case rate,100% WV Medicaid DRG rate,9786.23,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,4749.8,100,,,case rate,100% PEIA DRG rate,27900.44,100,,,case rate,100% The Health Plan DRG rate,4749.8,37517.19,
MAJOR CHEST TRAUMA WITH CC,184,MS-DRG,,,,,Inpatient,,,,,,19439.9975,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,19439.9975,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,7069.09,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,5309.68,102,,,case rate,102% WV Medicaid DRG rate,11663.9985,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,4852.56,100,,,case rate,100% PEIA with CHIP DRG base rate,19820.95,100,,,case rate,100% Highmark ACA DRG rate,25064.67,100,,,case rate,100% Highmark PPO DRG rate,25064.67,100,,,case rate,100% Highmark Trad DRG rate,5205.56,100,,,case rate,100% WV Medicaid DRG rate,7069.09,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,4127.58,100,,,case rate,100% PEIA DRG rate,18639.87,100,,,case rate,100% The Health Plan DRG rate,4127.58,25064.67,
MAJOR CHEST TRAUMA WITHOUT CC/MCC,185,MS-DRG,,,,,Inpatient,,,,,,39312.46,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,39312.46,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,14295.44,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,3817.14,102,,,case rate,102% WV Medicaid DRG rate,23587.476,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,3488.52,100,,,case rate,100% PEIA with CHIP DRG base rate,14239.66,100,,,case rate,100% Highmark ACA DRG rate,18006.82,100,,,case rate,100% Highmark PPO DRG rate,18006.82,100,,,case rate,100% Highmark Trad DRG rate,3742.29,100,,,case rate,100% WV Medicaid DRG rate,14295.44,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,2967.33,100,,,case rate,100% PEIA DRG rate,13391.15,100,,,case rate,100% The Health Plan DRG rate,2967.33,39312.46,
PLEURAL EFFUSION WITH MCC,186,MS-DRG,,,,,Inpatient,,,,,,26930.1175,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,26930.1175,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,9792.77,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,8245.73,102,,,case rate,102% WV Medicaid DRG rate,16158.0705,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,7535.85,100,,,case rate,100% PEIA with CHIP DRG base rate,29246.22,100,,,case rate,100% Highmark ACA DRG rate,36983.44,100,,,case rate,100% Highmark PPO DRG rate,36983.44,100,,,case rate,100% Highmark Trad DRG rate,8084.04,100,,,case rate,100% WV Medicaid DRG rate,9792.77,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,6409.98,100,,,case rate,100% PEIA DRG rate,27503.51,100,,,case rate,100% The Health Plan DRG rate,6409.98,36983.44,
PLEURAL EFFUSION WITH CC,187,MS-DRG,,,,,Inpatient,,,,,,18641.7825,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,18641.7825,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,6778.83,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,5079.27,102,,,case rate,102% WV Medicaid DRG rate,11185.0695,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,4641.99,100,,,case rate,100% PEIA with CHIP DRG base rate,18773.28,100,,,case rate,100% Highmark ACA DRG rate,23739.84,100,,,case rate,100% Highmark PPO DRG rate,23739.84,100,,,case rate,100% Highmark Trad DRG rate,4979.67,100,,,case rate,100% WV Medicaid DRG rate,6778.83,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,3948.47,100,,,case rate,100% PEIA DRG rate,17654.63,100,,,case rate,100% The Health Plan DRG rate,3948.47,23739.84,
PLEURAL EFFUSION WITHOUT CC/MCC,188,MS-DRG,,,,,Inpatient,,,,,,31078.1625,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,31078.1625,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,11301.15,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,3651.35,102,,,case rate,102% WV Medicaid DRG rate,18646.8975,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,3337,100,,,case rate,100% PEIA with CHIP DRG base rate,14066.3,100,,,case rate,100% Highmark ACA DRG rate,17787.6,100,,,case rate,100% Highmark PPO DRG rate,17787.6,100,,,case rate,100% Highmark Trad DRG rate,3579.75,100,,,case rate,100% WV Medicaid DRG rate,11301.15,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,2838.45,100,,,case rate,100% PEIA DRG rate,13228.12,100,,,case rate,100% The Health Plan DRG rate,2838.45,31078.1625,
PULMONARY EDEMA AND RESPIRATORY FAILURE,189,MS-DRG,,,,,Inpatient,,,,,,27949.7075,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,27949.7075,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,10163.53,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,5262.88,102,,,case rate,102% WV Medicaid DRG rate,16769.8245,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,4809.79,100,,,case rate,100% PEIA with CHIP DRG base rate,23214.58,100,,,case rate,100% Highmark ACA DRG rate,29356.1,100,,,case rate,100% Highmark PPO DRG rate,29356.1,100,,,case rate,100% Highmark Trad DRG rate,5159.68,100,,,case rate,100% WV Medicaid DRG rate,10163.53,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,4091.2,100,,,case rate,100% PEIA DRG rate,21831.27,100,,,case rate,100% The Health Plan DRG rate,4091.2,29356.1,
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH MCC,190,MS-DRG,,,,,Inpatient,,,,,,22251.6525,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,22251.6525,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,8091.51,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,5243.72,102,,,case rate,102% WV Medicaid DRG rate,13350.9915,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,4792.28,100,,,case rate,100% PEIA with CHIP DRG base rate,20764.99,100,,,case rate,100% Highmark ACA DRG rate,26258.46,100,,,case rate,100% Highmark PPO DRG rate,26258.46,100,,,case rate,100% Highmark Trad DRG rate,5140.89,100,,,case rate,100% WV Medicaid DRG rate,8091.51,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,4076.31,100,,,case rate,100% PEIA DRG rate,19527.65,100,,,case rate,100% The Health Plan DRG rate,4076.31,26258.46,
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH CC,191,MS-DRG,,,,,Inpatient,,,,,,16790.4825,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,16790.4825,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,6105.63,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,4426.36,102,,,case rate,102% WV Medicaid DRG rate,10074.2895,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,4045.29,100,,,case rate,100% PEIA with CHIP DRG base rate,15997.71,100,,,case rate,100% Highmark ACA DRG rate,20229.97,100,,,case rate,100% Highmark PPO DRG rate,20229.97,100,,,case rate,100% Highmark Trad DRG rate,4339.57,100,,,case rate,100% WV Medicaid DRG rate,6105.63,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,3440.92,100,,,case rate,100% PEIA DRG rate,15044.44,100,,,case rate,100% The Health Plan DRG rate,3440.92,20229.97,
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITHOUT CC/MCC,192,MS-DRG,,,,,Inpatient,,,,,,33439.285,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,33439.285,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,12159.74,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,4057.8,102,,,case rate,102% WV Medicaid DRG rate,20063.571,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,3708.46,100,,,case rate,100% PEIA with CHIP DRG base rate,12093.44,100,,,case rate,100% Highmark ACA DRG rate,15292.81,100,,,case rate,100% Highmark PPO DRG rate,15292.81,100,,,case rate,100% Highmark Trad DRG rate,3978.23,100,,,case rate,100% WV Medicaid DRG rate,12159.74,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,3154.41,100,,,case rate,100% PEIA DRG rate,11372.82,100,,,case rate,100% The Health Plan DRG rate,3154.41,33439.285,
SIMPLE PNEUMONIA AND PLEURISY WITH MCC,193,MS-DRG,,,,,Inpatient,,,,,,21633.7,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,21633.7,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,7866.8,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,5746.43,102,,,case rate,102% WV Medicaid DRG rate,12980.22,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,5251.71,100,,,case rate,100% PEIA with CHIP DRG base rate,24997.12,100,,,case rate,100% Highmark ACA DRG rate,31610.22,100,,,case rate,100% Highmark PPO DRG rate,31610.22,100,,,case rate,100% Highmark Trad DRG rate,5633.75,100,,,case rate,100% WV Medicaid DRG rate,7866.8,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,4467.1,100,,,case rate,100% PEIA DRG rate,23507.6,100,,,case rate,100% The Health Plan DRG rate,4467.1,31610.22,
SIMPLE PNEUMONIA AND PLEURISY WITH CC,194,MS-DRG,,,,,Inpatient,,,,,,16525.245,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,16525.245,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,6009.18,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,4089.44,102,,,case rate,102% WV Medicaid DRG rate,9915.147,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,3737.38,100,,,case rate,100% PEIA with CHIP DRG base rate,15492.71,100,,,case rate,100% Highmark ACA DRG rate,19591.38,100,,,case rate,100% Highmark PPO DRG rate,19591.38,100,,,case rate,100% Highmark Trad DRG rate,4009.25,100,,,case rate,100% WV Medicaid DRG rate,6009.18,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,3179.01,100,,,case rate,100% PEIA DRG rate,14569.54,100,,,case rate,100% The Health Plan DRG rate,3179.01,19591.38,
SIMPLE PNEUMONIA AND PLEURISY WITHOUT CC/MCC,195,MS-DRG,,,,,Inpatient,,,,,,44742.8025,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,44742.8025,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,16270.11,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,2785.42,102,,,case rate,102% WV Medicaid DRG rate,26845.6815,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,2545.62,100,,,case rate,100% PEIA with CHIP DRG base rate,11788.18,100,,,case rate,100% Highmark ACA DRG rate,14906.8,100,,,case rate,100% Highmark PPO DRG rate,14906.8,100,,,case rate,100% Highmark Trad DRG rate,2730.8,100,,,case rate,100% WV Medicaid DRG rate,16270.11,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,2165.3,100,,,case rate,100% PEIA DRG rate,11085.75,100,,,case rate,100% The Health Plan DRG rate,2165.3,44742.8025,
INTERSTITIAL LUNG DISEASE WITH MCC,196,MS-DRG,,,,,Inpatient,,,,,,25326.0425,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,25326.0425,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,9209.47,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,7153.85,102,,,case rate,102% WV Medicaid DRG rate,15195.6255,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,6537.96,100,,,case rate,100% PEIA with CHIP DRG base rate,35715.02,100,,,case rate,100% Highmark ACA DRG rate,45163.59,100,,,case rate,100% Highmark PPO DRG rate,45163.59,100,,,case rate,100% Highmark Trad DRG rate,7013.57,100,,,case rate,100% WV Medicaid DRG rate,9209.47,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,5561.18,100,,,case rate,100% PEIA DRG rate,33586.85,100,,,case rate,100% The Health Plan DRG rate,5561.18,45163.59,
INTERSTITIAL LUNG DISEASE WITH CC,197,MS-DRG,,,,,Inpatient,,,,,,18304.4675,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,18304.4675,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,6656.17,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,6142.63,102,,,case rate,102% WV Medicaid DRG rate,10982.6805,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,5613.8,100,,,case rate,100% PEIA with CHIP DRG base rate,18795.89,100,,,case rate,100% Highmark ACA DRG rate,23768.43,100,,,case rate,100% Highmark PPO DRG rate,23768.43,100,,,case rate,100% Highmark Trad DRG rate,6022.18,100,,,case rate,100% WV Medicaid DRG rate,6656.17,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,4775.09,100,,,case rate,100% PEIA DRG rate,17675.89,100,,,case rate,100% The Health Plan DRG rate,4775.09,23768.43,
INTERSTITIAL LUNG DISEASE WITHOUT CC/MCC,198,MS-DRG,,,,,Inpatient,,,,,,45280.9775,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,45280.9775,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,16465.81,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,4720.95,102,,,case rate,102% WV Medicaid DRG rate,27168.5865,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,4314.52,100,,,case rate,100% PEIA with CHIP DRG base rate,14663.62,100,,,case rate,100% Highmark ACA DRG rate,18542.95,100,,,case rate,100% Highmark PPO DRG rate,18542.95,100,,,case rate,100% Highmark Trad DRG rate,4628.38,100,,,case rate,100% WV Medicaid DRG rate,16465.81,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,3669.92,100,,,case rate,100% PEIA DRG rate,13789.85,100,,,case rate,100% The Health Plan DRG rate,3669.92,45280.9775,
PNEUMOTHORAX WITH MCC,199,MS-DRG,,,,,Inpatient,,,,,,27602.19,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,27602.19,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,10037.16,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,6195.22,102,,,case rate,102% WV Medicaid DRG rate,16561.314,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,5661.86,100,,,case rate,100% PEIA with CHIP DRG base rate,33429.37,100,,,case rate,100% Highmark ACA DRG rate,42273.25,100,,,case rate,100% Highmark PPO DRG rate,42273.25,100,,,case rate,100% Highmark Trad DRG rate,6073.74,100,,,case rate,100% WV Medicaid DRG rate,10037.16,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,4815.97,100,,,case rate,100% PEIA DRG rate,31437.39,100,,,case rate,100% The Health Plan DRG rate,4815.97,42273.25,
PNEUMOTHORAX WITH CC,200,MS-DRG,,,,,Inpatient,,,,,,18742.185,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,18742.185,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,6815.34,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,4602.4,102,,,case rate,102% WV Medicaid DRG rate,11245.311,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,4206.18,100,,,case rate,100% PEIA with CHIP DRG base rate,20293.91,100,,,case rate,100% Highmark ACA DRG rate,25662.76,100,,,case rate,100% Highmark PPO DRG rate,25662.76,100,,,case rate,100% Highmark Trad DRG rate,4512.16,100,,,case rate,100% WV Medicaid DRG rate,6815.34,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,3577.77,100,,,case rate,100% PEIA DRG rate,19084.64,100,,,case rate,100% The Health Plan DRG rate,3577.77,25662.76,
PNEUMOTHORAX WITHOUT CC/MCC,201,MS-DRG,,,,,Inpatient,,,,,,23837.77,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,23837.77,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,8668.28,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,2906.64,102,,,case rate,102% WV Medicaid DRG rate,14302.662,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,2656.4,100,,,case rate,100% PEIA with CHIP DRG base rate,13305.04,100,,,case rate,100% Highmark ACA DRG rate,16824.95,100,,,case rate,100% Highmark PPO DRG rate,16824.95,100,,,case rate,100% Highmark Trad DRG rate,2849.64,100,,,case rate,100% WV Medicaid DRG rate,8668.28,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,2259.53,100,,,case rate,100% PEIA DRG rate,12512.23,100,,,case rate,100% The Health Plan DRG rate,2259.53,23837.77,
BRONCHITIS AND ASTHMA WITH CC/MCC,202,MS-DRG,,,,,Inpatient,,,,,,17176.6925,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,17176.6925,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,6246.07,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,3543.05,102,,,case rate,102% WV Medicaid DRG rate,10306.0155,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,3238.03,100,,,case rate,100% PEIA with CHIP DRG base rate,18042.17,100,,,case rate,100% Highmark ACA DRG rate,22815.31,100,,,case rate,100% Highmark PPO DRG rate,22815.31,100,,,case rate,100% Highmark Trad DRG rate,3473.58,100,,,case rate,100% WV Medicaid DRG rate,6246.07,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,2754.26,100,,,case rate,100% PEIA DRG rate,16967.08,100,,,case rate,100% The Health Plan DRG rate,2754.26,22815.31,
BRONCHITIS AND ASTHMA WITHOUT CC/MCC,203,MS-DRG,,,,,Inpatient,,,,,,20840.6825,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,20840.6825,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,7578.43,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,2528.71,102,,,case rate,102% WV Medicaid DRG rate,12504.4095,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,2311.01,100,,,case rate,100% PEIA with CHIP DRG base rate,13094,100,,,case rate,100% Highmark ACA DRG rate,16558.08,100,,,case rate,100% Highmark PPO DRG rate,16558.08,100,,,case rate,100% Highmark Trad DRG rate,2479.13,100,,,case rate,100% WV Medicaid DRG rate,7578.43,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,1965.75,100,,,case rate,100% PEIA DRG rate,12313.76,100,,,case rate,100% The Health Plan DRG rate,1965.75,20840.6825,
RESPIRATORY SIGNS AND SYMPTOMS,204,MS-DRG,,,,,Inpatient,,,,,,45857.7075,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,45857.7075,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,16675.53,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,4584.58,102,,,case rate,102% WV Medicaid DRG rate,27514.6245,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,4189.88,100,,,case rate,100% PEIA with CHIP DRG base rate,15505.9,100,,,case rate,100% Highmark ACA DRG rate,19608.06,100,,,case rate,100% Highmark PPO DRG rate,19608.06,100,,,case rate,100% Highmark Trad DRG rate,4494.68,100,,,case rate,100% WV Medicaid DRG rate,16675.53,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,3563.91,100,,,case rate,100% PEIA DRG rate,14581.94,100,,,case rate,100% The Health Plan DRG rate,3563.91,45857.7075,
OTHER RESPIRATORY SYSTEM DIAGNOSES WITH MCC,205,MS-DRG,,,,,Inpatient,,,,,,23003.5025,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,23003.5025,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,8364.91,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,6667.62,102,,,case rate,102% WV Medicaid DRG rate,13802.1015,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,6093.6,100,,,case rate,100% PEIA with CHIP DRG base rate,34111.48,100,,,case rate,100% Highmark ACA DRG rate,43135.83,100,,,case rate,100% Highmark PPO DRG rate,43135.83,100,,,case rate,100% Highmark Trad DRG rate,6536.88,100,,,case rate,100% WV Medicaid DRG rate,8364.91,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,5183.21,100,,,case rate,100% PEIA DRG rate,32078.86,100,,,case rate,100% The Health Plan DRG rate,5183.21,43135.83,
OTHER RESPIRATORY SYSTEM DIAGNOSES WITHOUT MCC,206,MS-DRG,,,,,Inpatient,,,,,,169060.6775,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,169060.6775,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,61476.61,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,4203.98,102,,,case rate,102% WV Medicaid DRG rate,101436.4065,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,3842.05,100,,,case rate,100% PEIA with CHIP DRG base rate,17213.08,100,,,case rate,100% Highmark ACA DRG rate,21766.88,100,,,case rate,100% Highmark PPO DRG rate,21766.88,100,,,case rate,100% Highmark Trad DRG rate,4121.54,100,,,case rate,100% WV Medicaid DRG rate,61476.61,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,3268.04,100,,,case rate,100% PEIA DRG rate,16187.39,100,,,case rate,100% The Health Plan DRG rate,3268.04,169060.6775,
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT >96 HOURS,207,MS-DRG,,,,,Inpatient,,,,,,66948.145,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,66948.145,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,24344.78,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,29465.27,102,,,case rate,102% WV Medicaid DRG rate,40168.887,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,26928.57,100,,,case rate,100% PEIA with CHIP DRG base rate,130167.44,100,,,case rate,100% Highmark ACA DRG rate,164603.82,100,,,case rate,100% Highmark PPO DRG rate,164603.82,100,,,case rate,100% Highmark Trad DRG rate,28887.49,100,,,case rate,100% WV Medicaid DRG rate,24344.78,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,22905.41,100,,,case rate,100% PEIA DRG rate,122411.07,100,,,case rate,100% The Health Plan DRG rate,22905.41,164603.82,
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT <=96 HOURS,208,MS-DRG,,,,,Inpatient,,,,,,265289.7775,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,265289.7775,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,96469.01,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,10552.95,102,,,case rate,102% WV Medicaid DRG rate,159173.8665,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,9644.43,100,,,case rate,100% PEIA with CHIP DRG base rate,50947.7,100,,,case rate,100% Highmark ACA DRG rate,64426.15,100,,,case rate,100% Highmark PPO DRG rate,64426.15,100,,,case rate,100% Highmark Trad DRG rate,10346.02,100,,,case rate,100% WV Medicaid DRG rate,96469.01,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,8203.54,100,,,case rate,100% PEIA DRG rate,47911.85,100,,,case rate,100% The Health Plan DRG rate,8203.54,265289.7775,
CONCOMITANT AORTIC AND MITRAL VALVE PROCEDURES,212,MS-DRG,,,,,Inpatient,,,,,,250837.3175,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,250837.3175,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,91213.57,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,,,,,other,Not Separately reimbursable,150502.3905,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,,,,,other,Not Separately reimbursable,202952.3,100,,,case rate,100% Highmark ACA DRG rate,256644.24,100,,,case rate,100% Highmark PPO DRG rate,256644.24,100,,,case rate,100% Highmark Trad DRG rate,,,,,other,Not Separately reimbursable,91213.57,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,,,,,other,Not Separately reimbursable,190858.85,100,,,case rate,100% The Health Plan DRG rate,91213.57,256644.24,
OTHER HEART ASSIST SYSTEM IMPLANT,215,MS-DRG,,,,,Inpatient,,,,,,163470.725,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,163470.725,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,59443.9,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,51893.47,102,,,case rate,102% WV Medicaid DRG rate,98082.435,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,47425.9,100,,,case rate,100% PEIA with CHIP DRG base rate,192477.48,100,,,case rate,100% Highmark ACA DRG rate,243398.25,100,,,case rate,100% Highmark PPO DRG rate,243398.25,100,,,case rate,100% Highmark Trad DRG rate,50875.9,100,,,case rate,100% WV Medicaid DRG rate,59443.9,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,40340.41,100,,,case rate,100% PEIA DRG rate,181008.2,100,,,case rate,100% The Health Plan DRG rate,40340.41,243398.25,
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITH MCC,216,MS-DRG,,,,,Inpatient,,,,,,152911.385,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,152911.385,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,55604.14,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,53581.21,102,,,case rate,102% WV Medicaid DRG rate,91746.831,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,48968.34,100,,,case rate,100% PEIA with CHIP DRG base rate,182876.97,100,,,case rate,100% Highmark ACA DRG rate,231257.89,100,,,case rate,100% Highmark PPO DRG rate,231257.89,100,,,case rate,100% Highmark Trad DRG rate,52530.54,100,,,case rate,100% WV Medicaid DRG rate,55604.14,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,41652.4,100,,,case rate,100% PEIA DRG rate,171979.76,100,,,case rate,100% The Health Plan DRG rate,41652.4,231257.89,
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITH CC,217,MS-DRG,,,,,Inpatient,,,,,,209289.795,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,209289.795,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,76105.38,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,45702.71,102,,,case rate,102% WV Medicaid DRG rate,125573.877,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,41768.11,100,,,case rate,100% PEIA with CHIP DRG base rate,119941.35,100,,,case rate,100% Highmark ACA DRG rate,151672.37,100,,,case rate,100% Highmark PPO DRG rate,151672.37,100,,,case rate,100% Highmark Trad DRG rate,44806.53,100,,,case rate,100% WV Medicaid DRG rate,76105.38,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,35527.9,100,,,case rate,100% PEIA DRG rate,112794.33,100,,,case rate,100% The Health Plan DRG rate,35527.9,209289.795,
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITHOUT CC/MCC,218,MS-DRG,,,,,Inpatient,,,,,,139944.5025,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,139944.5025,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,50888.91,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,39441.98,102,,,case rate,102% WV Medicaid DRG rate,83966.7015,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,36046.37,100,,,case rate,100% PEIA with CHIP DRG base rate,107342.92,100,,,case rate,100% Highmark ACA DRG rate,135740.97,100,,,case rate,100% Highmark PPO DRG rate,135740.97,100,,,case rate,100% Highmark Trad DRG rate,38668.56,100,,,case rate,100% WV Medicaid DRG rate,50888.91,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,30660.99,100,,,case rate,100% PEIA DRG rate,100946.61,100,,,case rate,100% The Health Plan DRG rate,30660.99,139944.5025,
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITH MCC,219,MS-DRG,,,,,Inpatient,,,,,,121830.61,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,121830.61,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,44302.04,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,46453.21,102,,,case rate,102% WV Medicaid DRG rate,73098.366,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,42454,100,,,case rate,100% PEIA with CHIP DRG base rate,145302.14,100,,,case rate,100% Highmark ACA DRG rate,183742.47,100,,,case rate,100% Highmark PPO DRG rate,183742.47,100,,,case rate,100% Highmark Trad DRG rate,45542.32,100,,,case rate,100% WV Medicaid DRG rate,44302.04,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,36111.31,100,,,case rate,100% PEIA DRG rate,136643.93,100,,,case rate,100% The Health Plan DRG rate,36111.31,183742.47,
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITH CC,220,MS-DRG,,,,,Inpatient,,,,,,197144.3375,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,197144.3375,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,71688.85,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,31254.63,102,,,case rate,102% WV Medicaid DRG rate,118286.6025,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,28563.88,100,,,case rate,100% PEIA with CHIP DRG base rate,98824,100,,,case rate,100% Highmark ACA DRG rate,124968.33,100,,,case rate,100% Highmark PPO DRG rate,124968.33,100,,,case rate,100% Highmark Trad DRG rate,30641.76,100,,,case rate,100% WV Medicaid DRG rate,71688.85,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,24296.4,100,,,case rate,100% PEIA DRG rate,92935.31,100,,,case rate,100% The Health Plan DRG rate,24296.4,197144.3375,
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITHOUT CC/MCC,221,MS-DRG,,,,,Inpatient,,,,,,134372.535,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,134372.535,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,48862.74,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,20325.98,102,,,case rate,102% WV Medicaid DRG rate,80623.521,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,18576.09,100,,,case rate,100% PEIA with CHIP DRG base rate,87593.57,100,,,case rate,100% Highmark ACA DRG rate,110766.84,100,,,case rate,100% Highmark PPO DRG rate,110766.84,100,,,case rate,100% Highmark Trad DRG rate,19927.41,100,,,case rate,100% WV Medicaid DRG rate,48862.74,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,15800.8,100,,,case rate,100% PEIA DRG rate,82374.08,100,,,case rate,100% The Health Plan DRG rate,15800.8,134372.535,
OTHER CARDIOTHORACIC PROCEDURES WITH MCC,228,MS-DRG,,,,,Inpatient,,,,,,182534.77,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,182534.77,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,66376.28,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,32666.5,102,,,case rate,102% WV Medicaid DRG rate,109520.862,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,29854.2,100,,,case rate,100% PEIA with CHIP DRG base rate,94944.22,100,,,case rate,100% Highmark ACA DRG rate,120062.14,100,,,case rate,100% Highmark PPO DRG rate,120062.14,100,,,case rate,100% Highmark Trad DRG rate,32025.95,100,,,case rate,100% WV Medicaid DRG rate,66376.28,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,25393.95,100,,,case rate,100% PEIA DRG rate,89286.72,100,,,case rate,100% The Health Plan DRG rate,25393.95,182534.77,
OTHER CARDIOTHORACIC PROCEDURES WITHOUT MCC,229,MS-DRG,,,,,Inpatient,,,,,,130227.1025,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,130227.1025,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,47355.31,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,23951.48,102,,,case rate,102% WV Medicaid DRG rate,78136.2615,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,21889.47,100,,,case rate,100% PEIA with CHIP DRG base rate,59913.2,100,,,case rate,100% Highmark ACA DRG rate,75763.51,100,,,case rate,100% Highmark PPO DRG rate,75763.51,100,,,case rate,100% Highmark Trad DRG rate,23481.82,100,,,case rate,100% WV Medicaid DRG rate,47355.31,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,18619.15,100,,,case rate,100% PEIA DRG rate,56343.12,100,,,case rate,100% The Health Plan DRG rate,18619.15,130227.1025,
CORONARY BYPASS WITH PTCA WITH MCC,231,MS-DRG,,,,,Inpatient,,,,,,164812.23,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,164812.23,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,59931.72,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,49128.55,102,,,case rate,102% WV Medicaid DRG rate,98887.338,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,44899.01,100,,,case rate,100% PEIA with CHIP DRG base rate,152914.71,100,,,case rate,100% Highmark ACA DRG rate,193368.99,100,,,case rate,100% Highmark PPO DRG rate,193368.99,100,,,case rate,100% Highmark Trad DRG rate,48165.2,100,,,case rate,100% WV Medicaid DRG rate,59931.72,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,38191.04,100,,,case rate,100% PEIA DRG rate,143802.89,100,,,case rate,100% The Health Plan DRG rate,38191.04,193368.99,
CORONARY BYPASS WITH PTCA WITHOUT MCC,232,MS-DRG,,,,,Inpatient,,,,,,129274.3925,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,129274.3925,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,47008.87,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,43351.37,102,,,case rate,102% WV Medicaid DRG rate,77564.6355,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,39619.2,100,,,case rate,100% PEIA with CHIP DRG base rate,112089.47,100,,,case rate,100% Highmark ACA DRG rate,141743.24,100,,,case rate,100% Highmark PPO DRG rate,141743.24,100,,,case rate,100% Highmark Trad DRG rate,42501.3,100,,,case rate,100% WV Medicaid DRG rate,47008.87,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,33700.04,100,,,case rate,100% PEIA DRG rate,105410.32,100,,,case rate,100% The Health Plan DRG rate,33700.04,141743.24,
CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITH MCC,233,MS-DRG,,,,,Inpatient,,,,,,126895.285,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,126895.285,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,46143.74,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,44232.9,102,,,case rate,102% WV Medicaid DRG rate,76137.171,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,40424.83,100,,,case rate,100% PEIA with CHIP DRG base rate,146967.86,100,,,case rate,100% Highmark ACA DRG rate,185848.87,100,,,case rate,100% Highmark PPO DRG rate,185848.87,100,,,case rate,100% Highmark Trad DRG rate,43365.54,100,,,case rate,100% WV Medicaid DRG rate,46143.74,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,34385.31,100,,,case rate,100% PEIA DRG rate,138210.39,100,,,case rate,100% The Health Plan DRG rate,34385.31,185848.87,
CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITHOUT MCC,234,MS-DRG,,,,,Inpatient,,,,,,84992.5725,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,84992.5725,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,30906.39,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,33555.61,102,,,case rate,102% WV Medicaid DRG rate,50995.5435,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,30666.76,100,,,case rate,100% PEIA with CHIP DRG base rate,97944.03,100,,,case rate,100% Highmark ACA DRG rate,123855.56,100,,,case rate,100% Highmark PPO DRG rate,123855.56,100,,,case rate,100% Highmark Trad DRG rate,32897.62,100,,,case rate,100% WV Medicaid DRG rate,30906.39,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,26085.11,100,,,case rate,100% PEIA DRG rate,92107.78,100,,,case rate,100% The Health Plan DRG rate,26085.11,123855.56,
CORONARY BYPASS WITHOUT CARDIAC CATHETERIZATION WITH MCC,235,MS-DRG,,,,,Inpatient,,,,,,216110.5375,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,216110.5375,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,78585.65,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,33461.57,102,,,case rate,102% WV Medicaid DRG rate,129666.3225,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,30580.82,100,,,case rate,100% PEIA with CHIP DRG base rate,110808.15,100,,,case rate,100% Highmark ACA DRG rate,140122.94,100,,,case rate,100% Highmark PPO DRG rate,140122.94,100,,,case rate,100% Highmark Trad DRG rate,32805.43,100,,,case rate,100% WV Medicaid DRG rate,78585.65,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,26012.01,100,,,case rate,100% PEIA DRG rate,104205.35,100,,,case rate,100% The Health Plan DRG rate,26012.01,216110.5375,
CORONARY BYPASS WITHOUT CARDIAC CATHETERIZATION WITHOUT MCC,236,MS-DRG,,,,,Inpatient,,,,,,150828.3425,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,150828.3425,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,54846.67,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,28055.18,102,,,case rate,102% WV Medicaid DRG rate,90497.0055,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,25639.88,100,,,case rate,100% PEIA with CHIP DRG base rate,76148.33,100,,,case rate,100% Highmark ACA DRG rate,96293.71,100,,,case rate,100% Highmark PPO DRG rate,96293.71,100,,,case rate,100% Highmark Trad DRG rate,27505.05,100,,,case rate,100% WV Medicaid DRG rate,54846.67,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,21809.25,100,,,case rate,100% PEIA DRG rate,71610.83,100,,,case rate,100% The Health Plan DRG rate,21809.25,150828.3425,
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH MCC,239,MS-DRG,,,,,Inpatient,,,,,,199417.9275,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,199417.9275,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,72515.61,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,17106.48,102,,,case rate,102% WV Medicaid DRG rate,119650.7565,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,15633.76,100,,,case rate,100% PEIA with CHIP DRG base rate,90574.53,100,,,case rate,100% Highmark ACA DRG rate,114536.43,100,,,case rate,100% Highmark PPO DRG rate,114536.43,100,,,case rate,100% Highmark Trad DRG rate,16771.04,100,,,case rate,100% WV Medicaid DRG rate,72515.61,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,13298.06,100,,,case rate,100% PEIA DRG rate,85177.41,100,,,case rate,100% The Health Plan DRG rate,13298.06,199417.9275,
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH CC,240,MS-DRG,,,,,Inpatient,,,,,,133538.35,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,133538.35,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,48559.4,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,14329.53,102,,,case rate,102% WV Medicaid DRG rate,80123.01,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,13095.88,100,,,case rate,100% PEIA with CHIP DRG base rate,52933.76,100,,,case rate,100% Highmark ACA DRG rate,66937.62,100,,,case rate,100% Highmark PPO DRG rate,66937.62,100,,,case rate,100% Highmark Trad DRG rate,14048.55,100,,,case rate,100% WV Medicaid DRG rate,48559.4,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,11139.34,100,,,case rate,100% PEIA DRG rate,49779.56,100,,,case rate,100% The Health Plan DRG rate,11139.34,133538.35,
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITHOUT CC/MCC,241,MS-DRG,,,,,Inpatient,,,,,,154232.2375,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,154232.2375,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,56084.45,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,10287.33,102,,,case rate,102% WV Medicaid DRG rate,92539.3425,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,9401.68,100,,,case rate,100% PEIA with CHIP DRG base rate,26188,100,,,case rate,100% Highmark ACA DRG rate,33116.15,100,,,case rate,100% Highmark PPO DRG rate,33116.15,100,,,case rate,100% Highmark Trad DRG rate,10085.61,100,,,case rate,100% WV Medicaid DRG rate,56084.45,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,7997.06,100,,,case rate,100% PEIA DRG rate,24627.52,100,,,case rate,100% The Health Plan DRG rate,7997.06,154232.2375,
PERMANENT CARDIAC PACEMAKER IMPLANT WITH MCC,242,MS-DRG,,,,,Inpatient,,,,,,105011.83,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,105011.83,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,38186.12,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,19119.56,102,,,case rate,102% WV Medicaid DRG rate,63007.098,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,17473.53,100,,,case rate,100% PEIA with CHIP DRG base rate,65104.45,100,,,case rate,100% Highmark ACA DRG rate,82328.12,100,,,case rate,100% Highmark PPO DRG rate,82328.12,100,,,case rate,100% Highmark Trad DRG rate,18744.65,100,,,case rate,100% WV Medicaid DRG rate,38186.12,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,14862.97,100,,,case rate,100% PEIA DRG rate,61225.03,100,,,case rate,100% The Health Plan DRG rate,14862.97,105011.83,
PERMANENT CARDIAC PACEMAKER IMPLANT WITH CC,243,MS-DRG,,,,,Inpatient,,,,,,119732.1125,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,119732.1125,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,43538.95,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,13040.22,102,,,case rate,102% WV Medicaid DRG rate,71839.2675,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,11917.57,100,,,case rate,100% PEIA with CHIP DRG base rate,42916.82,100,,,case rate,100% Highmark ACA DRG rate,54270.65,100,,,case rate,100% Highmark PPO DRG rate,54270.65,100,,,case rate,100% Highmark Trad DRG rate,12784.51,100,,,case rate,100% WV Medicaid DRG rate,43538.95,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,10137.07,100,,,case rate,100% PEIA DRG rate,40359.5,100,,,case rate,100% The Health Plan DRG rate,10137.07,119732.1125,
PERMANENT CARDIAC PACEMAKER IMPLANT WITHOUT CC/MCC,244,MS-DRG,,,,,Inpatient,,,,,,69886.025,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,69886.025,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,25413.1,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,9373.71,102,,,case rate,102% WV Medicaid DRG rate,41931.615,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,8566.72,100,,,case rate,100% PEIA with CHIP DRG base rate,34473.27,100,,,case rate,100% Highmark ACA DRG rate,43593.33,100,,,case rate,100% Highmark PPO DRG rate,43593.33,100,,,case rate,100% Highmark Trad DRG rate,9189.91,100,,,case rate,100% WV Medicaid DRG rate,25413.1,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,7286.84,100,,,case rate,100% PEIA DRG rate,32419.09,100,,,case rate,100% The Health Plan DRG rate,7286.84,69886.025,
AICD GENERATOR PROCEDURES,245,MS-DRG,,,,,Inpatient,,,,,,39881.5175,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,39881.5175,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,14502.37,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,32383.95,102,,,case rate,102% WV Medicaid DRG rate,23928.9105,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,29595.97,100,,,case rate,100% PEIA with CHIP DRG base rate,85385.17,100,,,case rate,100% Highmark ACA DRG rate,107974.2,100,,,case rate,100% Highmark PPO DRG rate,107974.2,100,,,case rate,100% Highmark Trad DRG rate,31748.94,100,,,case rate,100% WV Medicaid DRG rate,14502.37,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,25174.3,100,,,case rate,100% PEIA DRG rate,80297.27,100,,,case rate,100% The Health Plan DRG rate,14502.37,107974.2,
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITHOUT INTRALUMINAL DEVICE WITH MCC,250,MS-DRG,,,,,Inpatient,,,,,,89436.71,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,89436.71,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,32522.44,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,10548.05,102,,,case rate,102% WV Medicaid DRG rate,53662.026,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,9639.95,100,,,case rate,100% PEIA with CHIP DRG base rate,44296.12,100,,,case rate,100% Highmark ACA DRG rate,56014.86,100,,,case rate,100% Highmark PPO DRG rate,56014.86,100,,,case rate,100% Highmark Trad DRG rate,10341.21,100,,,case rate,100% WV Medicaid DRG rate,32522.44,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,8199.73,100,,,case rate,100% PEIA DRG rate,41656.62,100,,,case rate,100% The Health Plan DRG rate,8199.73,89436.71,
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITHOUT INTRALUMINAL DEVICE WITHOUT MCC,251,MS-DRG,,,,,Inpatient,,,,,,60354.03,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,60354.03,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,21946.92,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,10035.53,102,,,case rate,102% WV Medicaid DRG rate,36212.418,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,9171.56,100,,,case rate,100% PEIA with CHIP DRG base rate,29901.96,100,,,case rate,100% Highmark ACA DRG rate,37812.65,100,,,case rate,100% Highmark PPO DRG rate,37812.65,100,,,case rate,100% Highmark Trad DRG rate,9838.74,100,,,case rate,100% WV Medicaid DRG rate,21946.92,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,7801.32,100,,,case rate,100% PEIA DRG rate,28120.17,100,,,case rate,100% The Health Plan DRG rate,7801.32,60354.03,
OTHER VASCULAR PROCEDURES WITH MCC,252,MS-DRG,,,,,Inpatient,,,,,,48950.055,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,48950.055,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,17800.02,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,22371.15,102,,,case rate,102% WV Medicaid DRG rate,29370.033,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,20445.19,100,,,case rate,100% PEIA with CHIP DRG base rate,63195.65,100,,,case rate,100% Highmark ACA DRG rate,79914.35,100,,,case rate,100% Highmark PPO DRG rate,79914.35,100,,,case rate,100% Highmark Trad DRG rate,21932.47,100,,,case rate,100% WV Medicaid DRG rate,17800.02,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,17390.65,100,,,case rate,100% PEIA DRG rate,59429.97,100,,,case rate,100% The Health Plan DRG rate,17390.65,79914.35,
OTHER VASCULAR PROCEDURES WITH CC,253,MS-DRG,,,,,Inpatient,,,,,,125548.665,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,125548.665,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,45654.06,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,12889.58,102,,,case rate,102% WV Medicaid DRG rate,75329.199,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,11779.9,100,,,case rate,100% PEIA with CHIP DRG base rate,48070.38,100,,,case rate,100% Highmark ACA DRG rate,60787.61,100,,,case rate,100% Highmark PPO DRG rate,60787.61,100,,,case rate,100% Highmark Trad DRG rate,12636.83,100,,,case rate,100% WV Medicaid DRG rate,45654.06,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,10019.97,100,,,case rate,100% PEIA DRG rate,45205.98,100,,,case rate,100% The Health Plan DRG rate,10019.97,125548.665,
OTHER VASCULAR PROCEDURES WITHOUT CC/MCC,254,MS-DRG,,,,,Inpatient,,,,,,77126.4175,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,77126.4175,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,28045.97,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,9265.86,102,,,case rate,102% WV Medicaid DRG rate,46275.8505,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,8468.15,100,,,case rate,100% PEIA with CHIP DRG base rate,32694.49,100,,,case rate,100% Highmark ACA DRG rate,41343.96,100,,,case rate,100% Highmark PPO DRG rate,41343.96,100,,,case rate,100% Highmark Trad DRG rate,9084.17,100,,,case rate,100% WV Medicaid DRG rate,28045.97,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,7203,100,,,case rate,100% PEIA DRG rate,30746.3,100,,,case rate,100% The Health Plan DRG rate,7203,77126.4175,
UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITH MCC,255,MS-DRG,,,,,Inpatient,,,,,,49166.3975,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,49166.3975,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,17878.69,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,17040.08,102,,,case rate,102% WV Medicaid DRG rate,29499.8385,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,15573.08,100,,,case rate,100% PEIA with CHIP DRG base rate,51769.26,100,,,case rate,100% Highmark ACA DRG rate,65465.05,100,,,case rate,100% Highmark PPO DRG rate,65465.05,100,,,case rate,100% Highmark Trad DRG rate,16705.94,100,,,case rate,100% WV Medicaid DRG rate,17878.69,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,13246.44,100,,,case rate,100% PEIA DRG rate,48684.45,100,,,case rate,100% The Health Plan DRG rate,13246.44,65465.05,
UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITH CC,256,MS-DRG,,,,,Inpatient,,,,,,77497.2,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,77497.2,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,28180.8,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,8538.09,102,,,case rate,102% WV Medicaid DRG rate,46498.32,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,7803.03,100,,,case rate,100% PEIA with CHIP DRG base rate,30896.87,100,,,case rate,100% Highmark ACA DRG rate,39070.77,100,,,case rate,100% Highmark PPO DRG rate,39070.77,100,,,case rate,100% Highmark Trad DRG rate,8370.67,100,,,case rate,100% WV Medicaid DRG rate,28180.8,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,6637.25,100,,,case rate,100% PEIA DRG rate,29055.8,100,,,case rate,100% The Health Plan DRG rate,6637.25,77497.2,
UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITHOUT CC/MCC,257,MS-DRG,,,,,Inpatient,,,,,,46776.895,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,46776.895,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,17009.78,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,6964.88,102,,,case rate,102% WV Medicaid DRG rate,28066.137,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,6365.27,100,,,case rate,100% PEIA with CHIP DRG base rate,18673.41,100,,,case rate,100% Highmark ACA DRG rate,23613.55,100,,,case rate,100% Highmark PPO DRG rate,23613.55,100,,,case rate,100% Highmark Trad DRG rate,6828.31,100,,,case rate,100% WV Medicaid DRG rate,17009.78,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,5414.29,100,,,case rate,100% PEIA DRG rate,17560.71,100,,,case rate,100% The Health Plan DRG rate,5414.29,46776.895,
CARDIAC PACEMAKER DEVICE REPLACEMENT WITH MCC,258,MS-DRG,,,,,Inpatient,,,,,,62303.1475,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,62303.1475,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,22655.69,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,18309.78,102,,,case rate,102% WV Medicaid DRG rate,37381.8885,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,16733.47,100,,,case rate,100% PEIA with CHIP DRG base rate,51038.15,100,,,case rate,100% Highmark ACA DRG rate,64540.52,100,,,case rate,100% Highmark PPO DRG rate,64540.52,100,,,case rate,100% Highmark Trad DRG rate,17950.75,100,,,case rate,100% WV Medicaid DRG rate,22655.69,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,14233.47,100,,,case rate,100% PEIA DRG rate,47996.91,100,,,case rate,100% The Health Plan DRG rate,14233.47,64540.52,
CARDIAC PACEMAKER DEVICE REPLACEMENT WITHOUT MCC,259,MS-DRG,,,,,Inpatient,,,,,,41848.73,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,41848.73,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,15217.72,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,13243.89,102,,,case rate,102% WV Medicaid DRG rate,25109.238,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,12103.7,100,,,case rate,100% PEIA with CHIP DRG base rate,35172.34,100,,,case rate,100% Highmark ACA DRG rate,44477.34,100,,,case rate,100% Highmark PPO DRG rate,44477.34,100,,,case rate,100% Highmark Trad DRG rate,12984.19,100,,,case rate,100% WV Medicaid DRG rate,15217.72,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,10295.4,100,,,case rate,100% PEIA DRG rate,33076.51,100,,,case rate,100% The Health Plan DRG rate,10295.4,44477.34,
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITH MCC,260,MS-DRG,,,,,Inpatient,,,,,,86084.24,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,86084.24,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,31303.36,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,23236.19,102,,,case rate,102% WV Medicaid DRG rate,51650.544,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,21235.76,100,,,case rate,100% PEIA with CHIP DRG base rate,62468.31,100,,,case rate,100% Highmark ACA DRG rate,78994.59,100,,,case rate,100% Highmark PPO DRG rate,78994.59,100,,,case rate,100% Highmark Trad DRG rate,22780.55,100,,,case rate,100% WV Medicaid DRG rate,31303.36,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,18063.11,100,,,case rate,100% PEIA DRG rate,58745.97,100,,,case rate,100% The Health Plan DRG rate,18063.11,86084.24,
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITH CC,261,MS-DRG,,,,,Inpatient,,,,,,68850.9525,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,68850.9525,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,25036.71,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,12690.37,102,,,case rate,102% WV Medicaid DRG rate,41310.5715,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,11597.84,100,,,case rate,100% PEIA with CHIP DRG base rate,35458.76,100,,,case rate,100% Highmark ACA DRG rate,44839.53,100,,,case rate,100% Highmark PPO DRG rate,44839.53,100,,,case rate,100% Highmark Trad DRG rate,12441.52,100,,,case rate,100% WV Medicaid DRG rate,25036.71,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,9865.11,100,,,case rate,100% PEIA DRG rate,33345.85,100,,,case rate,100% The Health Plan DRG rate,9865.11,68850.9525,
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITHOUT CC/MCC,262,MS-DRG,,,,,Inpatient,,,,,,47080.7425,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,47080.7425,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,17120.27,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,11136.77,102,,,case rate,102% WV Medicaid DRG rate,28248.4455,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,10177.99,100,,,case rate,100% PEIA with CHIP DRG base rate,31002.39,100,,,case rate,100% Highmark ACA DRG rate,39204.21,100,,,case rate,100% Highmark PPO DRG rate,39204.21,100,,,case rate,100% Highmark Trad DRG rate,10918.39,100,,,case rate,100% WV Medicaid DRG rate,17120.27,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,8657.39,100,,,case rate,100% PEIA DRG rate,29155.03,100,,,case rate,100% The Health Plan DRG rate,8657.39,47080.7425,
VEIN LIGATION AND STRIPPING,263,MS-DRG,,,,,Inpatient,,,,,,66059.8125,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,66059.8125,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,24021.75,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,18503.65,102,,,case rate,102% WV Medicaid DRG rate,39635.8875,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,16910.65,100,,,case rate,100% PEIA with CHIP DRG base rate,53235.24,100,,,case rate,100% Highmark ACA DRG rate,67318.87,100,,,case rate,100% Highmark PPO DRG rate,67318.87,100,,,case rate,100% Highmark Trad DRG rate,18140.81,100,,,case rate,100% WV Medicaid DRG rate,24021.75,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,14384.17,100,,,case rate,100% PEIA DRG rate,50063.08,100,,,case rate,100% The Health Plan DRG rate,14384.17,67318.87,
OTHER CIRCULATORY SYSTEM O.R. PROCEDURES,264,MS-DRG,,,,,Inpatient,,,,,,42026.325,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,42026.325,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,15282.3,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,10533.34,102,,,case rate,102% WV Medicaid DRG rate,25215.795,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,9626.51,100,,,case rate,100% PEIA with CHIP DRG base rate,61541.24,100,,,case rate,100% Highmark ACA DRG rate,77822.25,100,,,case rate,100% Highmark PPO DRG rate,77822.25,100,,,case rate,100% Highmark Trad DRG rate,10326.79,100,,,case rate,100% WV Medicaid DRG rate,15282.3,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,8188.3,100,,,case rate,100% PEIA DRG rate,57874.14,100,,,case rate,100% The Health Plan DRG rate,8188.3,77822.25,
AICD LEAD PROCEDURES,265,MS-DRG,,,,,Inpatient,,,,,,27002.2225,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,27002.2225,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,9818.99,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,22462.06,102,,,case rate,102% WV Medicaid DRG rate,16201.3335,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,20528.28,100,,,case rate,100% PEIA with CHIP DRG base rate,66593.05,100,,,case rate,100% Highmark ACA DRG rate,84210.53,100,,,case rate,100% Highmark PPO DRG rate,84210.53,100,,,case rate,100% Highmark Trad DRG rate,22021.61,100,,,case rate,100% WV Medicaid DRG rate,9818.99,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,17461.33,100,,,case rate,100% PEIA DRG rate,62624.92,100,,,case rate,100% The Health Plan DRG rate,9818.99,84210.53,
ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITH MCC,266,MS-DRG,,,,,Inpatient,,,,,,73416.145,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,73416.145,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,26696.78,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,38084.03,102,,,case rate,102% WV Medicaid DRG rate,44049.687,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,34805.33,100,,,case rate,100% PEIA with CHIP DRG base rate,117695.26,100,,,case rate,100% Highmark ACA DRG rate,148832.07,100,,,case rate,100% Highmark PPO DRG rate,148832.07,100,,,case rate,100% Highmark Trad DRG rate,37337.25,100,,,case rate,100% WV Medicaid DRG rate,26696.78,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,29605.37,100,,,case rate,100% PEIA DRG rate,110682.08,100,,,case rate,100% The Health Plan DRG rate,26696.78,148832.07,
ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITHOUT MCC,267,MS-DRG,,,,,Inpatient,,,,,,51344.645,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,51344.645,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,18670.78,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,30298.23,102,,,case rate,102% WV Medicaid DRG rate,30806.787,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,27689.82,100,,,case rate,100% PEIA with CHIP DRG base rate,91957.61,100,,,case rate,100% Highmark ACA DRG rate,116285.41,100,,,case rate,100% Highmark PPO DRG rate,116285.41,100,,,case rate,100% Highmark Trad DRG rate,29704.11,100,,,case rate,100% WV Medicaid DRG rate,18670.78,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,23552.92,100,,,case rate,100% PEIA DRG rate,86478.07,100,,,case rate,100% The Health Plan DRG rate,18670.78,116285.41,
AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITH MCC,268,MS-DRG,,,,,Inpatient,,,,,,90082.96,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,90082.96,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,32757.44,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,37596.91,102,,,case rate,102% WV Medicaid DRG rate,54049.776,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,34360.15,100,,,case rate,100% PEIA with CHIP DRG base rate,129163.11,100,,,case rate,100% Highmark ACA DRG rate,163333.79,100,,,case rate,100% Highmark PPO DRG rate,163333.79,100,,,case rate,100% Highmark Trad DRG rate,36859.68,100,,,case rate,100% WV Medicaid DRG rate,32757.44,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,29226.7,100,,,case rate,100% PEIA DRG rate,121466.59,100,,,case rate,100% The Health Plan DRG rate,29226.7,163333.79,
AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITHOUT MCC,269,MS-DRG,,,,,Inpatient,,,,,,49199.865,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,49199.865,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,17890.86,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,16351.52,102,,,case rate,102% WV Medicaid DRG rate,29519.919,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,14943.8,100,,,case rate,100% PEIA with CHIP DRG base rate,78360.5,100,,,case rate,100% Highmark ACA DRG rate,99091.12,100,,,case rate,100% Highmark PPO DRG rate,99091.12,100,,,case rate,100% Highmark Trad DRG rate,16030.89,100,,,case rate,100% WV Medicaid DRG rate,17890.86,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,12711.18,100,,,case rate,100% PEIA DRG rate,73691.18,100,,,case rate,100% The Health Plan DRG rate,12711.18,99091.12,
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH MCC,270,MS-DRG,,,,,Inpatient,,,,,,43174.725,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,43174.725,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,15699.9,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,25551.43,102,,,case rate,102% WV Medicaid DRG rate,25904.835,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,23351.67,100,,,case rate,100% PEIA with CHIP DRG base rate,95287.17,100,,,case rate,100% Highmark ACA DRG rate,120495.81,100,,,case rate,100% Highmark PPO DRG rate,120495.81,100,,,case rate,100% Highmark Trad DRG rate,25050.39,100,,,case rate,100% WV Medicaid DRG rate,15699.9,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,19862.9,100,,,case rate,100% PEIA DRG rate,89609.23,100,,,case rate,100% The Health Plan DRG rate,15699.9,120495.81,
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH CC,271,MS-DRG,,,,,Inpatient,,,,,,71734.7125,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,71734.7125,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,26085.35,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,21982.08,102,,,case rate,102% WV Medicaid DRG rate,43040.8275,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,20089.62,100,,,case rate,100% PEIA with CHIP DRG base rate,65125.18,100,,,case rate,100% Highmark ACA DRG rate,82354.33,100,,,case rate,100% Highmark PPO DRG rate,82354.33,100,,,case rate,100% Highmark Trad DRG rate,21551.04,100,,,case rate,100% WV Medicaid DRG rate,26085.35,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,17088.2,100,,,case rate,100% PEIA DRG rate,61244.52,100,,,case rate,100% The Health Plan DRG rate,17088.2,82354.33,
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITHOUT CC/MCC,272,MS-DRG,,,,,Inpatient,,,,,,85219.09,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,85219.09,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,30988.76,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,20330.88,102,,,case rate,102% WV Medicaid DRG rate,51131.454,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,18580.57,100,,,case rate,100% PEIA with CHIP DRG base rate,45967.5,100,,,case rate,100% Highmark ACA DRG rate,58128.41,100,,,case rate,100% Highmark PPO DRG rate,58128.41,100,,,case rate,100% Highmark Trad DRG rate,19932.22,100,,,case rate,100% WV Medicaid DRG rate,30988.76,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,15804.61,100,,,case rate,100% PEIA DRG rate,43228.4,100,,,case rate,100% The Health Plan DRG rate,15804.61,85219.09,
PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITH MCC,273,MS-DRG,,,,,Inpatient,,,,,,87083.26,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,87083.26,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,31666.64,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,24298.66,102,,,case rate,102% WV Medicaid DRG rate,52249.956,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,22206.76,100,,,case rate,100% PEIA with CHIP DRG base rate,73431.17,100,,,case rate,100% Highmark ACA DRG rate,92857.72,100,,,case rate,100% Highmark PPO DRG rate,92857.72,100,,,case rate,100% Highmark Trad DRG rate,23822.19,100,,,case rate,100% WV Medicaid DRG rate,31666.64,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,18889.04,100,,,case rate,100% PEIA DRG rate,69055.58,100,,,case rate,100% The Health Plan DRG rate,18889.04,92857.72,
PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITHOUT MCC,274,MS-DRG,,,,,Inpatient,,,,,,169956.7375,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,169956.7375,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,61802.45,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,22849.35,102,,,case rate,102% WV Medicaid DRG rate,101974.0425,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,20882.22,100,,,case rate,100% PEIA with CHIP DRG base rate,61066.39,100,,,case rate,100% Highmark ACA DRG rate,77221.78,100,,,case rate,100% Highmark PPO DRG rate,77221.78,100,,,case rate,100% Highmark Trad DRG rate,22401.3,100,,,case rate,100% WV Medicaid DRG rate,61802.45,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,17762.39,100,,,case rate,100% PEIA DRG rate,57427.59,100,,,case rate,100% The Health Plan DRG rate,17762.39,169956.7375,
CARDIAC DEFIBRILLATOR IMPLANT WITH CARDIAC CATHETERIZATION AND MCC,275,MS-DRG,,,,,Inpatient,,,,,,132876.6175,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,132876.6175,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,48318.77,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,,,,,other,Not Separately reimbursable,79725.9705,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,,,,,other,Not Separately reimbursable,132575.58,100,,,case rate,100% Highmark ACA DRG rate,167649.04,100,,,case rate,100% Highmark PPO DRG rate,167649.04,100,,,case rate,100% Highmark Trad DRG rate,,,,,other,Not Separately reimbursable,48318.77,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,,,,,other,Not Separately reimbursable,124675.71,100,,,case rate,100% The Health Plan DRG rate,48318.77,167649.04,
CARDIAC DEFIBRILLATOR IMPLANT WITH MCC,276,MS-DRG,,,,,Inpatient,,,,,,178198.7075,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,178198.7075,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,64799.53,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,,,,,other,Not Separately reimbursable,106919.2245,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,,,,,other,Not Separately reimbursable,117018.8,100,,,case rate,100% Highmark ACA DRG rate,147976.65,100,,,case rate,100% Highmark PPO DRG rate,147976.65,100,,,case rate,100% Highmark Trad DRG rate,,,,,other,Not Separately reimbursable,64799.53,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,,,,,other,Not Separately reimbursable,110045.92,100,,,case rate,100% The Health Plan DRG rate,64799.53,178198.7075,
CARDIAC DEFIBRILLATOR IMPLANT WITHOUT MCC,277,MS-DRG,,,,,Inpatient,,,,,,110107.415,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,110107.415,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,40039.06,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,,,,,other,Not Separately reimbursable,66064.449,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,,,,,other,Not Separately reimbursable,90114.76,100,,,case rate,100% Highmark ACA DRG rate,113955.03,100,,,case rate,100% Highmark PPO DRG rate,113955.03,100,,,case rate,100% Highmark Trad DRG rate,,,,,other,Not Separately reimbursable,40039.06,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,,,,,other,Not Separately reimbursable,84745.04,100,,,case rate,100% The Health Plan DRG rate,40039.06,113955.03,
ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS OF PERIPHERAL VASCULAR STRUCTURES WITH MCC,278,MS-DRG,,,,,Inpatient,,,,,,131640.74,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,131640.74,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,47869.36,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,,,,,other,Not Separately reimbursable,78984.444,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,,,,,other,Not Separately reimbursable,84047.32,100,,,case rate,100% Highmark ACA DRG rate,106282.41,100,,,case rate,100% Highmark PPO DRG rate,106282.41,100,,,case rate,100% Highmark Trad DRG rate,,,,,other,Not Separately reimbursable,47869.36,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,,,,,other,Not Separately reimbursable,79039.14,100,,,case rate,100% The Health Plan DRG rate,47869.36,131640.74,
ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS OF PERIPHERAL VASCULAR STRUCTURES WITHOUT MCC,279,MS-DRG,,,,,Inpatient,,,,,,89701.92,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,89701.92,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,32618.88,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,,,,,other,Not Separately reimbursable,53821.152,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,,,,,other,Not Separately reimbursable,60308.91,100,,,case rate,100% Highmark ACA DRG rate,76263.9,100,,,case rate,100% Highmark PPO DRG rate,76263.9,100,,,case rate,100% Highmark Trad DRG rate,,,,,other,Not Separately reimbursable,32618.88,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,,,,,other,Not Separately reimbursable,56715.24,100,,,case rate,100% The Health Plan DRG rate,32618.88,89701.92,
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH MCC",280,MS-DRG,,,,,Inpatient,,,,,,66852.83,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,66852.83,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,24310.12,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,8305,102,,,case rate,102% WV Medicaid DRG rate,40111.698,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,7590.02,100,,,case rate,100% PEIA with CHIP DRG base rate,29894.42,100,,,case rate,100% Highmark ACA DRG rate,37803.12,100,,,case rate,100% Highmark PPO DRG rate,37803.12,100,,,case rate,100% Highmark Trad DRG rate,8142.15,100,,,case rate,100% WV Medicaid DRG rate,24310.12,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,6456.06,100,,,case rate,100% PEIA DRG rate,28113.08,100,,,case rate,100% The Health Plan DRG rate,6456.06,66852.83,
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH CC",281,MS-DRG,,,,,Inpatient,,,,,,103327.8675,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,103327.8675,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,37573.77,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,6840.99,102,,,case rate,102% WV Medicaid DRG rate,61996.7205,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,6252.04,100,,,case rate,100% PEIA with CHIP DRG base rate,17203.66,100,,,case rate,100% Highmark ACA DRG rate,21754.96,100,,,case rate,100% Highmark PPO DRG rate,21754.96,100,,,case rate,100% Highmark Trad DRG rate,6706.84,100,,,case rate,100% WV Medicaid DRG rate,37573.77,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,5317.98,100,,,case rate,100% PEIA DRG rate,16178.53,100,,,case rate,100% The Health Plan DRG rate,5317.98,103327.8675,
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITHOUT CC/MCC",282,MS-DRG,,,,,Inpatient,,,,,,86501.36,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,86501.36,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,31455.04,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,6413.15,102,,,case rate,102% WV Medicaid DRG rate,51900.816,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,5861.03,100,,,case rate,100% PEIA with CHIP DRG base rate,13531.16,100,,,case rate,100% Highmark ACA DRG rate,17110.89,100,,,case rate,100% Highmark PPO DRG rate,17110.89,100,,,case rate,100% Highmark Trad DRG rate,6287.39,100,,,case rate,100% WV Medicaid DRG rate,31455.04,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,4985.39,100,,,case rate,100% PEIA DRG rate,12724.87,100,,,case rate,100% The Health Plan DRG rate,4985.39,86501.36,
"ACUTE MYOCARDIAL INFARCTION, EXPIRED WITH MCC",283,MS-DRG,,,,,Inpatient,,,,,,41362.0625,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,41362.0625,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,15040.75,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,9252.05,102,,,case rate,102% WV Medicaid DRG rate,24817.2375,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,8455.53,100,,,case rate,100% PEIA with CHIP DRG base rate,37147.09,100,,,case rate,100% Highmark ACA DRG rate,46974.52,100,,,case rate,100% Highmark PPO DRG rate,46974.52,100,,,case rate,100% Highmark Trad DRG rate,9070.63,100,,,case rate,100% WV Medicaid DRG rate,15040.75,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,7192.26,100,,,case rate,100% PEIA DRG rate,34933.58,100,,,case rate,100% The Health Plan DRG rate,7192.26,46974.52,
"ACUTE MYOCARDIAL INFARCTION, EXPIRED WITH CC",284,MS-DRG,,,,,Inpatient,,,,,,23652.3375,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,23652.3375,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,8600.85,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,4722.29,102,,,case rate,102% WV Medicaid DRG rate,14191.4025,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,4315.74,100,,,case rate,100% PEIA with CHIP DRG base rate,13938.17,100,,,case rate,100% Highmark ACA DRG rate,17625.57,100,,,case rate,100% Highmark PPO DRG rate,17625.57,100,,,case rate,100% Highmark Trad DRG rate,4629.69,100,,,case rate,100% WV Medicaid DRG rate,8600.85,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,3670.96,100,,,case rate,100% PEIA DRG rate,13107.62,100,,,case rate,100% The Health Plan DRG rate,3670.96,23652.3375,
"ACUTE MYOCARDIAL INFARCTION, EXPIRED WITHOUT CC/MCC",285,MS-DRG,,,,,Inpatient,,,,,,18453.82,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,18453.82,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,6710.48,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,3597.87,102,,,case rate,102% WV Medicaid DRG rate,11072.292,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,3288.12,100,,,case rate,100% PEIA with CHIP DRG base rate,9208.57,100,,,case rate,100% Highmark ACA DRG rate,11644.74,100,,,case rate,100% Highmark PPO DRG rate,11644.74,100,,,case rate,100% Highmark Trad DRG rate,3527.32,100,,,case rate,100% WV Medicaid DRG rate,6710.48,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,2796.87,100,,,case rate,100% PEIA DRG rate,8659.86,100,,,case rate,100% The Health Plan DRG rate,2796.87,18453.82,
"CIRCULATORY DISORDERS EXCEPT AMI, WITH CARDIAC CATHETERIZATION WITH MCC",286,MS-DRG,,,,,Inpatient,,,,,,49400.6425,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,49400.6425,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,17963.87,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,10231.62,102,,,case rate,102% WV Medicaid DRG rate,29640.3855,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,9350.77,100,,,case rate,100% PEIA with CHIP DRG base rate,40617.97,100,,,case rate,100% Highmark ACA DRG rate,51363.64,100,,,case rate,100% Highmark PPO DRG rate,51363.64,100,,,case rate,100% Highmark Trad DRG rate,10030.99,100,,,case rate,100% WV Medicaid DRG rate,17963.87,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,7953.75,100,,,case rate,100% PEIA DRG rate,38197.64,100,,,case rate,100% The Health Plan DRG rate,7953.75,51363.64,
"CIRCULATORY DISORDERS EXCEPT AMI, WITH CARDIAC CATHETERIZATION WITHOUT MCC",287,MS-DRG,,,,,Inpatient,,,,,,18935.2625,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,18935.2625,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,6885.55,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,7246.55,102,,,case rate,102% WV Medicaid DRG rate,11361.1575,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,6622.68,100,,,case rate,100% PEIA with CHIP DRG base rate,20380.59,100,,,case rate,100% Highmark ACA DRG rate,25772.36,100,,,case rate,100% Highmark PPO DRG rate,25772.36,100,,,case rate,100% Highmark Trad DRG rate,7104.45,100,,,case rate,100% WV Medicaid DRG rate,6885.55,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,5633.24,100,,,case rate,100% PEIA DRG rate,19166.16,100,,,case rate,100% The Health Plan DRG rate,5633.24,25772.36,
ACUTE AND SUBACUTE ENDOCARDITIS WITH MCC,288,MS-DRG,,,,,Inpatient,,,,,,13950.42,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,13950.42,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,5072.88,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,12701.06,102,,,case rate,102% WV Medicaid DRG rate,8370.252,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,11607.61,100,,,case rate,100% PEIA with CHIP DRG base rate,48859.9,100,,,case rate,100% Highmark ACA DRG rate,61786,100,,,case rate,100% Highmark PPO DRG rate,61786,100,,,case rate,100% Highmark Trad DRG rate,12452.01,100,,,case rate,100% WV Medicaid DRG rate,5072.88,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,9873.42,100,,,case rate,100% PEIA DRG rate,45948.45,100,,,case rate,100% The Health Plan DRG rate,5072.88,61786,
ACUTE AND SUBACUTE ENDOCARDITIS WITH CC,289,MS-DRG,,,,,Inpatient,,,,,,54612.085,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,54612.085,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,19858.94,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,7794.72,102,,,case rate,102% WV Medicaid DRG rate,32767.251,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,7123.66,100,,,case rate,100% PEIA with CHIP DRG base rate,27844.3,100,,,case rate,100% Highmark ACA DRG rate,35210.64,100,,,case rate,100% Highmark PPO DRG rate,35210.64,100,,,case rate,100% Highmark Trad DRG rate,7641.87,100,,,case rate,100% WV Medicaid DRG rate,19858.94,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,6059.38,100,,,case rate,100% PEIA DRG rate,26185.12,100,,,case rate,100% The Health Plan DRG rate,6059.38,54612.085,
ACUTE AND SUBACUTE ENDOCARDITIS WITHOUT CC/MCC,290,MS-DRG,,,,,Inpatient,,,,,,28328.245,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,28328.245,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,10301.18,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,5602.93,102,,,case rate,102% WV Medicaid DRG rate,16996.947,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,5120.56,100,,,case rate,100% PEIA with CHIP DRG base rate,19317.84,100,,,case rate,100% Highmark ACA DRG rate,24428.47,100,,,case rate,100% Highmark PPO DRG rate,24428.47,100,,,case rate,100% Highmark Trad DRG rate,5493.06,100,,,case rate,100% WV Medicaid DRG rate,10301.18,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,4355.54,100,,,case rate,100% PEIA DRG rate,18166.74,100,,,case rate,100% The Health Plan DRG rate,4355.54,28328.245,
HEART FAILURE AND SHOCK WITH MCC,291,MS-DRG,,,,,Inpatient,,,,,,69430.24,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,69430.24,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,25247.36,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,5972.83,102,,,case rate,102% WV Medicaid DRG rate,41658.144,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,5458.62,100,,,case rate,100% PEIA with CHIP DRG base rate,24192.53,100,,,case rate,100% Highmark ACA DRG rate,30592.77,100,,,case rate,100% Highmark PPO DRG rate,30592.77,100,,,case rate,100% Highmark Trad DRG rate,5855.71,100,,,case rate,100% WV Medicaid DRG rate,25247.36,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,4643.1,100,,,case rate,100% PEIA DRG rate,22750.95,100,,,case rate,100% The Health Plan DRG rate,4643.1,69430.24,
HEART FAILURE AND SHOCK WITH CC,292,MS-DRG,,,,,Inpatient,,,,,,41380.1025,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,41380.1025,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,15047.31,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,4110.39,102,,,case rate,102% WV Medicaid DRG rate,24828.0615,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,3756.52,100,,,case rate,100% PEIA with CHIP DRG base rate,16139.03,100,,,case rate,100% Highmark ACA DRG rate,20408.68,100,,,case rate,100% Highmark PPO DRG rate,20408.68,100,,,case rate,100% Highmark Trad DRG rate,4029.79,100,,,case rate,100% WV Medicaid DRG rate,15047.31,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,3195.29,100,,,case rate,100% PEIA DRG rate,15177.34,100,,,case rate,100% The Health Plan DRG rate,3195.29,41380.1025,
HEART FAILURE AND SHOCK WITHOUT CC/MCC,293,MS-DRG,,,,,Inpatient,,,,,,31044.695,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,31044.695,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,11288.98,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,3720.87,102,,,case rate,102% WV Medicaid DRG rate,18626.817,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,3400.54,100,,,case rate,100% PEIA with CHIP DRG base rate,10580.34,100,,,case rate,100% Highmark ACA DRG rate,13379.42,100,,,case rate,100% Highmark PPO DRG rate,13379.42,100,,,case rate,100% Highmark Trad DRG rate,3647.91,100,,,case rate,100% WV Medicaid DRG rate,11288.98,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,2892.49,100,,,case rate,100% PEIA DRG rate,9949.89,100,,,case rate,100% The Health Plan DRG rate,2892.49,31044.695,
DEEP VEIN THROMBOPHLEBITIS WITH CC/MCC,294,MS-DRG,,,,,Inpatient,,,,,,32952.645,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,32952.645,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,11982.78,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,7667.26,102,,,case rate,102% WV Medicaid DRG rate,19771.587,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,7007.17,100,,,case rate,100% PEIA with CHIP DRG base rate,20608.59,100,,,case rate,100% Highmark ACA DRG rate,26060.68,100,,,case rate,100% Highmark PPO DRG rate,26060.68,100,,,case rate,100% Highmark Trad DRG rate,7516.91,100,,,case rate,100% WV Medicaid DRG rate,11982.78,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,5960.29,100,,,case rate,100% PEIA DRG rate,19380.57,100,,,case rate,100% The Health Plan DRG rate,5960.29,32952.645,
DEEP VEIN THROMBOPHLEBITIS WITHOUT CC/MCC,295,MS-DRG,,,,,Inpatient,,,,,,22215.655,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,22215.655,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,8078.42,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,5687.6,102,,,case rate,102% WV Medicaid DRG rate,13329.393,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,5197.95,100,,,case rate,100% PEIA with CHIP DRG base rate,11899.35,100,,,case rate,100% Highmark ACA DRG rate,15047.38,100,,,case rate,100% Highmark PPO DRG rate,15047.38,100,,,case rate,100% Highmark Trad DRG rate,5576.08,100,,,case rate,100% WV Medicaid DRG rate,8078.42,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,4421.37,100,,,case rate,100% PEIA DRG rate,11190.3,100,,,case rate,100% The Health Plan DRG rate,4421.37,22215.655,
"CARDIAC ARREST, UNEXPLAINED WITH MCC",296,MS-DRG,,,,,Inpatient,,,,,,14426.8025,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,14426.8025,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,5246.11,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,8036.71,102,,,case rate,102% WV Medicaid DRG rate,8656.0815,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,7344.82,100,,,case rate,100% PEIA with CHIP DRG base rate,30209.1,100,,,case rate,100% Highmark ACA DRG rate,38201.05,100,,,case rate,100% Highmark PPO DRG rate,38201.05,100,,,case rate,100% Highmark Trad DRG rate,7879.12,100,,,case rate,100% WV Medicaid DRG rate,5246.11,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,6247.5,100,,,case rate,100% PEIA DRG rate,28409.01,100,,,case rate,100% The Health Plan DRG rate,5246.11,38201.05,
"CARDIAC ARREST, UNEXPLAINED WITH CC",297,MS-DRG,,,,,Inpatient,,,,,,29726.4275,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,29726.4275,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,10809.61,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,4226.26,102,,,case rate,102% WV Medicaid DRG rate,17835.8565,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,3862.42,100,,,case rate,100% PEIA with CHIP DRG base rate,13729.01,100,,,case rate,100% Highmark ACA DRG rate,17361.08,100,,,case rate,100% Highmark PPO DRG rate,17361.08,100,,,case rate,100% Highmark Trad DRG rate,4143.39,100,,,case rate,100% WV Medicaid DRG rate,10809.61,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,3285.37,100,,,case rate,100% PEIA DRG rate,12910.93,100,,,case rate,100% The Health Plan DRG rate,3285.37,29726.4275,
"CARDIAC ARREST, UNEXPLAINED WITHOUT CC/MCC",298,MS-DRG,,,,,Inpatient,,,,,,22805.2,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,22805.2,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,8292.8,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,3136.6,102,,,case rate,102% WV Medicaid DRG rate,13683.12,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,2866.57,100,,,case rate,100% PEIA with CHIP DRG base rate,8270.19,100,,,case rate,100% Highmark ACA DRG rate,10458.11,100,,,case rate,100% Highmark PPO DRG rate,10458.11,100,,,case rate,100% Highmark Trad DRG rate,3075.1,100,,,case rate,100% WV Medicaid DRG rate,8292.8,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,2438.3,100,,,case rate,100% PEIA DRG rate,7777.39,100,,,case rate,100% The Health Plan DRG rate,2438.3,22805.2,
PERIPHERAL VASCULAR DISORDERS WITH MCC,299,MS-DRG,,,,,Inpatient,,,,,,42183.405,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,42183.405,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,15339.42,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,7900.78,102,,,case rate,102% WV Medicaid DRG rate,25310.043,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,7220.6,100,,,case rate,100% PEIA with CHIP DRG base rate,29700.34,100,,,case rate,100% Highmark ACA DRG rate,37557.69,100,,,case rate,100% Highmark PPO DRG rate,37557.69,100,,,case rate,100% Highmark Trad DRG rate,7745.86,100,,,case rate,100% WV Medicaid DRG rate,15339.42,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,6141.83,100,,,case rate,100% PEIA DRG rate,27930.56,100,,,case rate,100% The Health Plan DRG rate,6141.83,42183.405,
PERIPHERAL VASCULAR DISORDERS WITH CC,300,MS-DRG,,,,,Inpatient,,,,,,16383.6475,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,16383.6475,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,5957.69,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,5925.59,102,,,case rate,102% WV Medicaid DRG rate,9830.1885,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,5415.45,100,,,case rate,100% PEIA with CHIP DRG base rate,20105.48,100,,,case rate,100% Highmark ACA DRG rate,25424.48,100,,,case rate,100% Highmark PPO DRG rate,25424.48,100,,,case rate,100% Highmark Trad DRG rate,5809.39,100,,,case rate,100% WV Medicaid DRG rate,5957.69,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,4606.37,100,,,case rate,100% PEIA DRG rate,18907.44,100,,,case rate,100% The Health Plan DRG rate,4606.37,25424.48,
PERIPHERAL VASCULAR DISORDERS WITHOUT CC/MCC,301,MS-DRG,,,,,Inpatient,,,,,,12578.0325,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,12578.0325,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,4573.83,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,4079.19,102,,,case rate,102% WV Medicaid DRG rate,7546.8195,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,3728.01,100,,,case rate,100% PEIA with CHIP DRG base rate,13374.76,100,,,case rate,100% Highmark ACA DRG rate,16913.11,100,,,case rate,100% Highmark PPO DRG rate,16913.11,100,,,case rate,100% Highmark Trad DRG rate,3999.2,100,,,case rate,100% WV Medicaid DRG rate,4573.83,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,3171.04,100,,,case rate,100% PEIA DRG rate,12577.79,100,,,case rate,100% The Health Plan DRG rate,3171.04,16913.11,
ATHEROSCLEROSIS WITH MCC,302,MS-DRG,,,,,Inpatient,,,,,,39600.88,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,39600.88,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,14400.32,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,8150.36,102,,,case rate,102% WV Medicaid DRG rate,23760.528,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,7448.68,100,,,case rate,100% PEIA with CHIP DRG base rate,21124.89,100,,,case rate,100% Highmark ACA DRG rate,26713.57,100,,,case rate,100% Highmark PPO DRG rate,26713.57,100,,,case rate,100% Highmark Trad DRG rate,7990.54,100,,,case rate,100% WV Medicaid DRG rate,14400.32,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,6335.84,100,,,case rate,100% PEIA DRG rate,19866.11,100,,,case rate,100% The Health Plan DRG rate,6335.84,39600.88,
ATHEROSCLEROSIS WITHOUT MCC,303,MS-DRG,,,,,Inpatient,,,,,,26549.05,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,26549.05,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,9654.2,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,6775.03,102,,,case rate,102% WV Medicaid DRG rate,15929.43,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,6191.76,100,,,case rate,100% PEIA with CHIP DRG base rate,12400.58,100,,,case rate,100% Highmark ACA DRG rate,15681.21,100,,,case rate,100% Highmark PPO DRG rate,15681.21,100,,,case rate,100% Highmark Trad DRG rate,6642.18,100,,,case rate,100% WV Medicaid DRG rate,9654.2,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,5266.7,100,,,case rate,100% PEIA DRG rate,11661.66,100,,,case rate,100% The Health Plan DRG rate,5266.7,26549.05,
HYPERTENSION WITH MCC,304,MS-DRG,,,,,Inpatient,,,,,,18440.9225,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,18440.9225,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,6705.79,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,5564.6,102,,,case rate,102% WV Medicaid DRG rate,11064.5535,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,5085.54,100,,,case rate,100% PEIA with CHIP DRG base rate,21650.61,100,,,case rate,100% Highmark ACA DRG rate,27378.37,100,,,case rate,100% Highmark PPO DRG rate,27378.37,100,,,case rate,100% Highmark Trad DRG rate,5455.48,100,,,case rate,100% WV Medicaid DRG rate,6705.79,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,4325.75,100,,,case rate,100% PEIA DRG rate,20360.5,100,,,case rate,100% The Health Plan DRG rate,4325.75,27378.37,
HYPERTENSION WITHOUT MCC,305,MS-DRG,,,,,Inpatient,,,,,,31047.3075,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,31047.3075,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,11289.93,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,4154.95,102,,,case rate,102% WV Medicaid DRG rate,18628.3845,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,3797.25,100,,,case rate,100% PEIA with CHIP DRG base rate,14198.2,100,,,case rate,100% Highmark ACA DRG rate,17954.4,100,,,case rate,100% Highmark PPO DRG rate,17954.4,100,,,case rate,100% Highmark Trad DRG rate,4073.48,100,,,case rate,100% WV Medicaid DRG rate,11289.93,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,3229.93,100,,,case rate,100% PEIA DRG rate,13352.16,100,,,case rate,100% The Health Plan DRG rate,3229.93,31047.3075,
CARDIAC CONGENITAL AND VALVULAR DISORDERS WITH MCC,306,MS-DRG,,,,,Inpatient,,,,,,17408.435,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,17408.435,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,6330.34,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,8763.6,102,,,case rate,102% WV Medicaid DRG rate,10445.061,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,8009.13,100,,,case rate,100% PEIA with CHIP DRG base rate,28957.92,100,,,case rate,100% Highmark ACA DRG rate,36618.87,100,,,case rate,100% Highmark PPO DRG rate,36618.87,100,,,case rate,100% Highmark Trad DRG rate,8591.75,100,,,case rate,100% WV Medicaid DRG rate,6330.34,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,6812.55,100,,,case rate,100% PEIA DRG rate,27232.39,100,,,case rate,100% The Health Plan DRG rate,6330.34,36618.87,
CARDIAC CONGENITAL AND VALVULAR DISORDERS WITHOUT MCC,307,MS-DRG,,,,,Inpatient,,,,,,28287.0775,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,28287.0775,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,10286.21,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,7081.2,102,,,case rate,102% WV Medicaid DRG rate,16972.2465,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,6471.57,100,,,case rate,100% PEIA with CHIP DRG base rate,17761.41,100,,,case rate,100% Highmark ACA DRG rate,22460.27,100,,,case rate,100% Highmark PPO DRG rate,22460.27,100,,,case rate,100% Highmark Trad DRG rate,6942.35,100,,,case rate,100% WV Medicaid DRG rate,10286.21,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,5504.71,100,,,case rate,100% PEIA DRG rate,16703.05,100,,,case rate,100% The Health Plan DRG rate,5504.71,28287.0775,
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH MCC,308,MS-DRG,,,,,Inpatient,,,,,,19197.915,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,19197.915,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,6981.06,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,6441.67,102,,,case rate,102% WV Medicaid DRG rate,11518.749,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,5887.1,100,,,case rate,100% PEIA with CHIP DRG base rate,22653.05,100,,,case rate,100% Highmark ACA DRG rate,28646.02,100,,,case rate,100% Highmark PPO DRG rate,28646.02,100,,,case rate,100% Highmark Trad DRG rate,6315.36,100,,,case rate,100% WV Medicaid DRG rate,6981.06,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,5007.56,100,,,case rate,100% PEIA DRG rate,21303.21,100,,,case rate,100% The Health Plan DRG rate,5007.56,28646.02,
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH CC,309,MS-DRG,,,,,Inpatient,,,,,,37999.3075,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,37999.3075,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,13817.93,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,4280.63,102,,,case rate,102% WV Medicaid DRG rate,22799.5845,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,3912.11,100,,,case rate,100% PEIA with CHIP DRG base rate,14032.38,100,,,case rate,100% Highmark ACA DRG rate,17744.71,100,,,case rate,100% Highmark PPO DRG rate,17744.71,100,,,case rate,100% Highmark Trad DRG rate,4196.69,100,,,case rate,100% WV Medicaid DRG rate,13817.93,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,3327.63,100,,,case rate,100% PEIA DRG rate,13196.23,100,,,case rate,100% The Health Plan DRG rate,3327.63,37999.3075,
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITHOUT CC/MCC,310,MS-DRG,,,,,Inpatient,,,,,,23466.9875,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,23466.9875,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,8533.45,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,3641.99,102,,,case rate,102% WV Medicaid DRG rate,14080.1925,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,3328.45,100,,,case rate,100% PEIA with CHIP DRG base rate,10420.18,100,,,case rate,100% Highmark ACA DRG rate,13176.88,100,,,case rate,100% Highmark PPO DRG rate,13176.88,100,,,case rate,100% Highmark Trad DRG rate,3570.58,100,,,case rate,100% WV Medicaid DRG rate,8533.45,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,2831.17,100,,,case rate,100% PEIA DRG rate,9799.27,100,,,case rate,100% The Health Plan DRG rate,2831.17,23466.9875,
ANGINA PECTORIS,311,MS-DRG,,,,,Inpatient,,,,,,30192.4425,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,30192.4425,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,10979.07,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,3991.84,102,,,case rate,102% WV Medicaid DRG rate,18115.4655,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,3648.18,100,,,case rate,100% PEIA with CHIP DRG base rate,13154.3,100,,,case rate,100% Highmark ACA DRG rate,16634.33,100,,,case rate,100% Highmark PPO DRG rate,16634.33,100,,,case rate,100% Highmark Trad DRG rate,3913.56,100,,,case rate,100% WV Medicaid DRG rate,10979.07,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,3103.13,100,,,case rate,100% PEIA DRG rate,12370.46,100,,,case rate,100% The Health Plan DRG rate,3103.13,30192.4425,
SYNCOPE AND COLLAPSE,312,MS-DRG,,,,,Inpatient,,,,,,18991.94,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,18991.94,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,6906.16,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,4928.63,102,,,case rate,102% WV Medicaid DRG rate,11395.164,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,4504.32,100,,,case rate,100% PEIA with CHIP DRG base rate,16270.93,100,,,case rate,100% Highmark ACA DRG rate,20575.48,100,,,case rate,100% Highmark PPO DRG rate,20575.48,100,,,case rate,100% Highmark Trad DRG rate,4831.99,100,,,case rate,100% WV Medicaid DRG rate,6906.16,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,3831.37,100,,,case rate,100% PEIA DRG rate,15301.38,100,,,case rate,100% The Health Plan DRG rate,3831.37,20575.48,
CHEST PAIN,313,MS-DRG,,,,,Inpatient,,,,,,14192.475,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,14192.475,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,5160.9,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,4140.69,102,,,case rate,102% WV Medicaid DRG rate,8515.485,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,3784.22,100,,,case rate,100% PEIA with CHIP DRG base rate,13634.79,100,,,case rate,100% Highmark ACA DRG rate,17241.94,100,,,case rate,100% Highmark PPO DRG rate,17241.94,100,,,case rate,100% Highmark Trad DRG rate,4059.5,100,,,case rate,100% WV Medicaid DRG rate,5160.9,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,3218.85,100,,,case rate,100% PEIA DRG rate,12822.33,100,,,case rate,100% The Health Plan DRG rate,3218.85,17241.94,
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH MCC,314,MS-DRG,,,,,Inpatient,,,,,,17202.46,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,17202.46,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,6255.44,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,11759.82,102,,,case rate,102% WV Medicaid DRG rate,10321.476,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,10747.4,100,,,case rate,100% PEIA with CHIP DRG base rate,39447.82,100,,,case rate,100% Highmark ACA DRG rate,49883.92,100,,,case rate,100% Highmark PPO DRG rate,49883.92,100,,,case rate,100% Highmark Trad DRG rate,11529.22,100,,,case rate,100% WV Medicaid DRG rate,6255.44,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,9141.72,100,,,case rate,100% PEIA DRG rate,37097.22,100,,,case rate,100% The Health Plan DRG rate,6255.44,49883.92,
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH CC,315,MS-DRG,,,,,Inpatient,,,,,,21955.56,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,21955.56,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,7983.84,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,6429.64,102,,,case rate,102% WV Medicaid DRG rate,13173.336,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,5876.1,100,,,case rate,100% PEIA with CHIP DRG base rate,18226.83,100,,,case rate,100% Highmark ACA DRG rate,23048.82,100,,,case rate,100% Highmark PPO DRG rate,23048.82,100,,,case rate,100% Highmark Trad DRG rate,6303.56,100,,,case rate,100% WV Medicaid DRG rate,7983.84,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,4998.21,100,,,case rate,100% PEIA DRG rate,17140.74,100,,,case rate,100% The Health Plan DRG rate,4998.21,23048.82,
OTHER CIRCULATORY SYSTEM DIAGNOSES WITHOUT CC/MCC,316,MS-DRG,,,,,Inpatient,,,,,,18626.3275,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,18626.3275,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,6773.21,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,4621.57,102,,,case rate,102% WV Medicaid DRG rate,11175.7965,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,4223.69,100,,,case rate,100% PEIA with CHIP DRG base rate,13052.55,100,,,case rate,100% Highmark ACA DRG rate,16505.66,100,,,case rate,100% Highmark PPO DRG rate,16505.66,100,,,case rate,100% Highmark Trad DRG rate,4530.94,100,,,case rate,100% WV Medicaid DRG rate,6773.21,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,3592.67,100,,,case rate,100% PEIA DRG rate,12274.78,100,,,case rate,100% The Health Plan DRG rate,3592.67,18626.3275,
OTHER ENDOVASCULAR CARDIAC VALVE PROCEDURES WITH MCC,319,MS-DRG,,,,,Inpatient,,,,,,53623.3775,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,53623.3775,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,19499.41,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,27655.42,102,,,case rate,102% WV Medicaid DRG rate,32174.0265,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,25274.53,100,,,case rate,100% PEIA with CHIP DRG base rate,82191.28,100,,,case rate,100% Highmark ACA DRG rate,103935.35,100,,,case rate,100% Highmark PPO DRG rate,103935.35,100,,,case rate,100% Highmark Trad DRG rate,27113.13,100,,,case rate,100% WV Medicaid DRG rate,19499.41,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,21498.48,100,,,case rate,100% PEIA DRG rate,77293.7,100,,,case rate,100% The Health Plan DRG rate,19499.41,103935.35,
OTHER ENDOVASCULAR CARDIAC VALVE PROCEDURES WITHOUT MCC,320,MS-DRG,,,,,Inpatient,,,,,,24937.22,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,24937.22,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,9068.08,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,16414.36,102,,,case rate,102% WV Medicaid DRG rate,14962.332,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,15001.23,100,,,case rate,100% PEIA with CHIP DRG base rate,41944.52,100,,,case rate,100% Highmark ACA DRG rate,53041.13,100,,,case rate,100% Highmark PPO DRG rate,53041.13,100,,,case rate,100% Highmark Trad DRG rate,16092.5,100,,,case rate,100% WV Medicaid DRG rate,9068.08,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,12760.03,100,,,case rate,100% PEIA DRG rate,39445.14,100,,,case rate,100% The Health Plan DRG rate,9068.08,53041.13,
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH INTRALUMINAL DEVICE WITH MCC OR 4+ ARTERIES/INTRALUMINAL DEVICES,321,MS-DRG,,,,,Inpatient,,,,,,17560.3175,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,17560.3175,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,6385.57,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,,,,,other,Not Separately reimbursable,10536.1905,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,,,,,other,Not Separately reimbursable,54167.97,100,,,case rate,100% Highmark ACA DRG rate,68498.35,100,,,case rate,100% Highmark PPO DRG rate,68498.35,100,,,case rate,100% Highmark Trad DRG rate,,,,,other,Not Separately reimbursable,6385.57,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,,,,,other,Not Separately reimbursable,50940.23,100,,,case rate,100% The Health Plan DRG rate,6385.57,68498.35,
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH INTRALUMINAL DEVICE WITHOUT MCC,322,MS-DRG,,,,,Inpatient,,,,,,110887.59,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,110887.59,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,40322.76,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,,,,,other,Not Separately reimbursable,66532.554,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,,,,,other,Not Separately reimbursable,34358.33,100,,,case rate,100% Highmark ACA DRG rate,43447.98,100,,,case rate,100% Highmark PPO DRG rate,43447.98,100,,,case rate,100% Highmark Trad DRG rate,,,,,other,Not Separately reimbursable,40322.76,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,,,,,other,Not Separately reimbursable,32310.99,100,,,case rate,100% The Health Plan DRG rate,32310.99,110887.59,
CORONARY INTRAVASCULAR LITHOTRIPSY WITH INTRALUMINAL DEVICE WITH MCC,323,MS-DRG,,,,,Inpatient,,,,,,63634.3125,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,63634.3125,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,23139.75,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,,,,,other,Not Separately reimbursable,38180.5875,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,,,,,other,Not Separately reimbursable,78010.02,100,,,case rate,100% Highmark ACA DRG rate,98647.92,100,,,case rate,100% Highmark PPO DRG rate,98647.92,100,,,case rate,100% Highmark Trad DRG rate,,,,,other,Not Separately reimbursable,23139.75,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,,,,,other,Not Separately reimbursable,73361.59,100,,,case rate,100% The Health Plan DRG rate,23139.75,98647.92,
CORONARY INTRAVASCULAR LITHOTRIPSY WITH INTRALUMINAL DEVICE WITHOUT MCC,324,MS-DRG,,,,,Inpatient,,,,,,131800.3225,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,131800.3225,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,47927.39,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,,,,,other,Not Separately reimbursable,79080.1935,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,,,,,other,Not Separately reimbursable,55937.33,100,,,case rate,100% Highmark ACA DRG rate,70735.8,100,,,case rate,100% Highmark PPO DRG rate,70735.8,100,,,case rate,100% Highmark Trad DRG rate,,,,,other,Not Separately reimbursable,47927.39,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,,,,,other,Not Separately reimbursable,52604.16,100,,,case rate,100% The Health Plan DRG rate,47927.39,131800.3225,
CORONARY INTRAVASCULAR LITHOTRIPSY WITHOUT INTRALUMINAL DEVICE,325,MS-DRG,,,,,Inpatient,,,,,,65949.07,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,65949.07,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,23981.48,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,,,,,other,Not Separately reimbursable,39569.442,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,,,,,other,Not Separately reimbursable,49826.54,100,,,case rate,100% Highmark ACA DRG rate,63008.38,100,,,case rate,100% Highmark PPO DRG rate,63008.38,100,,,case rate,100% Highmark Trad DRG rate,,,,,other,Not Separately reimbursable,23981.48,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,,,,,other,Not Separately reimbursable,46857.5,100,,,case rate,100% The Health Plan DRG rate,23981.48,65949.07,
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH MCC",326,MS-DRG,,,,,Inpatient,,,,,,42682.9425,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,42682.9425,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,15521.07,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,22757.99,102,,,case rate,102% WV Medicaid DRG rate,25609.7655,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,20798.72,100,,,case rate,100% PEIA with CHIP DRG base rate,95703.6,100,,,case rate,100% Highmark ACA DRG rate,121022.41,100,,,case rate,100% Highmark PPO DRG rate,121022.41,100,,,case rate,100% Highmark Trad DRG rate,22311.73,100,,,case rate,100% WV Medicaid DRG rate,15521.07,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,17691.37,100,,,case rate,100% PEIA DRG rate,90000.85,100,,,case rate,100% The Health Plan DRG rate,15521.07,121022.41,
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH CC",327,MS-DRG,,,,,Inpatient,,,,,,119042.0275,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,119042.0275,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,43288.01,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,12923.45,102,,,case rate,102% WV Medicaid DRG rate,71425.2165,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,11810.86,100,,,case rate,100% PEIA with CHIP DRG base rate,47058.51,100,,,case rate,100% Highmark ACA DRG rate,59508.05,100,,,case rate,100% Highmark PPO DRG rate,59508.05,100,,,case rate,100% Highmark Trad DRG rate,12670.04,100,,,case rate,100% WV Medicaid DRG rate,43288.01,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,10046.3,100,,,case rate,100% PEIA DRG rate,44254.4,100,,,case rate,100% The Health Plan DRG rate,10046.3,119042.0275,
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITHOUT CC/MCC",328,MS-DRG,,,,,Inpatient,,,,,,63222.3075,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,63222.3075,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,22989.93,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,8924.93,102,,,case rate,102% WV Medicaid DRG rate,37933.3845,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,8156.57,100,,,case rate,100% PEIA with CHIP DRG base rate,30097.92,100,,,case rate,100% Highmark ACA DRG rate,38060.46,100,,,case rate,100% Highmark PPO DRG rate,38060.46,100,,,case rate,100% Highmark Trad DRG rate,8749.92,100,,,case rate,100% WV Medicaid DRG rate,22989.93,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,6937.97,100,,,case rate,100% PEIA DRG rate,28304.46,100,,,case rate,100% The Health Plan DRG rate,6937.97,63222.3075,
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,329,MS-DRG,,,,,Inpatient,,,,,,43998.68,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,43998.68,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,15999.52,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,22300.73,102,,,case rate,102% WV Medicaid DRG rate,26399.208,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,20380.83,100,,,case rate,100% PEIA with CHIP DRG base rate,85110.06,100,,,case rate,100% Highmark ACA DRG rate,107626.31,100,,,case rate,100% Highmark PPO DRG rate,107626.31,100,,,case rate,100% Highmark Trad DRG rate,21863.44,100,,,case rate,100% WV Medicaid DRG rate,15999.52,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,17335.91,100,,,case rate,100% PEIA DRG rate,80038.55,100,,,case rate,100% The Health Plan DRG rate,15999.52,107626.31,
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,330,MS-DRG,,,,,Inpatient,,,,,,104545.76,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,104545.76,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,38016.64,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,14827.79,102,,,case rate,102% WV Medicaid DRG rate,62727.456,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,13551.25,100,,,case rate,100% PEIA with CHIP DRG base rate,44697.48,100,,,case rate,100% Highmark ACA DRG rate,56522.4,100,,,case rate,100% Highmark PPO DRG rate,56522.4,100,,,case rate,100% Highmark Trad DRG rate,14537.03,100,,,case rate,100% WV Medicaid DRG rate,38016.64,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,11526.67,100,,,case rate,100% PEIA DRG rate,42034.06,100,,,case rate,100% The Health Plan DRG rate,11526.67,104545.76,
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,331,MS-DRG,,,,,Inpatient,,,,,,57498.54,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,57498.54,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,20908.56,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,12245.15,102,,,case rate,102% WV Medicaid DRG rate,34499.124,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,11190.95,100,,,case rate,100% PEIA with CHIP DRG base rate,31505.5,100,,,case rate,100% Highmark ACA DRG rate,39840.42,100,,,case rate,100% Highmark PPO DRG rate,39840.42,100,,,case rate,100% Highmark Trad DRG rate,12005.03,100,,,case rate,100% WV Medicaid DRG rate,20908.56,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,9519.01,100,,,case rate,100% PEIA DRG rate,29628.16,100,,,case rate,100% The Health Plan DRG rate,9519.01,57498.54,
RECTAL RESECTION WITH MCC,332,MS-DRG,,,,,Inpatient,,,,,,44145.4475,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,44145.4475,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,16052.89,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,26074.19,102,,,case rate,102% WV Medicaid DRG rate,26487.2685,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,23829.44,100,,,case rate,100% PEIA with CHIP DRG base rate,68354.87,100,,,case rate,100% Highmark ACA DRG rate,86438.45,100,,,case rate,100% Highmark PPO DRG rate,86438.45,100,,,case rate,100% Highmark Trad DRG rate,25562.91,100,,,case rate,100% WV Medicaid DRG rate,16052.89,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,20269.29,100,,,case rate,100% PEIA DRG rate,64281.76,100,,,case rate,100% The Health Plan DRG rate,16052.89,86438.45,
RECTAL RESECTION WITH CC,333,MS-DRG,,,,,Inpatient,,,,,,94851.5975,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,94851.5975,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,34491.49,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,14831.35,102,,,case rate,102% WV Medicaid DRG rate,56910.9585,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,13554.5,100,,,case rate,100% PEIA with CHIP DRG base rate,39184.02,100,,,case rate,100% Highmark ACA DRG rate,49550.33,100,,,case rate,100% Highmark PPO DRG rate,49550.33,100,,,case rate,100% Highmark Trad DRG rate,14540.53,100,,,case rate,100% WV Medicaid DRG rate,34491.49,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,11529.44,100,,,case rate,100% PEIA DRG rate,36849.14,100,,,case rate,100% The Health Plan DRG rate,11529.44,94851.5975,
RECTAL RESECTION WITHOUT CC/MCC,334,MS-DRG,,,,,Inpatient,,,,,,54766.6075,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,54766.6075,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,19915.13,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,11387.24,102,,,case rate,102% WV Medicaid DRG rate,32859.9645,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,10406.9,100,,,case rate,100% PEIA with CHIP DRG base rate,30244.9,100,,,case rate,100% Highmark ACA DRG rate,38246.32,100,,,case rate,100% Highmark PPO DRG rate,38246.32,100,,,case rate,100% Highmark Trad DRG rate,11163.95,100,,,case rate,100% WV Medicaid DRG rate,19915.13,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,8852.09,100,,,case rate,100% PEIA DRG rate,28442.68,100,,,case rate,100% The Health Plan DRG rate,8852.09,54766.6075,
PERITONEAL ADHESIOLYSIS WITH MCC,335,MS-DRG,,,,,Inpatient,,,,,,40566.4325,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,40566.4325,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,14751.43,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,19028.2,102,,,case rate,102% WV Medicaid DRG rate,24339.8595,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,17390.04,100,,,case rate,100% PEIA with CHIP DRG base rate,67363.73,100,,,case rate,100% Highmark ACA DRG rate,85185.1,100,,,case rate,100% Highmark PPO DRG rate,85185.1,100,,,case rate,100% Highmark Trad DRG rate,18655.08,100,,,case rate,100% WV Medicaid DRG rate,14751.43,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,14791.94,100,,,case rate,100% PEIA DRG rate,63349.68,100,,,case rate,100% The Health Plan DRG rate,14751.43,85185.1,
PERITONEAL ADHESIOLYSIS WITH CC,336,MS-DRG,,,,,Inpatient,,,,,,68400.3375,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,68400.3375,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,24872.85,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,11169.75,102,,,case rate,102% WV Medicaid DRG rate,41040.2025,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,10208.13,100,,,case rate,100% PEIA with CHIP DRG base rate,39670.17,100,,,case rate,100% Highmark ACA DRG rate,50165.09,100,,,case rate,100% Highmark PPO DRG rate,50165.09,100,,,case rate,100% Highmark Trad DRG rate,10950.73,100,,,case rate,100% WV Medicaid DRG rate,24872.85,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,8683.03,100,,,case rate,100% PEIA DRG rate,37306.32,100,,,case rate,100% The Health Plan DRG rate,8683.03,68400.3375,
PERITONEAL ADHESIOLYSIS WITHOUT CC/MCC,337,MS-DRG,,,,,Inpatient,,,,,,41928.48,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,41928.48,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,15246.72,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,9100.52,102,,,case rate,102% WV Medicaid DRG rate,25157.088,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,8317.05,100,,,case rate,100% PEIA with CHIP DRG base rate,28196.67,100,,,case rate,100% Highmark ACA DRG rate,35656.22,100,,,case rate,100% Highmark PPO DRG rate,35656.22,100,,,case rate,100% Highmark Trad DRG rate,8922.07,100,,,case rate,100% WV Medicaid DRG rate,15246.72,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,7074.47,100,,,case rate,100% PEIA DRG rate,26516.49,100,,,case rate,100% The Health Plan DRG rate,7074.47,41928.48,
MINOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,344,MS-DRG,,,,,Inpatient,,,,,,30895.37,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,30895.37,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,11234.68,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,17483.52,102,,,case rate,102% WV Medicaid DRG rate,18537.222,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,15978.34,100,,,case rate,100% PEIA with CHIP DRG base rate,51637.36,100,,,case rate,100% Highmark ACA DRG rate,65298.25,100,,,case rate,100% Highmark PPO DRG rate,65298.25,100,,,case rate,100% Highmark Trad DRG rate,17140.69,100,,,case rate,100% WV Medicaid DRG rate,11234.68,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,13591.16,100,,,case rate,100% PEIA DRG rate,48560.41,100,,,case rate,100% The Health Plan DRG rate,11234.68,65298.25,
MINOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,345,MS-DRG,,,,,Inpatient,,,,,,58165.36,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,58165.36,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,21151.04,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,10520.42,102,,,case rate,102% WV Medicaid DRG rate,34899.216,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,9614.7,100,,,case rate,100% PEIA with CHIP DRG base rate,29029.53,100,,,case rate,100% Highmark ACA DRG rate,36709.42,100,,,case rate,100% Highmark PPO DRG rate,36709.42,100,,,case rate,100% Highmark Trad DRG rate,10314.12,100,,,case rate,100% WV Medicaid DRG rate,21151.04,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,8178.25,100,,,case rate,100% PEIA DRG rate,27299.72,100,,,case rate,100% The Health Plan DRG rate,8178.25,58165.36,
MINOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,346,MS-DRG,,,,,Inpatient,,,,,,37417.4075,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,37417.4075,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,13606.33,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,6385.96,102,,,case rate,102% WV Medicaid DRG rate,22450.4445,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,5836.19,100,,,case rate,100% PEIA with CHIP DRG base rate,24266.02,100,,,case rate,100% Highmark ACA DRG rate,30685.7,100,,,case rate,100% Highmark PPO DRG rate,30685.7,100,,,case rate,100% Highmark Trad DRG rate,6260.74,100,,,case rate,100% WV Medicaid DRG rate,13606.33,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,4964.25,100,,,case rate,100% PEIA DRG rate,22820.06,100,,,case rate,100% The Health Plan DRG rate,4964.25,37417.4075,
ANAL AND STOMAL PROCEDURES WITH MCC,347,MS-DRG,,,,,Inpatient,,,,,,28135.1675,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,28135.1675,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,10230.97,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,16857.35,102,,,case rate,102% WV Medicaid DRG rate,16881.1005,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,15406.08,100,,,case rate,100% PEIA with CHIP DRG base rate,48032.69,100,,,case rate,100% Highmark ACA DRG rate,60739.95,100,,,case rate,100% Highmark PPO DRG rate,60739.95,100,,,case rate,100% Highmark Trad DRG rate,16526.8,100,,,case rate,100% WV Medicaid DRG rate,10230.97,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,13104.4,100,,,case rate,100% PEIA DRG rate,45170.54,100,,,case rate,100% The Health Plan DRG rate,10230.97,60739.95,
ANAL AND STOMAL PROCEDURES WITH CC,348,MS-DRG,,,,,Inpatient,,,,,,67782.3575,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,67782.3575,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,24648.13,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,5529.39,102,,,case rate,102% WV Medicaid DRG rate,40669.4145,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,5053.36,100,,,case rate,100% PEIA with CHIP DRG base rate,24522.28,100,,,case rate,100% Highmark ACA DRG rate,31009.76,100,,,case rate,100% Highmark PPO DRG rate,31009.76,100,,,case rate,100% Highmark Trad DRG rate,5420.97,100,,,case rate,100% WV Medicaid DRG rate,24648.13,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,4298.38,100,,,case rate,100% PEIA DRG rate,23061.06,100,,,case rate,100% The Health Plan DRG rate,4298.38,67782.3575,
ANAL AND STOMAL PROCEDURES WITHOUT CC/MCC,349,MS-DRG,,,,,Inpatient,,,,,,39948.48,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,39948.48,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,14526.72,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,3974.46,102,,,case rate,102% WV Medicaid DRG rate,23969.088,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,3632.29,100,,,case rate,100% PEIA with CHIP DRG base rate,18387,100,,,case rate,100% Highmark ACA DRG rate,23251.36,100,,,case rate,100% Highmark PPO DRG rate,23251.36,100,,,case rate,100% Highmark Trad DRG rate,3896.52,100,,,case rate,100% WV Medicaid DRG rate,14526.72,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,3089.62,100,,,case rate,100% PEIA DRG rate,17291.36,100,,,case rate,100% The Health Plan DRG rate,3089.62,39948.48,
INGUINAL AND FEMORAL HERNIA PROCEDURES WITH MCC,350,MS-DRG,,,,,Inpatient,,,,,,32203.38,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,32203.38,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,11710.32,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,15654.05,102,,,case rate,102% WV Medicaid DRG rate,19322.028,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,14306.38,100,,,case rate,100% PEIA with CHIP DRG base rate,45223.2,100,,,case rate,100% Highmark ACA DRG rate,57187.2,100,,,case rate,100% Highmark PPO DRG rate,57187.2,100,,,case rate,100% Highmark Trad DRG rate,15347.1,100,,,case rate,100% WV Medicaid DRG rate,11710.32,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,12168.99,100,,,case rate,100% PEIA DRG rate,42528.46,100,,,case rate,100% The Health Plan DRG rate,11710.32,57187.2,
INGUINAL AND FEMORAL HERNIA PROCEDURES WITH CC,351,MS-DRG,,,,,Inpatient,,,,,,65354.3275,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,65354.3275,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,23765.21,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,9764.56,102,,,case rate,102% WV Medicaid DRG rate,39212.5965,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,8923.92,100,,,case rate,100% PEIA with CHIP DRG base rate,27427.87,100,,,case rate,100% Highmark ACA DRG rate,34684.04,100,,,case rate,100% Highmark PPO DRG rate,34684.04,100,,,case rate,100% Highmark Trad DRG rate,9573.09,100,,,case rate,100% WV Medicaid DRG rate,23765.21,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,7590.68,100,,,case rate,100% PEIA DRG rate,25793.51,100,,,case rate,100% The Health Plan DRG rate,7590.68,65354.3275,
INGUINAL AND FEMORAL HERNIA PROCEDURES WITHOUT CC/MCC,352,MS-DRG,,,,,Inpatient,,,,,,35558.38,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,35558.38,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,12930.32,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,4927.74,102,,,case rate,102% WV Medicaid DRG rate,21335.028,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,4503.51,100,,,case rate,100% PEIA with CHIP DRG base rate,20896.89,100,,,case rate,100% Highmark ACA DRG rate,26425.25,100,,,case rate,100% Highmark PPO DRG rate,26425.25,100,,,case rate,100% Highmark Trad DRG rate,4831.11,100,,,case rate,100% WV Medicaid DRG rate,12930.32,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,3830.68,100,,,case rate,100% PEIA DRG rate,19651.69,100,,,case rate,100% The Health Plan DRG rate,3830.68,35558.38,
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH MCC,353,MS-DRG,,,,,Inpatient,,,,,,25676.1725,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,25676.1725,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,9336.79,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,15870.2,102,,,case rate,102% WV Medicaid DRG rate,15405.7035,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,14503.92,100,,,case rate,100% PEIA with CHIP DRG base rate,55102.58,100,,,case rate,100% Highmark ACA DRG rate,69680.22,100,,,case rate,100% Highmark PPO DRG rate,69680.22,100,,,case rate,100% Highmark Trad DRG rate,15559.01,100,,,case rate,100% WV Medicaid DRG rate,9336.79,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,12337.01,100,,,case rate,100% PEIA DRG rate,51819.15,100,,,case rate,100% The Health Plan DRG rate,9336.79,69680.22,
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH CC,354,MS-DRG,,,,,Inpatient,,,,,,60688.705,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,60688.705,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,22068.62,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,9744.51,102,,,case rate,102% WV Medicaid DRG rate,36413.223,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,8905.59,100,,,case rate,100% PEIA with CHIP DRG base rate,32368.51,100,,,case rate,100% Highmark ACA DRG rate,40931.74,100,,,case rate,100% Highmark PPO DRG rate,40931.74,100,,,case rate,100% Highmark Trad DRG rate,9553.43,100,,,case rate,100% WV Medicaid DRG rate,22068.62,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,7575.09,100,,,case rate,100% PEIA DRG rate,30439.74,100,,,case rate,100% The Health Plan DRG rate,7575.09,60688.705,
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITHOUT CC/MCC,355,MS-DRG,,,,,Inpatient,,,,,,37855.18,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,37855.18,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,13765.52,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,8629,102,,,case rate,102% WV Medicaid DRG rate,22713.108,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,7886.12,100,,,case rate,100% PEIA with CHIP DRG base rate,25675.47,100,,,case rate,100% Highmark ACA DRG rate,32468.03,100,,,case rate,100% Highmark PPO DRG rate,32468.03,100,,,case rate,100% Highmark Trad DRG rate,8459.8,100,,,case rate,100% WV Medicaid DRG rate,13765.52,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,6707.93,100,,,case rate,100% PEIA DRG rate,24145.53,100,,,case rate,100% The Health Plan DRG rate,6707.93,37855.18,
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH MCC,356,MS-DRG,,,,,Inpatient,,,,,,28377.195,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,28377.195,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,10318.98,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,12947.52,102,,,case rate,102% WV Medicaid DRG rate,17026.317,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,11832.85,100,,,case rate,100% PEIA with CHIP DRG base rate,80623.54,100,,,case rate,100% Highmark ACA DRG rate,101952.86,100,,,case rate,100% Highmark PPO DRG rate,101952.86,100,,,case rate,100% Highmark Trad DRG rate,12693.63,100,,,case rate,100% WV Medicaid DRG rate,10318.98,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,10065.01,100,,,case rate,100% PEIA DRG rate,75819.38,100,,,case rate,100% The Health Plan DRG rate,10065.01,101952.86,
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH CC,357,MS-DRG,,,,,Inpatient,,,,,,73840.9375,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,73840.9375,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,26851.25,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,9985.17,102,,,case rate,102% WV Medicaid DRG rate,44304.5625,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,9125.53,100,,,case rate,100% PEIA with CHIP DRG base rate,41394.3,100,,,case rate,100% Highmark ACA DRG rate,52345.35,100,,,case rate,100% Highmark PPO DRG rate,52345.35,100,,,case rate,100% Highmark Trad DRG rate,9789.37,100,,,case rate,100% WV Medicaid DRG rate,26851.25,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,7762.17,100,,,case rate,100% PEIA DRG rate,38927.71,100,,,case rate,100% The Health Plan DRG rate,7762.17,73840.9375,
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITHOUT CC/MCC,358,MS-DRG,,,,,Inpatient,,,,,,45111,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,45111,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,16404,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,7177.47,102,,,case rate,102% WV Medicaid DRG rate,27066.6,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,6559.55,100,,,case rate,100% PEIA with CHIP DRG base rate,24139.77,100,,,case rate,100% Highmark ACA DRG rate,30526.05,100,,,case rate,100% Highmark PPO DRG rate,30526.05,100,,,case rate,100% Highmark Trad DRG rate,7036.73,100,,,case rate,100% WV Medicaid DRG rate,16404,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,5579.55,100,,,case rate,100% PEIA DRG rate,22701.34,100,,,case rate,100% The Health Plan DRG rate,5579.55,45111,
MAJOR ESOPHAGEAL DISORDERS WITH MCC,368,MS-DRG,,,,,Inpatient,,,,,,35334.3375,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,35334.3375,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,12848.85,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,7146.72,102,,,case rate,102% WV Medicaid DRG rate,21200.6025,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,6531.45,100,,,case rate,100% PEIA with CHIP DRG base rate,31128.64,100,,,case rate,100% Highmark ACA DRG rate,39363.86,100,,,case rate,100% Highmark PPO DRG rate,39363.86,100,,,case rate,100% Highmark Trad DRG rate,7006.58,100,,,case rate,100% WV Medicaid DRG rate,12848.85,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,5555.64,100,,,case rate,100% PEIA DRG rate,29273.75,100,,,case rate,100% The Health Plan DRG rate,5555.64,39363.86,
MAJOR ESOPHAGEAL DISORDERS WITH CC,369,MS-DRG,,,,,Inpatient,,,,,,108722.13,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,108722.13,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,39535.32,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,5316.81,102,,,case rate,102% WV Medicaid DRG rate,65233.278,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,4859.08,100,,,case rate,100% PEIA with CHIP DRG base rate,18622.54,100,,,case rate,100% Highmark ACA DRG rate,23549.21,100,,,case rate,100% Highmark PPO DRG rate,23549.21,100,,,case rate,100% Highmark Trad DRG rate,5212.55,100,,,case rate,100% WV Medicaid DRG rate,39535.32,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,4133.12,100,,,case rate,100% PEIA DRG rate,17512.86,100,,,case rate,100% The Health Plan DRG rate,4133.12,108722.13,
MAJOR ESOPHAGEAL DISORDERS WITHOUT CC/MCC,370,MS-DRG,,,,,Inpatient,,,,,,57835.7725,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,57835.7725,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,21031.19,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,4971.86,102,,,case rate,102% WV Medicaid DRG rate,34701.4635,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,4543.83,100,,,case rate,100% PEIA with CHIP DRG base rate,14013.54,100,,,case rate,100% Highmark ACA DRG rate,17720.88,100,,,case rate,100% Highmark PPO DRG rate,17720.88,100,,,case rate,100% Highmark Trad DRG rate,4874.37,100,,,case rate,100% WV Medicaid DRG rate,21031.19,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,3864.97,100,,,case rate,100% PEIA DRG rate,13178.51,100,,,case rate,100% The Health Plan DRG rate,3864.97,57835.7725,
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH MCC,371,MS-DRG,,,,,Inpatient,,,,,,35718.045,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,35718.045,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,12988.38,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,7301.81,102,,,case rate,102% WV Medicaid DRG rate,21430.827,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,6673.19,100,,,case rate,100% PEIA with CHIP DRG base rate,32931.91,100,,,case rate,100% Highmark ACA DRG rate,41644.2,100,,,case rate,100% Highmark PPO DRG rate,41644.2,100,,,case rate,100% Highmark Trad DRG rate,7158.63,100,,,case rate,100% WV Medicaid DRG rate,12988.38,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,5676.2,100,,,case rate,100% PEIA DRG rate,30969.58,100,,,case rate,100% The Health Plan DRG rate,5676.2,41644.2,
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH CC,372,MS-DRG,,,,,Inpatient,,,,,,45167.65,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,45167.65,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,16424.6,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,5170.18,102,,,case rate,102% WV Medicaid DRG rate,27100.59,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,4725.08,100,,,case rate,100% PEIA with CHIP DRG base rate,19640.06,100,,,case rate,100% Highmark ACA DRG rate,24835.92,100,,,case rate,100% Highmark PPO DRG rate,24835.92,100,,,case rate,100% Highmark Trad DRG rate,5068.8,100,,,case rate,100% WV Medicaid DRG rate,16424.6,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,4019.14,100,,,case rate,100% PEIA DRG rate,18469.75,100,,,case rate,100% The Health Plan DRG rate,4019.14,45167.65,
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITHOUT CC/MCC,373,MS-DRG,,,,,Inpatient,,,,,,26317.3075,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,26317.3075,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,9569.93,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,4027.49,102,,,case rate,102% WV Medicaid DRG rate,15790.3845,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,3680.76,100,,,case rate,100% PEIA with CHIP DRG base rate,13501.01,100,,,case rate,100% Highmark ACA DRG rate,17072.76,100,,,case rate,100% Highmark PPO DRG rate,17072.76,100,,,case rate,100% Highmark Trad DRG rate,3948.52,100,,,case rate,100% WV Medicaid DRG rate,9569.93,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,3130.85,100,,,case rate,100% PEIA DRG rate,12696.52,100,,,case rate,100% The Health Plan DRG rate,3130.85,26317.3075,
DIGESTIVE MALIGNANCY WITH MCC,374,MS-DRG,,,,,Inpatient,,,,,,19277.7475,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,19277.7475,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,7010.09,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,13250.57,102,,,case rate,102% WV Medicaid DRG rate,11566.6485,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,12109.81,100,,,case rate,100% PEIA with CHIP DRG base rate,39551.46,100,,,case rate,100% Highmark ACA DRG rate,50014.97,100,,,case rate,100% Highmark PPO DRG rate,50014.97,100,,,case rate,100% Highmark Trad DRG rate,12990.74,100,,,case rate,100% WV Medicaid DRG rate,7010.09,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,10300.59,100,,,case rate,100% PEIA DRG rate,37194.68,100,,,case rate,100% The Health Plan DRG rate,7010.09,50014.97,
DIGESTIVE MALIGNANCY WITH CC,375,MS-DRG,,,,,Inpatient,,,,,,43560.9625,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,43560.9625,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,15840.35,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,9022.97,102,,,case rate,102% WV Medicaid DRG rate,26136.5775,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,8246.18,100,,,case rate,100% PEIA with CHIP DRG base rate,22579.57,100,,,case rate,100% Highmark ACA DRG rate,28553.09,100,,,case rate,100% Highmark PPO DRG rate,28553.09,100,,,case rate,100% Highmark Trad DRG rate,8846.04,100,,,case rate,100% WV Medicaid DRG rate,15840.35,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,7014.19,100,,,case rate,100% PEIA DRG rate,21234.1,100,,,case rate,100% The Health Plan DRG rate,7014.19,43560.9625,
DIGESTIVE MALIGNANCY WITHOUT CC/MCC,376,MS-DRG,,,,,Inpatient,,,,,,26211.735,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,26211.735,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,9531.54,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,7431.05,102,,,case rate,102% WV Medicaid DRG rate,15727.041,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,6791.3,100,,,case rate,100% PEIA with CHIP DRG base rate,16796.65,100,,,case rate,100% Highmark ACA DRG rate,21240.28,100,,,case rate,100% Highmark PPO DRG rate,21240.28,100,,,case rate,100% Highmark Trad DRG rate,7285.34,100,,,case rate,100% WV Medicaid DRG rate,9531.54,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,5776.67,100,,,case rate,100% PEIA DRG rate,15795.78,100,,,case rate,100% The Health Plan DRG rate,5776.67,26211.735,
GASTROINTESTINAL HEMORRHAGE WITH MCC,377,MS-DRG,,,,,Inpatient,,,,,,18693.2625,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,18693.2625,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,6797.55,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,6261.18,102,,,case rate,102% WV Medicaid DRG rate,11215.9575,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,5722.14,100,,,case rate,100% PEIA with CHIP DRG base rate,33734.62,100,,,case rate,100% Highmark ACA DRG rate,42659.27,100,,,case rate,100% Highmark PPO DRG rate,42659.27,100,,,case rate,100% Highmark Trad DRG rate,6138.4,100,,,case rate,100% WV Medicaid DRG rate,6797.55,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,4867.25,100,,,case rate,100% PEIA DRG rate,31724.46,100,,,case rate,100% The Health Plan DRG rate,4867.25,42659.27,
GASTROINTESTINAL HEMORRHAGE WITH CC,378,MS-DRG,,,,,Inpatient,,,,,,51324.075,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,51324.075,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,18663.3,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,5298.53,102,,,case rate,102% WV Medicaid DRG rate,30794.445,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,4842.38,100,,,case rate,100% PEIA with CHIP DRG base rate,18537.74,100,,,case rate,100% Highmark ACA DRG rate,23441.99,100,,,case rate,100% Highmark PPO DRG rate,23441.99,100,,,case rate,100% Highmark Trad DRG rate,5194.64,100,,,case rate,100% WV Medicaid DRG rate,18663.3,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,4118.92,100,,,case rate,100% PEIA DRG rate,17433.12,100,,,case rate,100% The Health Plan DRG rate,4118.92,51324.075,
GASTROINTESTINAL HEMORRHAGE WITHOUT CC/MCC,379,MS-DRG,,,,,Inpatient,,,,,,31016.425,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,31016.425,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,11278.7,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,4108.16,102,,,case rate,102% WV Medicaid DRG rate,18609.855,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,3754.48,100,,,case rate,100% PEIA with CHIP DRG base rate,11931.39,100,,,case rate,100% Highmark ACA DRG rate,15087.89,100,,,case rate,100% Highmark PPO DRG rate,15087.89,100,,,case rate,100% Highmark Trad DRG rate,4027.6,100,,,case rate,100% WV Medicaid DRG rate,11278.7,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,3193.56,100,,,case rate,100% PEIA DRG rate,11220.42,100,,,case rate,100% The Health Plan DRG rate,3193.56,31016.425,
COMPLICATED PEPTIC ULCER WITH MCC,380,MS-DRG,,,,,Inpatient,,,,,,22601.8375,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,22601.8375,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,8218.85,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,7565.2,102,,,case rate,102% WV Medicaid DRG rate,13561.1025,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,6913.9,100,,,case rate,100% PEIA with CHIP DRG base rate,36715.59,100,,,case rate,100% Highmark ACA DRG rate,46428.86,100,,,case rate,100% Highmark PPO DRG rate,46428.86,100,,,case rate,100% Highmark Trad DRG rate,7416.85,100,,,case rate,100% WV Medicaid DRG rate,8218.85,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,5880.95,100,,,case rate,100% PEIA DRG rate,34527.79,100,,,case rate,100% The Health Plan DRG rate,5880.95,46428.86,
COMPLICATED PEPTIC ULCER WITH CC,381,MS-DRG,,,,,Inpatient,,,,,,45780.4325,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,45780.4325,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,16647.43,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,4673.71,102,,,case rate,102% WV Medicaid DRG rate,27468.2595,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,4271.34,100,,,case rate,100% PEIA with CHIP DRG base rate,20218.54,100,,,case rate,100% Highmark ACA DRG rate,25567.44,100,,,case rate,100% Highmark PPO DRG rate,25567.44,100,,,case rate,100% Highmark Trad DRG rate,4582.06,100,,,case rate,100% WV Medicaid DRG rate,16647.43,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,3633.2,100,,,case rate,100% PEIA DRG rate,19013.76,100,,,case rate,100% The Health Plan DRG rate,3633.2,45780.4325,
COMPLICATED PEPTIC ULCER WITHOUT CC/MCC,382,MS-DRG,,,,,Inpatient,,,,,,25362.04,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,25362.04,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,9222.56,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,3462.39,102,,,case rate,102% WV Medicaid DRG rate,15217.224,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,3164.31,100,,,case rate,100% PEIA with CHIP DRG base rate,14266.04,100,,,case rate,100% Highmark ACA DRG rate,18040.18,100,,,case rate,100% Highmark PPO DRG rate,18040.18,100,,,case rate,100% Highmark Trad DRG rate,3394.49,100,,,case rate,100% WV Medicaid DRG rate,9222.56,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,2691.55,100,,,case rate,100% PEIA DRG rate,13415.96,100,,,case rate,100% The Health Plan DRG rate,2691.55,25362.04,
UNCOMPLICATED PEPTIC ULCER WITH MCC,383,MS-DRG,,,,,Inpatient,,,,,,16319.2425,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,16319.2425,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,5934.27,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,9032.78,102,,,case rate,102% WV Medicaid DRG rate,9791.5455,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,8255.14,100,,,case rate,100% PEIA with CHIP DRG base rate,26346.28,100,,,case rate,100% Highmark ACA DRG rate,33316.31,100,,,case rate,100% Highmark PPO DRG rate,33316.31,100,,,case rate,100% Highmark Trad DRG rate,8855.66,100,,,case rate,100% WV Medicaid DRG rate,5934.27,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,7021.81,100,,,case rate,100% PEIA DRG rate,24776.37,100,,,case rate,100% The Health Plan DRG rate,5934.27,33316.31,
UNCOMPLICATED PEPTIC ULCER WITHOUT MCC,384,MS-DRG,,,,,Inpatient,,,,,,49027.3025,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,49027.3025,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,17828.11,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,3982.93,102,,,case rate,102% WV Medicaid DRG rate,29416.3815,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,3640.03,100,,,case rate,100% PEIA with CHIP DRG base rate,16500.82,100,,,case rate,100% Highmark ACA DRG rate,20866.18,100,,,case rate,100% Highmark PPO DRG rate,20866.18,100,,,case rate,100% Highmark Trad DRG rate,3904.83,100,,,case rate,100% WV Medicaid DRG rate,17828.11,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,3096.21,100,,,case rate,100% PEIA DRG rate,15517.57,100,,,case rate,100% The Health Plan DRG rate,3096.21,49027.3025,
INFLAMMATORY BOWEL DISEASE WITH MCC,385,MS-DRG,,,,,Inpatient,,,,,,27177.2875,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,27177.2875,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,9882.65,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,6369.03,102,,,case rate,102% WV Medicaid DRG rate,16306.3725,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,5820.71,100,,,case rate,100% PEIA with CHIP DRG base rate,29525.1,100,,,case rate,100% Highmark ACA DRG rate,37336.09,100,,,case rate,100% Highmark PPO DRG rate,37336.09,100,,,case rate,100% Highmark Trad DRG rate,6244.14,100,,,case rate,100% WV Medicaid DRG rate,9882.65,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,4951.09,100,,,case rate,100% PEIA DRG rate,27765.77,100,,,case rate,100% The Health Plan DRG rate,4951.09,37336.09,
INFLAMMATORY BOWEL DISEASE WITH CC,386,MS-DRG,,,,,Inpatient,,,,,,19821.065,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,19821.065,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,7207.66,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,4675.49,102,,,case rate,102% WV Medicaid DRG rate,11892.639,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,4272.97,100,,,case rate,100% PEIA with CHIP DRG base rate,18307.86,100,,,case rate,100% Highmark ACA DRG rate,23151.28,100,,,case rate,100% Highmark PPO DRG rate,23151.28,100,,,case rate,100% Highmark Trad DRG rate,4583.81,100,,,case rate,100% WV Medicaid DRG rate,7207.66,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,3634.59,100,,,case rate,100% PEIA DRG rate,17216.94,100,,,case rate,100% The Health Plan DRG rate,3634.59,23151.28,
INFLAMMATORY BOWEL DISEASE WITHOUT CC/MCC,387,MS-DRG,,,,,Inpatient,,,,,,35017.675,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,35017.675,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,12733.7,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,4067.16,102,,,case rate,102% WV Medicaid DRG rate,21010.605,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,3717.01,100,,,case rate,100% PEIA with CHIP DRG base rate,12890.5,100,,,case rate,100% Highmark ACA DRG rate,16300.73,100,,,case rate,100% Highmark PPO DRG rate,16300.73,100,,,case rate,100% Highmark Trad DRG rate,3987.4,100,,,case rate,100% WV Medicaid DRG rate,12733.7,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,3161.68,100,,,case rate,100% PEIA DRG rate,12122.38,100,,,case rate,100% The Health Plan DRG rate,3161.68,35017.675,
GASTROINTESTINAL OBSTRUCTION WITH MCC,388,MS-DRG,,,,,Inpatient,,,,,,23214.6475,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,23214.6475,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,8441.69,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,6530.36,102,,,case rate,102% WV Medicaid DRG rate,13928.7885,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,5968.15,100,,,case rate,100% PEIA with CHIP DRG base rate,27388.3,100,,,case rate,100% Highmark ACA DRG rate,34634,100,,,case rate,100% Highmark PPO DRG rate,34634,100,,,case rate,100% Highmark Trad DRG rate,6402.31,100,,,case rate,100% WV Medicaid DRG rate,8441.69,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,5076.5,100,,,case rate,100% PEIA DRG rate,25756.3,100,,,case rate,100% The Health Plan DRG rate,5076.5,34634,
GASTROINTESTINAL OBSTRUCTION WITH CC,389,MS-DRG,,,,,Inpatient,,,,,,41936.2075,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,41936.2075,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,15249.53,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,3984.71,102,,,case rate,102% WV Medicaid DRG rate,25161.7245,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,3641.66,100,,,case rate,100% PEIA with CHIP DRG base rate,15006.57,100,,,case rate,100% Highmark ACA DRG rate,18976.62,100,,,case rate,100% Highmark PPO DRG rate,18976.62,100,,,case rate,100% Highmark Trad DRG rate,3906.57,100,,,case rate,100% WV Medicaid DRG rate,15249.53,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,3097.59,100,,,case rate,100% PEIA DRG rate,14112.36,100,,,case rate,100% The Health Plan DRG rate,3097.59,41936.2075,
GASTROINTESTINAL OBSTRUCTION WITHOUT CC/MCC,390,MS-DRG,,,,,Inpatient,,,,,,25485.68,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,25485.68,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,9267.52,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,3198.55,102,,,case rate,102% WV Medicaid DRG rate,15291.408,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,2923.18,100,,,case rate,100% PEIA with CHIP DRG base rate,10533.24,100,,,case rate,100% Highmark ACA DRG rate,13319.85,100,,,case rate,100% Highmark PPO DRG rate,13319.85,100,,,case rate,100% Highmark Trad DRG rate,3135.83,100,,,case rate,100% WV Medicaid DRG rate,9267.52,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,2486.46,100,,,case rate,100% PEIA DRG rate,9905.59,100,,,case rate,100% The Health Plan DRG rate,2486.46,25485.68,
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITH MCC",391,MS-DRG,,,,,Inpatient,,,,,,17807.4875,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,17807.4875,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,6475.45,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,6750.96,102,,,case rate,102% WV Medicaid DRG rate,10684.4925,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,6169.77,100,,,case rate,100% PEIA with CHIP DRG base rate,24038.02,100,,,case rate,100% Highmark ACA DRG rate,30397.38,100,,,case rate,100% Highmark PPO DRG rate,30397.38,100,,,case rate,100% Highmark Trad DRG rate,6618.59,100,,,case rate,100% WV Medicaid DRG rate,6475.45,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,5247.99,100,,,case rate,100% PEIA DRG rate,22605.65,100,,,case rate,100% The Health Plan DRG rate,5247.99,30397.38,
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITHOUT MCC",392,MS-DRG,,,,,Inpatient,,,,,,37783.075,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,37783.075,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,13739.3,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,4226.71,102,,,case rate,102% WV Medicaid DRG rate,22669.845,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,3862.82,100,,,case rate,100% PEIA with CHIP DRG base rate,14803.06,100,,,case rate,100% Highmark ACA DRG rate,18719.28,100,,,case rate,100% Highmark PPO DRG rate,18719.28,100,,,case rate,100% Highmark Trad DRG rate,4143.83,100,,,case rate,100% WV Medicaid DRG rate,13739.3,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,3285.71,100,,,case rate,100% PEIA DRG rate,13920.98,100,,,case rate,100% The Health Plan DRG rate,3285.71,37783.075,
OTHER DIGESTIVE SYSTEM DIAGNOSES WITH MCC,393,MS-DRG,,,,,Inpatient,,,,,,20781.42,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,20781.42,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,7556.88,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,8261.33,102,,,case rate,102% WV Medicaid DRG rate,12468.852,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,7550.1,100,,,case rate,100% PEIA with CHIP DRG base rate,30518.12,100,,,case rate,100% Highmark ACA DRG rate,38591.83,100,,,case rate,100% Highmark PPO DRG rate,38591.83,100,,,case rate,100% Highmark Trad DRG rate,8099.33,100,,,case rate,100% WV Medicaid DRG rate,7556.88,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,6422.11,100,,,case rate,100% PEIA DRG rate,28699.62,100,,,case rate,100% The Health Plan DRG rate,6422.11,38591.83,
OTHER DIGESTIVE SYSTEM DIAGNOSES WITH CC,394,MS-DRG,,,,,Inpatient,,,,,,14560.6725,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,14560.6725,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,5294.79,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,5487.94,102,,,case rate,102% WV Medicaid DRG rate,8736.4035,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,5015.48,100,,,case rate,100% PEIA with CHIP DRG base rate,17654.01,100,,,case rate,100% Highmark ACA DRG rate,22324.45,100,,,case rate,100% Highmark PPO DRG rate,22324.45,100,,,case rate,100% Highmark Trad DRG rate,5380.33,100,,,case rate,100% WV Medicaid DRG rate,5294.79,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,4266.16,100,,,case rate,100% PEIA DRG rate,16602.05,100,,,case rate,100% The Health Plan DRG rate,4266.16,22324.45,
OTHER DIGESTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC,395,MS-DRG,,,,,Inpatient,,,,,,33060.8025,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,33060.8025,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,12022.11,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,4042.65,102,,,case rate,102% WV Medicaid DRG rate,19836.4815,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,3694.61,100,,,case rate,100% PEIA with CHIP DRG base rate,12200.84,100,,,case rate,100% Highmark ACA DRG rate,15428.63,100,,,case rate,100% Highmark PPO DRG rate,15428.63,100,,,case rate,100% Highmark Trad DRG rate,3963.37,100,,,case rate,100% WV Medicaid DRG rate,12022.11,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,3142.63,100,,,case rate,100% PEIA DRG rate,11473.82,100,,,case rate,100% The Health Plan DRG rate,3142.63,33060.8025,
APPENDIX PROCEDURES WITH MCC,397,MS-DRG,,,,,Inpatient,,,,,,20279.3525,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,20279.3525,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,7374.31,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,,,,,other,Not Separately reimbursable,12167.6115,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,,,,,other,Not Separately reimbursable,42332.68,100,,,case rate,100% Highmark ACA DRG rate,53531.98,100,,,case rate,100% Highmark PPO DRG rate,53531.98,100,,,case rate,100% Highmark Trad DRG rate,,,,,other,Not Separately reimbursable,7374.31,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,,,,,other,Not Separately reimbursable,39810.18,100,,,case rate,100% The Health Plan DRG rate,7374.31,53531.98,
APPENDIX PROCEDURES WITH CC,398,MS-DRG,,,,,Inpatient,,,,,,41488.205,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,41488.205,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,15086.62,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,,,,,other,Not Separately reimbursable,24892.923,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,,,,,other,Not Separately reimbursable,28515.11,100,,,case rate,100% Highmark ACA DRG rate,36058.91,100,,,case rate,100% Highmark PPO DRG rate,36058.91,100,,,case rate,100% Highmark Trad DRG rate,,,,,other,Not Separately reimbursable,15086.62,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,,,,,other,Not Separately reimbursable,26815.96,100,,,case rate,100% The Health Plan DRG rate,15086.62,41488.205,
APPENDIX PROCEDURES WITHOUT CC/MCC,399,MS-DRG,,,,,Inpatient,,,,,,24280.685,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,24280.685,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,8829.34,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,,,,,other,Not Separately reimbursable,14568.411,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,,,,,other,Not Separately reimbursable,20974.14,100,,,case rate,100% Highmark ACA DRG rate,26522.95,100,,,case rate,100% Highmark PPO DRG rate,26522.95,100,,,case rate,100% Highmark Trad DRG rate,,,,,other,Not Separately reimbursable,8829.34,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,,,,,other,Not Separately reimbursable,19724.34,100,,,case rate,100% The Health Plan DRG rate,8829.34,26522.95,
"PANCREAS, LIVER AND SHUNT PROCEDURES WITH MCC",405,MS-DRG,,,,,Inpatient,,,,,,16605.05,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,16605.05,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,6038.2,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,21270.79,102,,,case rate,102% WV Medicaid DRG rate,9963.03,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,19439.57,100,,,case rate,100% PEIA with CHIP DRG base rate,103734.48,100,,,case rate,100% Highmark ACA DRG rate,131177.91,100,,,case rate,100% Highmark PPO DRG rate,131177.91,100,,,case rate,100% Highmark Trad DRG rate,20853.7,100,,,case rate,100% WV Medicaid DRG rate,6038.2,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,16535.27,100,,,case rate,100% PEIA DRG rate,97553.19,100,,,case rate,100% The Health Plan DRG rate,6038.2,131177.91,
"PANCREAS, LIVER AND SHUNT PROCEDURES WITH CC",406,MS-DRG,,,,,Inpatient,,,,,,142694.3925,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,142694.3925,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,51888.87,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,17725.07,102,,,case rate,102% WV Medicaid DRG rate,85616.6355,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,16199.1,100,,,case rate,100% PEIA with CHIP DRG base rate,54407.28,100,,,case rate,100% Highmark ACA DRG rate,68800.97,100,,,case rate,100% Highmark PPO DRG rate,68800.97,100,,,case rate,100% Highmark Trad DRG rate,17377.5,100,,,case rate,100% WV Medicaid DRG rate,51888.87,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,13778.93,100,,,case rate,100% PEIA DRG rate,51165.28,100,,,case rate,100% The Health Plan DRG rate,13778.93,142694.3925,
"PANCREAS, LIVER AND SHUNT PROCEDURES WITHOUT CC/MCC",407,MS-DRG,,,,,Inpatient,,,,,,75434.7825,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,75434.7825,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,27430.83,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,12742.51,102,,,case rate,102% WV Medicaid DRG rate,45260.8695,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,11645.49,100,,,case rate,100% PEIA with CHIP DRG base rate,40531.29,100,,,case rate,100% Highmark ACA DRG rate,51254.03,100,,,case rate,100% Highmark PPO DRG rate,51254.03,100,,,case rate,100% Highmark Trad DRG rate,12492.65,100,,,case rate,100% WV Medicaid DRG rate,27430.83,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,9905.64,100,,,case rate,100% PEIA DRG rate,38116.13,100,,,case rate,100% The Health Plan DRG rate,9905.64,75434.7825,
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH MCC,408,MS-DRG,,,,,Inpatient,,,,,,57307.965,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,57307.965,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,20839.26,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,24370.85,102,,,case rate,102% WV Medicaid DRG rate,34384.779,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,22272.74,100,,,case rate,100% PEIA with CHIP DRG base rate,70137.41,100,,,case rate,100% Highmark ACA DRG rate,88692.58,100,,,case rate,100% Highmark PPO DRG rate,88692.58,100,,,case rate,100% Highmark Trad DRG rate,23892.97,100,,,case rate,100% WV Medicaid DRG rate,20839.26,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,18945.16,100,,,case rate,100% PEIA DRG rate,65958.09,100,,,case rate,100% The Health Plan DRG rate,18945.16,88692.58,
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH CC,409,MS-DRG,,,,,Inpatient,,,,,,94483.345,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,94483.345,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,34357.58,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,14156.61,102,,,case rate,102% WV Medicaid DRG rate,56690.007,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,12937.85,100,,,case rate,100% PEIA with CHIP DRG base rate,36881.4,100,,,case rate,100% Highmark ACA DRG rate,46638.54,100,,,case rate,100% Highmark PPO DRG rate,46638.54,100,,,case rate,100% Highmark Trad DRG rate,13879.02,100,,,case rate,100% WV Medicaid DRG rate,34357.58,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,11004.92,100,,,case rate,100% PEIA DRG rate,34683.73,100,,,case rate,100% The Health Plan DRG rate,11004.92,94483.345,
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITHOUT CC/MCC,410,MS-DRG,,,,,Inpatient,,,,,,54879.9075,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,54879.9075,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,19956.33,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,11275.38,102,,,case rate,102% WV Medicaid DRG rate,32927.9445,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,10304.66,100,,,case rate,100% PEIA with CHIP DRG base rate,29493.06,100,,,case rate,100% Highmark ACA DRG rate,37295.59,100,,,case rate,100% Highmark PPO DRG rate,37295.59,100,,,case rate,100% Highmark Trad DRG rate,11054.28,100,,,case rate,100% WV Medicaid DRG rate,19956.33,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,8765.13,100,,,case rate,100% PEIA DRG rate,27735.64,100,,,case rate,100% The Health Plan DRG rate,8765.13,54879.9075,
CHOLECYSTECTOMY WITH C.D.E. WITH MCC,411,MS-DRG,,,,,Inpatient,,,,,,43712.8725,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,43712.8725,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,15895.59,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,22436.21,102,,,case rate,102% WV Medicaid DRG rate,26227.7235,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,20504.65,100,,,case rate,100% PEIA with CHIP DRG base rate,54277.26,100,,,case rate,100% Highmark ACA DRG rate,68636.55,100,,,case rate,100% Highmark PPO DRG rate,68636.55,100,,,case rate,100% Highmark Trad DRG rate,21996.27,100,,,case rate,100% WV Medicaid DRG rate,15895.59,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,17441.23,100,,,case rate,100% PEIA DRG rate,51043.01,100,,,case rate,100% The Health Plan DRG rate,15895.59,68636.55,
CHOLECYSTECTOMY WITH C.D.E. WITH CC,412,MS-DRG,,,,,Inpatient,,,,,,86982.885,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,86982.885,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,31630.14,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,15247.16,102,,,case rate,102% WV Medicaid DRG rate,52189.731,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,13934.51,100,,,case rate,100% PEIA with CHIP DRG base rate,38543.36,100,,,case rate,100% Highmark ACA DRG rate,48740.17,100,,,case rate,100% Highmark PPO DRG rate,48740.17,100,,,case rate,100% Highmark Trad DRG rate,14948.18,100,,,case rate,100% WV Medicaid DRG rate,31630.14,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,11852.68,100,,,case rate,100% PEIA DRG rate,36246.65,100,,,case rate,100% The Health Plan DRG rate,11852.68,86982.885,
CHOLECYSTECTOMY WITH C.D.E. WITHOUT CC/MCC,413,MS-DRG,,,,,Inpatient,,,,,,59110.3425,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,59110.3425,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,21494.67,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,10761.97,102,,,case rate,102% WV Medicaid DRG rate,35466.2055,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,9835.46,100,,,case rate,100% PEIA with CHIP DRG base rate,28445.39,100,,,case rate,100% Highmark ACA DRG rate,35970.75,100,,,case rate,100% Highmark PPO DRG rate,35970.75,100,,,case rate,100% Highmark Trad DRG rate,10550.94,100,,,case rate,100% WV Medicaid DRG rate,21494.67,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,8366.03,100,,,case rate,100% PEIA DRG rate,26750.4,100,,,case rate,100% The Health Plan DRG rate,8366.03,59110.3425,
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH MCC,414,MS-DRG,,,,,Inpatient,,,,,,41722.505,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,41722.505,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,15171.82,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,18079.37,102,,,case rate,102% WV Medicaid DRG rate,25033.503,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,16522.9,100,,,case rate,100% PEIA with CHIP DRG base rate,66425.34,100,,,case rate,100% Highmark ACA DRG rate,83998.47,100,,,case rate,100% Highmark PPO DRG rate,83998.47,100,,,case rate,100% Highmark Trad DRG rate,17724.86,100,,,case rate,100% WV Medicaid DRG rate,15171.82,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,14054.36,100,,,case rate,100% PEIA DRG rate,62467.21,100,,,case rate,100% The Health Plan DRG rate,14054.36,83998.47,
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH CC,415,MS-DRG,,,,,Inpatient,,,,,,91012.46,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,91012.46,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,33095.44,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,10417.02,102,,,case rate,102% WV Medicaid DRG rate,54607.476,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,9520.21,100,,,case rate,100% PEIA with CHIP DRG base rate,37230,100,,,case rate,100% Highmark ACA DRG rate,47079.36,100,,,case rate,100% Highmark PPO DRG rate,47079.36,100,,,case rate,100% Highmark Trad DRG rate,10212.76,100,,,case rate,100% WV Medicaid DRG rate,33095.44,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,8097.88,100,,,case rate,100% PEIA DRG rate,35011.55,100,,,case rate,100% The Health Plan DRG rate,8097.88,91012.46,
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITHOUT CC/MCC,416,MS-DRG,,,,,Inpatient,,,,,,51496.5825,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,51496.5825,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,18726.03,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,8338.88,102,,,case rate,102% WV Medicaid DRG rate,30897.9495,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,7620.97,100,,,case rate,100% PEIA with CHIP DRG base rate,25234.55,100,,,case rate,100% Highmark ACA DRG rate,31910.46,100,,,case rate,100% Highmark PPO DRG rate,31910.46,100,,,case rate,100% Highmark Trad DRG rate,8175.36,100,,,case rate,100% WV Medicaid DRG rate,18726.03,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,6482.39,100,,,case rate,100% PEIA DRG rate,23730.88,100,,,case rate,100% The Health Plan DRG rate,6482.39,51496.5825,
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH MCC,417,MS-DRG,,,,,Inpatient,,,,,,35439.9375,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,35439.9375,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,12887.25,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,12375.73,102,,,case rate,102% WV Medicaid DRG rate,21263.9625,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,11310.29,100,,,case rate,100% PEIA with CHIP DRG base rate,43674.31,100,,,case rate,100% Highmark ACA DRG rate,55228.54,100,,,case rate,100% Highmark PPO DRG rate,55228.54,100,,,case rate,100% Highmark Trad DRG rate,12133.05,100,,,case rate,100% WV Medicaid DRG rate,12887.25,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,9620.51,100,,,case rate,100% PEIA DRG rate,41071.86,100,,,case rate,100% The Health Plan DRG rate,9620.51,55228.54,
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH CC,418,MS-DRG,,,,,Inpatient,,,,,,61221.6825,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,61221.6825,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,22262.43,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,10482.53,102,,,case rate,102% WV Medicaid DRG rate,36733.0095,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,9580.08,100,,,case rate,100% PEIA with CHIP DRG base rate,30802.65,100,,,case rate,100% Highmark ACA DRG rate,38951.63,100,,,case rate,100% Highmark PPO DRG rate,38951.63,100,,,case rate,100% Highmark Trad DRG rate,10276.98,100,,,case rate,100% WV Medicaid DRG rate,22262.43,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,8148.8,100,,,case rate,100% PEIA DRG rate,28967.19,100,,,case rate,100% The Health Plan DRG rate,8148.8,61221.6825,
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITHOUT CC/MCC,419,MS-DRG,,,,,Inpatient,,,,,,42767.8625,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,42767.8625,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,15551.95,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,8044.29,102,,,case rate,102% WV Medicaid DRG rate,25660.7175,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,7351.75,100,,,case rate,100% PEIA with CHIP DRG base rate,24744.63,100,,,case rate,100% Highmark ACA DRG rate,31290.93,100,,,case rate,100% Highmark PPO DRG rate,31290.93,100,,,case rate,100% Highmark Trad DRG rate,7886.55,100,,,case rate,100% WV Medicaid DRG rate,15551.95,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,6253.39,100,,,case rate,100% PEIA DRG rate,23270.15,100,,,case rate,100% The Health Plan DRG rate,6253.39,42767.8625,
HEPATOBILIARY DIAGNOSTIC PROCEDURES WITH MCC,420,MS-DRG,,,,,Inpatient,,,,,,33601.48,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,33601.48,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,12218.72,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,13646.32,102,,,case rate,102% WV Medicaid DRG rate,20160.888,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,12471.5,100,,,case rate,100% PEIA with CHIP DRG base rate,60312.67,100,,,case rate,100% Highmark ACA DRG rate,76268.66,100,,,case rate,100% Highmark PPO DRG rate,76268.66,100,,,case rate,100% Highmark Trad DRG rate,13378.74,100,,,case rate,100% WV Medicaid DRG rate,12218.72,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,10608.24,100,,,case rate,100% PEIA DRG rate,56718.78,100,,,case rate,100% The Health Plan DRG rate,10608.24,76268.66,
HEPATOBILIARY DIAGNOSTIC PROCEDURES WITH CC,421,MS-DRG,,,,,Inpatient,,,,,,83970.3425,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,83970.3425,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,30534.67,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,11723.27,102,,,case rate,102% WV Medicaid DRG rate,50382.2055,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,10714,100,,,case rate,100% PEIA with CHIP DRG base rate,32213.99,100,,,case rate,100% Highmark ACA DRG rate,40736.35,100,,,case rate,100% Highmark PPO DRG rate,40736.35,100,,,case rate,100% Highmark Trad DRG rate,11493.39,100,,,case rate,100% WV Medicaid DRG rate,30534.67,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,9113.31,100,,,case rate,100% PEIA DRG rate,30294.44,100,,,case rate,100% The Health Plan DRG rate,9113.31,83970.3425,
HEPATOBILIARY DIAGNOSTIC PROCEDURES WITHOUT CC/MCC,422,MS-DRG,,,,,Inpatient,,,,,,46645.555,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,46645.555,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,16962.02,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,8898.19,102,,,case rate,102% WV Medicaid DRG rate,27987.333,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,8132.13,100,,,case rate,100% PEIA with CHIP DRG base rate,26587.47,100,,,case rate,100% Highmark ACA DRG rate,33621.31,100,,,case rate,100% Highmark PPO DRG rate,33621.31,100,,,case rate,100% Highmark Trad DRG rate,8723.7,100,,,case rate,100% WV Medicaid DRG rate,16962.02,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,6917.18,100,,,case rate,100% PEIA DRG rate,25003.19,100,,,case rate,100% The Health Plan DRG rate,6917.18,46645.555,
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITH MCC,423,MS-DRG,,,,,Inpatient,,,,,,35676.85,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,35676.85,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,12973.4,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,19819.7,102,,,case rate,102% WV Medicaid DRG rate,21406.11,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,18113.4,100,,,case rate,100% PEIA with CHIP DRG base rate,73693.09,100,,,case rate,100% Highmark ACA DRG rate,93188.93,100,,,case rate,100% Highmark PPO DRG rate,93188.93,100,,,case rate,100% Highmark Trad DRG rate,19431.06,100,,,case rate,100% WV Medicaid DRG rate,12973.4,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,15407.24,100,,,case rate,100% PEIA DRG rate,69301.89,100,,,case rate,100% The Health Plan DRG rate,12973.4,93188.93,
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITH CC,424,MS-DRG,,,,,Inpatient,,,,,,101239.71,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,101239.71,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,36814.44,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,15731.6,102,,,case rate,102% WV Medicaid DRG rate,60743.826,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,14377.25,100,,,case rate,100% PEIA with CHIP DRG base rate,39330.99,100,,,case rate,100% Highmark ACA DRG rate,49736.18,100,,,case rate,100% Highmark PPO DRG rate,49736.18,100,,,case rate,100% Highmark Trad DRG rate,15423.12,100,,,case rate,100% WV Medicaid DRG rate,36814.44,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,12229.27,100,,,case rate,100% PEIA DRG rate,36987.35,100,,,case rate,100% The Health Plan DRG rate,12229.27,101239.71,
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITHOUT CC/MCC,425,MS-DRG,,,,,Inpatient,,,,,,60987.41,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,60987.41,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,22177.24,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,9501.62,102,,,case rate,102% WV Medicaid DRG rate,36592.446,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,8683.61,100,,,case rate,100% PEIA with CHIP DRG base rate,30184.6,100,,,case rate,100% Highmark ACA DRG rate,38170.07,100,,,case rate,100% Highmark PPO DRG rate,38170.07,100,,,case rate,100% Highmark Trad DRG rate,9315.3,100,,,case rate,100% WV Medicaid DRG rate,22177.24,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,7386.27,100,,,case rate,100% PEIA DRG rate,28385.97,100,,,case rate,100% The Health Plan DRG rate,7386.27,60987.41,
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH MCC,432,MS-DRG,,,,,Inpatient,,,,,,36835.535,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,36835.535,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,13394.74,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,7966.74,102,,,case rate,102% WV Medicaid DRG rate,22101.321,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,7280.88,100,,,case rate,100% PEIA with CHIP DRG base rate,36103.19,100,,,case rate,100% Highmark ACA DRG rate,45654.45,100,,,case rate,100% Highmark PPO DRG rate,45654.45,100,,,case rate,100% Highmark Trad DRG rate,7810.52,100,,,case rate,100% WV Medicaid DRG rate,13394.74,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,6193.1,100,,,case rate,100% PEIA DRG rate,33951.88,100,,,case rate,100% The Health Plan DRG rate,6193.1,45654.45,
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH CC,433,MS-DRG,,,,,Inpatient,,,,,,48617.9375,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,48617.9375,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,17679.25,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,4875.6,102,,,case rate,102% WV Medicaid DRG rate,29170.7625,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,4455.85,100,,,case rate,100% PEIA with CHIP DRG base rate,19427.13,100,,,case rate,100% Highmark ACA DRG rate,24566.67,100,,,case rate,100% Highmark PPO DRG rate,24566.67,100,,,case rate,100% Highmark Trad DRG rate,4779.99,100,,,case rate,100% WV Medicaid DRG rate,17679.25,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,3790.14,100,,,case rate,100% PEIA DRG rate,18269.52,100,,,case rate,100% The Health Plan DRG rate,3790.14,48617.9375,
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITHOUT CC/MCC,434,MS-DRG,,,,,Inpatient,,,,,,26773.065,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,26773.065,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,9735.66,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,3190.53,102,,,case rate,102% WV Medicaid DRG rate,16063.839,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,2915.85,100,,,case rate,100% PEIA with CHIP DRG base rate,12615.39,100,,,case rate,100% Highmark ACA DRG rate,15952.85,100,,,case rate,100% Highmark PPO DRG rate,15952.85,100,,,case rate,100% Highmark Trad DRG rate,3127.97,100,,,case rate,100% WV Medicaid DRG rate,9735.66,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,2480.22,100,,,case rate,100% PEIA DRG rate,11863.67,100,,,case rate,100% The Health Plan DRG rate,2480.22,26773.065,
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH MCC,435,MS-DRG,,,,,Inpatient,,,,,,16162.19,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,16162.19,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,5877.16,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,9212.38,102,,,case rate,102% WV Medicaid DRG rate,9697.314,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,8419.28,100,,,case rate,100% PEIA with CHIP DRG base rate,33161.8,100,,,case rate,100% Highmark ACA DRG rate,41934.9,100,,,case rate,100% Highmark PPO DRG rate,41934.9,100,,,case rate,100% Highmark Trad DRG rate,9031.74,100,,,case rate,100% WV Medicaid DRG rate,5877.16,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,7161.43,100,,,case rate,100% PEIA DRG rate,31185.76,100,,,case rate,100% The Health Plan DRG rate,5877.16,41934.9,
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH CC,436,MS-DRG,,,,,Inpatient,,,,,,45013.155,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,45013.155,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,16368.42,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,7448.43,102,,,case rate,102% WV Medicaid DRG rate,27007.893,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,6807.19,100,,,case rate,100% PEIA with CHIP DRG base rate,20740.49,100,,,case rate,100% Highmark ACA DRG rate,26227.48,100,,,case rate,100% Highmark PPO DRG rate,26227.48,100,,,case rate,100% Highmark Trad DRG rate,7302.38,100,,,case rate,100% WV Medicaid DRG rate,16368.42,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,5790.19,100,,,case rate,100% PEIA DRG rate,19504.61,100,,,case rate,100% The Health Plan DRG rate,5790.19,45013.155,
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITHOUT CC/MCC,437,MS-DRG,,,,,Inpatient,,,,,,28333.415,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,28333.415,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,10303.06,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,5617.63,102,,,case rate,102% WV Medicaid DRG rate,17000.049,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,5134,100,,,case rate,100% PEIA with CHIP DRG base rate,15660.42,100,,,case rate,100% Highmark ACA DRG rate,19803.45,100,,,case rate,100% Highmark PPO DRG rate,19803.45,100,,,case rate,100% Highmark Trad DRG rate,5507.48,100,,,case rate,100% WV Medicaid DRG rate,10303.06,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,4366.98,100,,,case rate,100% PEIA DRG rate,14727.25,100,,,case rate,100% The Health Plan DRG rate,4366.98,28333.415,
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH MCC,438,MS-DRG,,,,,Inpatient,,,,,,21780.495,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,21780.495,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,7920.18,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,7931.98,102,,,case rate,102% WV Medicaid DRG rate,13068.297,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,7249.11,100,,,case rate,100% PEIA with CHIP DRG base rate,31445.2,100,,,case rate,100% Highmark ACA DRG rate,39764.17,100,,,case rate,100% Highmark PPO DRG rate,39764.17,100,,,case rate,100% Highmark Trad DRG rate,7776.44,100,,,case rate,100% WV Medicaid DRG rate,7920.18,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,6166.08,100,,,case rate,100% PEIA DRG rate,29571.45,100,,,case rate,100% The Health Plan DRG rate,6166.08,39764.17,
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH CC,439,MS-DRG,,,,,Inpatient,,,,,,42675.215,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,42675.215,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,15518.26,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,4453.1,102,,,case rate,102% WV Medicaid DRG rate,25605.129,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,4069.73,100,,,case rate,100% PEIA with CHIP DRG base rate,16114.53,100,,,case rate,100% Highmark ACA DRG rate,20377.71,100,,,case rate,100% Highmark PPO DRG rate,20377.71,100,,,case rate,100% Highmark Trad DRG rate,4365.78,100,,,case rate,100% WV Medicaid DRG rate,15518.26,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,3461.71,100,,,case rate,100% PEIA DRG rate,15154.31,100,,,case rate,100% The Health Plan DRG rate,3461.71,42675.215,
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITHOUT CC/MCC,440,MS-DRG,,,,,Inpatient,,,,,,22395.89,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,22395.89,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,8143.96,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,3242.67,102,,,case rate,102% WV Medicaid DRG rate,13437.534,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,2963.51,100,,,case rate,100% PEIA with CHIP DRG base rate,11599.75,100,,,case rate,100% Highmark ACA DRG rate,14668.52,100,,,case rate,100% Highmark PPO DRG rate,14668.52,100,,,case rate,100% Highmark Trad DRG rate,3179.09,100,,,case rate,100% WV Medicaid DRG rate,8143.96,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,2520.76,100,,,case rate,100% PEIA DRG rate,10908.55,100,,,case rate,100% The Health Plan DRG rate,2520.76,22395.89,
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH MCC",441,MS-DRG,,,,,Inpatient,,,,,,15613.7575,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,15613.7575,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,5677.73,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,8702.99,102,,,case rate,102% WV Medicaid DRG rate,9368.2545,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,7953.73,100,,,case rate,100% PEIA with CHIP DRG base rate,34448.77,100,,,case rate,100% Highmark ACA DRG rate,43562.35,100,,,case rate,100% Highmark PPO DRG rate,43562.35,100,,,case rate,100% Highmark Trad DRG rate,8532.33,100,,,case rate,100% WV Medicaid DRG rate,5677.73,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,6765.44,100,,,case rate,100% PEIA DRG rate,32396.05,100,,,case rate,100% The Health Plan DRG rate,5677.73,43562.35,
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH CC",442,MS-DRG,,,,,Inpatient,,,,,,48787.86,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,48787.86,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,17741.04,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,3956.63,102,,,case rate,102% WV Medicaid DRG rate,29272.716,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,3616,100,,,case rate,100% PEIA with CHIP DRG base rate,17929.11,100,,,case rate,100% Highmark ACA DRG rate,22672.34,100,,,case rate,100% Highmark PPO DRG rate,22672.34,100,,,case rate,100% Highmark Trad DRG rate,3879.05,100,,,case rate,100% WV Medicaid DRG rate,17741.04,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,3075.77,100,,,case rate,100% PEIA DRG rate,16860.76,100,,,case rate,100% The Health Plan DRG rate,3075.77,48787.86,
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITHOUT CC/MCC",443,MS-DRG,,,,,Inpatient,,,,,,24357.8775,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,24357.8775,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,8857.41,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,2611.16,102,,,case rate,102% WV Medicaid DRG rate,14614.7265,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,2386.36,100,,,case rate,100% PEIA with CHIP DRG base rate,13467.09,100,,,case rate,100% Highmark ACA DRG rate,17029.87,100,,,case rate,100% Highmark PPO DRG rate,17029.87,100,,,case rate,100% Highmark Trad DRG rate,2559.96,100,,,case rate,100% WV Medicaid DRG rate,8857.41,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,2029.84,100,,,case rate,100% PEIA DRG rate,12664.62,100,,,case rate,100% The Health Plan DRG rate,2029.84,24357.8775,
DISORDERS OF THE BILIARY TRACT WITH MCC,444,MS-DRG,,,,,Inpatient,,,,,,16785.34,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,16785.34,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,6103.76,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,7066.94,102,,,case rate,102% WV Medicaid DRG rate,10071.204,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,6458.54,100,,,case rate,100% PEIA with CHIP DRG base rate,30774.39,100,,,case rate,100% Highmark ACA DRG rate,38915.89,100,,,case rate,100% Highmark PPO DRG rate,38915.89,100,,,case rate,100% Highmark Trad DRG rate,6928.37,100,,,case rate,100% WV Medicaid DRG rate,6103.76,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,5493.63,100,,,case rate,100% PEIA DRG rate,28940.61,100,,,case rate,100% The Health Plan DRG rate,5493.63,38915.89,
DISORDERS OF THE BILIARY TRACT WITH CC,445,MS-DRG,,,,,Inpatient,,,,,,42863.15,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,42863.15,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,15586.6,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,5597.58,102,,,case rate,102% WV Medicaid DRG rate,25717.89,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,5115.68,100,,,case rate,100% PEIA with CHIP DRG base rate,20478.57,100,,,case rate,100% Highmark ACA DRG rate,25896.27,100,,,case rate,100% Highmark PPO DRG rate,25896.27,100,,,case rate,100% Highmark Trad DRG rate,5487.82,100,,,case rate,100% WV Medicaid DRG rate,15586.6,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,4351.39,100,,,case rate,100% PEIA DRG rate,19258.3,100,,,case rate,100% The Health Plan DRG rate,4351.39,42863.15,
DISORDERS OF THE BILIARY TRACT WITHOUT CC/MCC,446,MS-DRG,,,,,Inpatient,,,,,,28312.79,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,28312.79,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,10295.56,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,5081.5,102,,,case rate,102% WV Medicaid DRG rate,16987.674,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,4644.02,100,,,case rate,100% PEIA with CHIP DRG base rate,15102.66,100,,,case rate,100% Highmark ACA DRG rate,19098.14,100,,,case rate,100% Highmark PPO DRG rate,19098.14,100,,,case rate,100% Highmark Trad DRG rate,4981.85,100,,,case rate,100% WV Medicaid DRG rate,10295.56,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,3950.2,100,,,case rate,100% PEIA DRG rate,14202.73,100,,,case rate,100% The Health Plan DRG rate,3950.2,28312.79,
COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION WITH MCC,453,MS-DRG,,,,,Inpatient,,,,,,20899.89,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,20899.89,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,7599.96,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,65731.87,102,,,case rate,102% WV Medicaid DRG rate,12539.934,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,60072.94,100,,,case rate,100% PEIA with CHIP DRG base rate,166975.36,100,,,case rate,100% Highmark ACA DRG rate,211149.44,100,,,case rate,100% Highmark PPO DRG rate,211149.44,100,,,case rate,100% Highmark Trad DRG rate,64442.95,100,,,case rate,100% WV Medicaid DRG rate,7599.96,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,51097.96,100,,,case rate,100% PEIA DRG rate,157025.69,100,,,case rate,100% The Health Plan DRG rate,7599.96,211149.44,
COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION WITH CC,454,MS-DRG,,,,,Inpatient,,,,,,235720.43,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,235720.43,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,85716.52,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,37870.55,102,,,case rate,102% WV Medicaid DRG rate,141432.258,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,34610.23,100,,,case rate,100% PEIA with CHIP DRG base rate,115249.44,100,,,case rate,100% Highmark ACA DRG rate,145739.2,100,,,case rate,100% Highmark PPO DRG rate,145739.2,100,,,case rate,100% Highmark Trad DRG rate,37127.96,100,,,case rate,100% WV Medicaid DRG rate,85716.52,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,29439.42,100,,,case rate,100% PEIA DRG rate,108382,100,,,case rate,100% The Health Plan DRG rate,29439.42,235720.43,
COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION WITHOUT CC/MCC,455,MS-DRG,,,,,Inpatient,,,,,,156830.2725,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,156830.2725,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,57029.19,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,30133.33,102,,,case rate,102% WV Medicaid DRG rate,94098.1635,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,27539.11,100,,,case rate,100% PEIA with CHIP DRG base rate,86783.32,100,,,case rate,100% Highmark ACA DRG rate,109742.24,100,,,case rate,100% Highmark PPO DRG rate,109742.24,100,,,case rate,100% Highmark Trad DRG rate,29542.45,100,,,case rate,100% WV Medicaid DRG rate,57029.19,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,23424.74,100,,,case rate,100% PEIA DRG rate,81612.11,100,,,case rate,100% The Health Plan DRG rate,23424.74,156830.2725,
"SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EXTENSIVE FUSIONS WITH MCC",456,MS-DRG,,,,,Inpatient,,,,,,123282.7475,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,123282.7475,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,44830.09,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,46686.29,102,,,case rate,102% WV Medicaid DRG rate,73969.6485,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,42667.01,100,,,case rate,100% PEIA with CHIP DRG base rate,158835.18,100,,,case rate,100% Highmark ACA DRG rate,200855.74,100,,,case rate,100% Highmark PPO DRG rate,200855.74,100,,,case rate,100% Highmark Trad DRG rate,45770.83,100,,,case rate,100% WV Medicaid DRG rate,44830.09,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,36292.51,100,,,case rate,100% PEIA DRG rate,149370.57,100,,,case rate,100% The Health Plan DRG rate,36292.51,200855.74,
"SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EXTENSIVE FUSIONS WITH CC",457,MS-DRG,,,,,Inpatient,,,,,,217552.445,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,217552.445,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,79109.98,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,26897.79,102,,,case rate,102% WV Medicaid DRG rate,130531.467,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,24582.12,100,,,case rate,100% PEIA with CHIP DRG base rate,114476.88,100,,,case rate,100% Highmark ACA DRG rate,144762.25,100,,,case rate,100% Highmark PPO DRG rate,144762.25,100,,,case rate,100% Highmark Trad DRG rate,26370.35,100,,,case rate,100% WV Medicaid DRG rate,79109.98,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,20909.52,100,,,case rate,100% PEIA DRG rate,107655.47,100,,,case rate,100% The Health Plan DRG rate,20909.52,217552.445,
"SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EXTENSIVE FUSIONS WITHOUT CC/MCC",458,MS-DRG,,,,,Inpatient,,,,,,155437.26,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,155437.26,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,56522.64,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,19335.26,102,,,case rate,102% WV Medicaid DRG rate,93262.356,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,17670.67,100,,,case rate,100% PEIA with CHIP DRG base rate,85377.63,100,,,case rate,100% Highmark ACA DRG rate,107964.67,100,,,case rate,100% Highmark PPO DRG rate,107964.67,100,,,case rate,100% Highmark Trad DRG rate,18956.12,100,,,case rate,100% WV Medicaid DRG rate,56522.64,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,15030.65,100,,,case rate,100% PEIA DRG rate,80290.18,100,,,case rate,100% The Health Plan DRG rate,15030.65,155437.26,
SPINAL FUSION EXCEPT CERVICAL WITH MCC,459,MS-DRG,,,,,Inpatient,,,,,,123929.1075,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,123929.1075,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,45065.13,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,44053.74,102,,,case rate,102% WV Medicaid DRG rate,74357.4645,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,40261.1,100,,,case rate,100% PEIA with CHIP DRG base rate,124972.43,100,,,case rate,100% Highmark ACA DRG rate,158034.44,100,,,case rate,100% Highmark PPO DRG rate,158034.44,100,,,case rate,100% Highmark Trad DRG rate,43189.9,100,,,case rate,100% WV Medicaid DRG rate,45065.13,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,34246.04,100,,,case rate,100% PEIA DRG rate,117525.62,100,,,case rate,100% The Health Plan DRG rate,34246.04,158034.44,
SPINAL FUSION EXCEPT CERVICAL WITHOUT MCC,460,MS-DRG,,,,,Inpatient,,,,,,170788.42,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,170788.42,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,62104.88,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,21596.58,102,,,case rate,102% WV Medicaid DRG rate,102473.052,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,19737.3,100,,,case rate,100% PEIA with CHIP DRG base rate,68925.81,100,,,case rate,100% Highmark ACA DRG rate,87160.44,100,,,case rate,100% Highmark PPO DRG rate,87160.44,100,,,case rate,100% Highmark Trad DRG rate,21173.09,100,,,case rate,100% WV Medicaid DRG rate,62104.88,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,16788.52,100,,,case rate,100% PEIA DRG rate,64818.68,100,,,case rate,100% The Health Plan DRG rate,16788.52,170788.42,
BILATERAL OR MULTIPLE MAJOR JOINT PROCEDURES OF LOWER EXTREMITY WITH MCC,461,MS-DRG,,,,,Inpatient,,,,,,96968.08,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,96968.08,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,35261.12,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,42606.66,102,,,case rate,102% WV Medicaid DRG rate,58180.848,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,38938.6,100,,,case rate,100% PEIA with CHIP DRG base rate,128481,100,,,case rate,100% Highmark ACA DRG rate,162471.22,100,,,case rate,100% Highmark PPO DRG rate,162471.22,100,,,case rate,100% Highmark Trad DRG rate,41771.19,100,,,case rate,100% WV Medicaid DRG rate,35261.12,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,33121.12,100,,,case rate,100% PEIA DRG rate,120825.12,100,,,case rate,100% The Health Plan DRG rate,33121.12,162471.22,
BILATERAL OR MULTIPLE MAJOR JOINT PROCEDURES OF LOWER EXTREMITY WITHOUT MCC,462,MS-DRG,,,,,Inpatient,,,,,,165180.4,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,165180.4,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,60065.6,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,19314.32,102,,,case rate,102% WV Medicaid DRG rate,99108.24,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,17651.52,100,,,case rate,100% PEIA with CHIP DRG base rate,53632.83,100,,,case rate,100% Highmark ACA DRG rate,67821.64,100,,,case rate,100% Highmark PPO DRG rate,67821.64,100,,,case rate,100% Highmark Trad DRG rate,18935.59,100,,,case rate,100% WV Medicaid DRG rate,60065.6,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,15014.36,100,,,case rate,100% PEIA DRG rate,50436.98,100,,,case rate,100% The Health Plan DRG rate,15014.36,165180.4,
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH MCC,463,MS-DRG,,,,,Inpatient,,,,,,76874.1325,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,76874.1325,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,27954.23,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,20264.48,102,,,case rate,102% WV Medicaid DRG rate,46124.4795,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,18519.89,100,,,case rate,100% PEIA with CHIP DRG base rate,106721.1,100,,,case rate,100% Highmark ACA DRG rate,134954.64,100,,,case rate,100% Highmark PPO DRG rate,134954.64,100,,,case rate,100% Highmark Trad DRG rate,19867.12,100,,,case rate,100% WV Medicaid DRG rate,27954.23,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,15752.99,100,,,case rate,100% PEIA DRG rate,100361.84,100,,,case rate,100% The Health Plan DRG rate,15752.99,134954.64,
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH CC,464,MS-DRG,,,,,Inpatient,,,,,,134962.245,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,134962.245,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,49077.18,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,13446.66,102,,,case rate,102% WV Medicaid DRG rate,80977.347,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,12289.03,100,,,case rate,100% PEIA with CHIP DRG base rate,56555.38,100,,,case rate,100% Highmark ACA DRG rate,71517.36,100,,,case rate,100% Highmark PPO DRG rate,71517.36,100,,,case rate,100% Highmark Trad DRG rate,13182.99,100,,,case rate,100% WV Medicaid DRG rate,49077.18,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,10453.03,100,,,case rate,100% PEIA DRG rate,53185.38,100,,,case rate,100% The Health Plan DRG rate,10453.03,134962.245,
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,465,MS-DRG,,,,,Inpatient,,,,,,76915.3,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,76915.3,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,27969.2,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,7929.31,102,,,case rate,102% WV Medicaid DRG rate,46149.18,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,7246.66,100,,,case rate,100% PEIA with CHIP DRG base rate,35251.48,100,,,case rate,100% Highmark ACA DRG rate,44577.42,100,,,case rate,100% Highmark PPO DRG rate,44577.42,100,,,case rate,100% Highmark Trad DRG rate,7773.82,100,,,case rate,100% WV Medicaid DRG rate,27969.2,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,6164,100,,,case rate,100% PEIA DRG rate,33150.93,100,,,case rate,100% The Health Plan DRG rate,6164,76915.3,
REVISION OF HIP OR KNEE REPLACEMENT WITH MCC,466,MS-DRG,,,,,Inpatient,,,,,,51308.62,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,51308.62,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,18657.68,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,34569.5,102,,,case rate,102% WV Medicaid DRG rate,30785.172,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,31593.37,100,,,case rate,100% PEIA with CHIP DRG base rate,97731.1,100,,,case rate,100% Highmark ACA DRG rate,123586.3,100,,,case rate,100% Highmark PPO DRG rate,123586.3,100,,,case rate,100% Highmark Trad DRG rate,33891.63,100,,,case rate,100% WV Medicaid DRG rate,18657.68,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,26873.28,100,,,case rate,100% PEIA DRG rate,91907.54,100,,,case rate,100% The Health Plan DRG rate,18657.68,123586.3,
REVISION OF HIP OR KNEE REPLACEMENT WITH CC,467,MS-DRG,,,,,Inpatient,,,,,,135052.335,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,135052.335,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,49109.94,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,16633.63,102,,,case rate,102% WV Medicaid DRG rate,81031.401,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,15201.62,100,,,case rate,100% PEIA with CHIP DRG base rate,65692.35,100,,,case rate,100% Highmark ACA DRG rate,83071.56,100,,,case rate,100% Highmark PPO DRG rate,83071.56,100,,,case rate,100% Highmark Trad DRG rate,16307.46,100,,,case rate,100% WV Medicaid DRG rate,49109.94,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,12930.48,100,,,case rate,100% PEIA DRG rate,61777.9,100,,,case rate,100% The Health Plan DRG rate,12930.48,135052.335,
REVISION OF HIP OR KNEE REPLACEMENT WITHOUT CC/MCC,468,MS-DRG,,,,,Inpatient,,,,,,93360.7125,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,93360.7125,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,33949.35,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,10864.47,102,,,case rate,102% WV Medicaid DRG rate,56016.4275,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,9929.14,100,,,case rate,100% PEIA with CHIP DRG base rate,50303.27,100,,,case rate,100% Highmark ACA DRG rate,63611.23,100,,,case rate,100% Highmark PPO DRG rate,63611.23,100,,,case rate,100% Highmark Trad DRG rate,10651.43,100,,,case rate,100% WV Medicaid DRG rate,33949.35,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,8445.71,100,,,case rate,100% PEIA DRG rate,47305.82,100,,,case rate,100% The Health Plan DRG rate,8445.71,93360.7125,
MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITH MCC OR TOTAL ANKLE REPLACEMENT,469,MS-DRG,,,,,Inpatient,,,,,,71819.715,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,71819.715,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,26116.26,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,21141.11,102,,,case rate,102% WV Medicaid DRG rate,43091.829,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,19321.04,100,,,case rate,100% PEIA with CHIP DRG base rate,62743.42,100,,,case rate,100% Highmark ACA DRG rate,79342.47,100,,,case rate,100% Highmark PPO DRG rate,79342.47,100,,,case rate,100% Highmark Trad DRG rate,20726.55,100,,,case rate,100% WV Medicaid DRG rate,26116.26,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,16434.45,100,,,case rate,100% PEIA DRG rate,59004.69,100,,,case rate,100% The Health Plan DRG rate,16434.45,79342.47,
MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITHOUT MCC,470,MS-DRG,,,,,Inpatient,,,,,,83202.9825,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,83202.9825,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,30255.63,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,12496.06,102,,,case rate,102% WV Medicaid DRG rate,49921.7895,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,11420.26,100,,,case rate,100% PEIA with CHIP DRG base rate,35456.87,100,,,case rate,100% Highmark ACA DRG rate,44837.15,100,,,case rate,100% Highmark PPO DRG rate,44837.15,100,,,case rate,100% Highmark Trad DRG rate,12251.02,100,,,case rate,100% WV Medicaid DRG rate,30255.63,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,9714.06,100,,,case rate,100% PEIA DRG rate,33344.08,100,,,case rate,100% The Health Plan DRG rate,9714.06,83202.9825,
CERVICAL SPINAL FUSION WITH MCC,471,MS-DRG,,,,,Inpatient,,,,,,49228.135,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,49228.135,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,17901.14,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,21852.84,102,,,case rate,102% WV Medicaid DRG rate,29536.881,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,19971.5,100,,,case rate,100% PEIA with CHIP DRG base rate,92688.72,100,,,case rate,100% Highmark ACA DRG rate,117209.93,100,,,case rate,100% Highmark PPO DRG rate,117209.93,100,,,case rate,100% Highmark Trad DRG rate,21424.33,100,,,case rate,100% WV Medicaid DRG rate,17901.14,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,16987.73,100,,,case rate,100% PEIA DRG rate,87165.61,100,,,case rate,100% The Health Plan DRG rate,16987.73,117209.93,
CERVICAL SPINAL FUSION WITH CC,472,MS-DRG,,,,,Inpatient,,,,,,129694.125,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,129694.125,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,47161.5,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,18466.21,102,,,case rate,102% WV Medicaid DRG rate,77816.475,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,16876.43,100,,,case rate,100% PEIA with CHIP DRG base rate,55688.6,100,,,case rate,100% Highmark ACA DRG rate,70421.27,100,,,case rate,100% Highmark PPO DRG rate,70421.27,100,,,case rate,100% Highmark Trad DRG rate,18104.11,100,,,case rate,100% WV Medicaid DRG rate,47161.5,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,14355.07,100,,,case rate,100% PEIA DRG rate,52370.25,100,,,case rate,100% The Health Plan DRG rate,14355.07,129694.125,
CERVICAL SPINAL FUSION WITHOUT CC/MCC,473,MS-DRG,,,,,Inpatient,,,,,,79073.005,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,79073.005,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,28753.82,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,16826.6,102,,,case rate,102% WV Medicaid DRG rate,47443.803,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,15377.98,100,,,case rate,100% PEIA with CHIP DRG base rate,46365.09,100,,,case rate,100% Highmark ACA DRG rate,58631.18,100,,,case rate,100% Highmark PPO DRG rate,58631.18,100,,,case rate,100% Highmark Trad DRG rate,16496.65,100,,,case rate,100% WV Medicaid DRG rate,28753.82,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,13080.49,100,,,case rate,100% PEIA DRG rate,43602.3,100,,,case rate,100% The Health Plan DRG rate,13080.49,79073.005,
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH MCC,474,MS-DRG,,,,,Inpatient,,,,,,65274.5225,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,65274.5225,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,23736.19,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,26378.14,102,,,case rate,102% WV Medicaid DRG rate,39164.7135,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,24107.21,100,,,case rate,100% PEIA with CHIP DRG base rate,81077.66,100,,,case rate,100% Highmark ACA DRG rate,102527.12,100,,,case rate,100% Highmark PPO DRG rate,102527.12,100,,,case rate,100% Highmark Trad DRG rate,25860.89,100,,,case rate,100% WV Medicaid DRG rate,23736.19,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,20505.56,100,,,case rate,100% PEIA DRG rate,76246.43,100,,,case rate,100% The Health Plan DRG rate,20505.56,102527.12,
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH CC,475,MS-DRG,,,,,Inpatient,,,,,,105488.2125,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,105488.2125,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,38359.35,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,11993.34,102,,,case rate,102% WV Medicaid DRG rate,63292.9275,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,10960.82,100,,,case rate,100% PEIA with CHIP DRG base rate,40412.58,100,,,case rate,100% Highmark ACA DRG rate,51103.91,100,,,case rate,100% Highmark PPO DRG rate,51103.91,100,,,case rate,100% Highmark Trad DRG rate,11758.17,100,,,case rate,100% WV Medicaid DRG rate,38359.35,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,9323.26,100,,,case rate,100% PEIA DRG rate,38004.49,100,,,case rate,100% The Health Plan DRG rate,9323.26,105488.2125,
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,476,MS-DRG,,,,,Inpatient,,,,,,57192.1075,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,57192.1075,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,20797.13,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,8152.14,102,,,case rate,102% WV Medicaid DRG rate,34315.2645,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,7450.31,100,,,case rate,100% PEIA with CHIP DRG base rate,22176.33,100,,,case rate,100% Highmark ACA DRG rate,28043.17,100,,,case rate,100% Highmark PPO DRG rate,28043.17,100,,,case rate,100% Highmark Trad DRG rate,7992.29,100,,,case rate,100% WV Medicaid DRG rate,20797.13,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,6337.23,100,,,case rate,100% PEIA DRG rate,20854.89,100,,,case rate,100% The Health Plan DRG rate,6337.23,57192.1075,
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,477,MS-DRG,,,,,Inpatient,,,,,,31605.97,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,31605.97,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,11493.08,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,16090.81,102,,,case rate,102% WV Medicaid DRG rate,18963.582,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,14705.53,100,,,case rate,100% PEIA with CHIP DRG base rate,63482.07,100,,,case rate,100% Highmark ACA DRG rate,80276.53,100,,,case rate,100% Highmark PPO DRG rate,80276.53,100,,,case rate,100% Highmark Trad DRG rate,15775.29,100,,,case rate,100% WV Medicaid DRG rate,11493.08,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,12508.51,100,,,case rate,100% PEIA DRG rate,59699.32,100,,,case rate,100% The Health Plan DRG rate,11493.08,80276.53,
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC,478,MS-DRG,,,,,Inpatient,,,,,,87616.32,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,87616.32,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,31860.48,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,10355.07,102,,,case rate,102% WV Medicaid DRG rate,52569.792,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,9463.59,100,,,case rate,100% PEIA with CHIP DRG base rate,44916.06,100,,,case rate,100% Highmark ACA DRG rate,56798.8,100,,,case rate,100% Highmark PPO DRG rate,56798.8,100,,,case rate,100% Highmark Trad DRG rate,10152.02,100,,,case rate,100% WV Medicaid DRG rate,31860.48,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,8049.72,100,,,case rate,100% PEIA DRG rate,42239.62,100,,,case rate,100% The Health Plan DRG rate,8049.72,87616.32,
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC,479,MS-DRG,,,,,Inpatient,,,,,,60480.145,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,60480.145,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,21992.78,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,7418.57,102,,,case rate,102% WV Medicaid DRG rate,36288.087,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,6779.9,100,,,case rate,100% PEIA with CHIP DRG base rate,35123.35,100,,,case rate,100% Highmark ACA DRG rate,44415.39,100,,,case rate,100% Highmark PPO DRG rate,44415.39,100,,,case rate,100% Highmark Trad DRG rate,7273.1,100,,,case rate,100% WV Medicaid DRG rate,21992.78,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,5766.97,100,,,case rate,100% PEIA DRG rate,33030.43,100,,,case rate,100% The Health Plan DRG rate,5766.97,60480.145,
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH MCC,480,MS-DRG,,,,,Inpatient,,,,,,45533.2625,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,45533.2625,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,16557.55,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,16712.51,102,,,case rate,102% WV Medicaid DRG rate,27319.9575,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,15273.71,100,,,case rate,100% PEIA with CHIP DRG base rate,55566.12,100,,,case rate,100% Highmark ACA DRG rate,70266.39,100,,,case rate,100% Highmark PPO DRG rate,70266.39,100,,,case rate,100% Highmark Trad DRG rate,16384.8,100,,,case rate,100% WV Medicaid DRG rate,16557.55,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,12991.8,100,,,case rate,100% PEIA DRG rate,52255.07,100,,,case rate,100% The Health Plan DRG rate,12991.8,70266.39,
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH CC,481,MS-DRG,,,,,Inpatient,,,,,,76369.3975,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,76369.3975,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,27770.69,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,10343.49,102,,,case rate,102% WV Medicaid DRG rate,45821.6385,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,9453,100,,,case rate,100% PEIA with CHIP DRG base rate,39097.34,100,,,case rate,100% Highmark ACA DRG rate,49440.72,100,,,case rate,100% Highmark PPO DRG rate,49440.72,100,,,case rate,100% Highmark Trad DRG rate,10140.66,100,,,case rate,100% WV Medicaid DRG rate,27770.69,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,8040.71,100,,,case rate,100% PEIA DRG rate,36767.62,100,,,case rate,100% The Health Plan DRG rate,8040.71,76369.3975,
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITHOUT CC/MCC,482,MS-DRG,,,,,Inpatient,,,,,,54390.655,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,54390.655,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,19778.42,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,7438.63,102,,,case rate,102% WV Medicaid DRG rate,32634.393,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,6798.23,100,,,case rate,100% PEIA with CHIP DRG base rate,29930.22,100,,,case rate,100% Highmark ACA DRG rate,37848.4,100,,,case rate,100% Highmark PPO DRG rate,37848.4,100,,,case rate,100% Highmark Trad DRG rate,7292.77,100,,,case rate,100% WV Medicaid DRG rate,19778.42,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,5782.56,100,,,case rate,100% PEIA DRG rate,28146.75,100,,,case rate,100% The Health Plan DRG rate,5782.56,54390.655,
MAJOR JOINT OR LIMB REATTACHMENT PROCEDURES OF UPPER EXTREMITIES,483,MS-DRG,,,,,Inpatient,,,,,,42384.265,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,42384.265,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,15412.46,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,12058.41,102,,,case rate,102% WV Medicaid DRG rate,25430.559,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,11020.29,100,,,case rate,100% PEIA with CHIP DRG base rate,46809.78,100,,,case rate,100% Highmark ACA DRG rate,59193.52,100,,,case rate,100% Highmark PPO DRG rate,59193.52,100,,,case rate,100% Highmark Trad DRG rate,11821.96,100,,,case rate,100% WV Medicaid DRG rate,15412.46,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,9373.84,100,,,case rate,100% PEIA DRG rate,44020.5,100,,,case rate,100% The Health Plan DRG rate,9373.84,59193.52,
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH MCC,485,MS-DRG,,,,,Inpatient,,,,,,60704.1325,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,60704.1325,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,22074.23,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,14628.13,102,,,case rate,102% WV Medicaid DRG rate,36422.4795,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,13368.78,100,,,case rate,100% PEIA with CHIP DRG base rate,62068.84,100,,,case rate,100% Highmark ACA DRG rate,78489.43,100,,,case rate,100% Highmark PPO DRG rate,78489.43,100,,,case rate,100% Highmark Trad DRG rate,14341.29,100,,,case rate,100% WV Medicaid DRG rate,22074.23,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,11371.46,100,,,case rate,100% PEIA DRG rate,58370.31,100,,,case rate,100% The Health Plan DRG rate,11371.46,78489.43,
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH CC,486,MS-DRG,,,,,Inpatient,,,,,,83707.7175,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,83707.7175,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,30439.17,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,10860.9,102,,,case rate,102% WV Medicaid DRG rate,50224.6305,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,9925.88,100,,,case rate,100% PEIA with CHIP DRG base rate,37842.4,100,,,case rate,100% Highmark ACA DRG rate,47853.77,100,,,case rate,100% Highmark PPO DRG rate,47853.77,100,,,case rate,100% Highmark Trad DRG rate,10647.94,100,,,case rate,100% WV Medicaid DRG rate,30439.17,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,8442.94,100,,,case rate,100% PEIA DRG rate,35587.46,100,,,case rate,100% The Health Plan DRG rate,8442.94,83707.7175,
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC,487,MS-DRG,,,,,Inpatient,,,,,,53710.91,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,53710.91,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,19531.24,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,7806.3,102,,,case rate,102% WV Medicaid DRG rate,32226.546,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,7134.25,100,,,case rate,100% PEIA with CHIP DRG base rate,29110.55,100,,,case rate,100% Highmark ACA DRG rate,36811.88,100,,,case rate,100% Highmark PPO DRG rate,36811.88,100,,,case rate,100% Highmark Trad DRG rate,7653.23,100,,,case rate,100% WV Medicaid DRG rate,19531.24,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,6068.38,100,,,case rate,100% PEIA DRG rate,27375.92,100,,,case rate,100% The Health Plan DRG rate,6068.38,53710.91,
KNEE PROCEDURES WITHOUT PRINCIPAL DIAGNOSIS OF INFECTION WITH CC/MCC,488,MS-DRG,,,,,Inpatient,,,,,,41300.2425,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,41300.2425,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,15018.27,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,9313.1,102,,,case rate,102% WV Medicaid DRG rate,24780.1455,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,8511.33,100,,,case rate,100% PEIA with CHIP DRG base rate,39694.66,100,,,case rate,100% Highmark ACA DRG rate,50196.06,100,,,case rate,100% Highmark PPO DRG rate,50196.06,100,,,case rate,100% Highmark Trad DRG rate,9130.48,100,,,case rate,100% WV Medicaid DRG rate,15018.27,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,7239.72,100,,,case rate,100% PEIA DRG rate,37329.35,100,,,case rate,100% The Health Plan DRG rate,7239.72,50196.06,
KNEE PROCEDURES WITHOUT PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC,489,MS-DRG,,,,,Inpatient,,,,,,58428.0125,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,58428.0125,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,21246.55,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,8122.28,102,,,case rate,102% WV Medicaid DRG rate,35056.8075,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,7423.02,100,,,case rate,100% PEIA with CHIP DRG base rate,23321.98,100,,,case rate,100% Highmark ACA DRG rate,29491.92,100,,,case rate,100% Highmark PPO DRG rate,29491.92,100,,,case rate,100% Highmark Trad DRG rate,7963.01,100,,,case rate,100% WV Medicaid DRG rate,21246.55,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,6314.01,100,,,case rate,100% PEIA DRG rate,21932.28,100,,,case rate,100% The Health Plan DRG rate,6314.01,58428.0125,
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH MCC",492,MS-DRG,,,,,Inpatient,,,,,,34232.385,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,34232.385,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,12448.14,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,20297.9,102,,,case rate,102% WV Medicaid DRG rate,20539.431,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,18550.43,100,,,case rate,100% PEIA with CHIP DRG base rate,65236.35,100,,,case rate,100% Highmark ACA DRG rate,82494.92,100,,,case rate,100% Highmark PPO DRG rate,82494.92,100,,,case rate,100% Highmark Trad DRG rate,19899.89,100,,,case rate,100% WV Medicaid DRG rate,12448.14,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,15778.97,100,,,case rate,100% PEIA DRG rate,61349.07,100,,,case rate,100% The Health Plan DRG rate,12448.14,82494.92,
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH CC",493,MS-DRG,,,,,Inpatient,,,,,,89755.93,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,89755.93,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,32638.52,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,9986.51,102,,,case rate,102% WV Medicaid DRG rate,53853.558,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,9126.76,100,,,case rate,100% PEIA with CHIP DRG base rate,45255.23,100,,,case rate,100% Highmark ACA DRG rate,57227.71,100,,,case rate,100% Highmark PPO DRG rate,57227.71,100,,,case rate,100% Highmark Trad DRG rate,9790.68,100,,,case rate,100% WV Medicaid DRG rate,32638.52,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,7763.21,100,,,case rate,100% PEIA DRG rate,42558.58,100,,,case rate,100% The Health Plan DRG rate,7763.21,89755.93,
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITHOUT CC/MCC",494,MS-DRG,,,,,Inpatient,,,,,,61172.76,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,61172.76,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,22244.64,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,8492.63,102,,,case rate,102% WV Medicaid DRG rate,36703.656,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,7761.49,100,,,case rate,100% PEIA with CHIP DRG base rate,35221.34,100,,,case rate,100% Highmark ACA DRG rate,44539.3,100,,,case rate,100% Highmark PPO DRG rate,44539.3,100,,,case rate,100% Highmark Trad DRG rate,8326.1,100,,,case rate,100% WV Medicaid DRG rate,22244.64,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,6601.91,100,,,case rate,100% PEIA DRG rate,33122.58,100,,,case rate,100% The Health Plan DRG rate,6601.91,61172.76,
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITH MCC,495,MS-DRG,,,,,Inpatient,,,,,,48633.3925,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,48633.3925,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,17684.87,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,24632.02,102,,,case rate,102% WV Medicaid DRG rate,29180.0355,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,22511.42,100,,,case rate,100% PEIA with CHIP DRG base rate,67480.55,100,,,case rate,100% Highmark ACA DRG rate,85332.83,100,,,case rate,100% Highmark PPO DRG rate,85332.83,100,,,case rate,100% Highmark Trad DRG rate,24149.01,100,,,case rate,100% WV Medicaid DRG rate,17684.87,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,19148.18,100,,,case rate,100% PEIA DRG rate,63459.54,100,,,case rate,100% The Health Plan DRG rate,17684.87,85332.83,
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITH CC,496,MS-DRG,,,,,Inpatient,,,,,,95639.4175,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,95639.4175,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,34777.97,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,10863.13,102,,,case rate,102% WV Medicaid DRG rate,57383.6505,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,9927.91,100,,,case rate,100% PEIA with CHIP DRG base rate,37450.46,100,,,case rate,100% Highmark ACA DRG rate,47358.15,100,,,case rate,100% Highmark PPO DRG rate,47358.15,100,,,case rate,100% Highmark Trad DRG rate,10650.12,100,,,case rate,100% WV Medicaid DRG rate,34777.97,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,8444.67,100,,,case rate,100% PEIA DRG rate,35218.88,100,,,case rate,100% The Health Plan DRG rate,8444.67,95639.4175,
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITHOUT CC/MCC,497,MS-DRG,,,,,Inpatient,,,,,,54063.68,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,54063.68,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,19659.52,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,10107.28,102,,,case rate,102% WV Medicaid DRG rate,32438.208,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,9237.13,100,,,case rate,100% PEIA with CHIP DRG base rate,26896.5,100,,,case rate,100% Highmark ACA DRG rate,34012.09,100,,,case rate,100% Highmark PPO DRG rate,34012.09,100,,,case rate,100% Highmark Trad DRG rate,9909.09,100,,,case rate,100% WV Medicaid DRG rate,19659.52,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,7857.09,100,,,case rate,100% PEIA DRG rate,25293.8,100,,,case rate,100% The Health Plan DRG rate,7857.09,54063.68,
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES OF HIP AND FEMUR WITH CC/MCC,498,MS-DRG,,,,,Inpatient,,,,,,39181.2025,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,39181.2025,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,14247.71,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,17023.14,102,,,case rate,102% WV Medicaid DRG rate,23508.7215,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,15557.6,100,,,case rate,100% PEIA with CHIP DRG base rate,49199.07,100,,,case rate,100% Highmark ACA DRG rate,62214.91,100,,,case rate,100% Highmark PPO DRG rate,62214.91,100,,,case rate,100% Highmark Trad DRG rate,16689.34,100,,,case rate,100% WV Medicaid DRG rate,14247.71,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,13233.27,100,,,case rate,100% PEIA DRG rate,46267.42,100,,,case rate,100% The Health Plan DRG rate,13233.27,62214.91,
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES OF HIP AND FEMUR WITHOUT CC/MCC,499,MS-DRG,,,,,Inpatient,,,,,,65995.4625,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,65995.4625,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,23998.35,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,8467.67,102,,,case rate,102% WV Medicaid DRG rate,39597.2775,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,7738.68,100,,,case rate,100% PEIA with CHIP DRG base rate,24303.7,100,,,case rate,100% Highmark ACA DRG rate,30733.35,100,,,case rate,100% Highmark PPO DRG rate,30733.35,100,,,case rate,100% Highmark Trad DRG rate,8301.63,100,,,case rate,100% WV Medicaid DRG rate,23998.35,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,6582.51,100,,,case rate,100% PEIA DRG rate,22855.5,100,,,case rate,100% The Health Plan DRG rate,6582.51,65995.4625,
SOFT TISSUE PROCEDURES WITH MCC,500,MS-DRG,,,,,Inpatient,,,,,,33954.2775,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,33954.2775,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,12347.01,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,14695.42,102,,,case rate,102% WV Medicaid DRG rate,20372.5665,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,13430.28,100,,,case rate,100% PEIA with CHIP DRG base rate,61104.08,100,,,case rate,100% Highmark ACA DRG rate,77269.44,100,,,case rate,100% Highmark PPO DRG rate,77269.44,100,,,case rate,100% Highmark Trad DRG rate,14407.26,100,,,case rate,100% WV Medicaid DRG rate,12347.01,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,11423.78,100,,,case rate,100% PEIA DRG rate,57463.03,100,,,case rate,100% The Health Plan DRG rate,11423.78,77269.44,
SOFT TISSUE PROCEDURES WITH CC,501,MS-DRG,,,,,Inpatient,,,,,,82510.3675,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,82510.3675,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,30003.77,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,8078.61,102,,,case rate,102% WV Medicaid DRG rate,49506.2205,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,7383.11,100,,,case rate,100% PEIA with CHIP DRG base rate,32705.8,100,,,case rate,100% Highmark ACA DRG rate,41358.26,100,,,case rate,100% Highmark PPO DRG rate,41358.26,100,,,case rate,100% Highmark Trad DRG rate,7920.19,100,,,case rate,100% WV Medicaid DRG rate,30003.77,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,6280.06,100,,,case rate,100% PEIA DRG rate,30756.93,100,,,case rate,100% The Health Plan DRG rate,6280.06,82510.3675,
SOFT TISSUE PROCEDURES WITHOUT CC/MCC,502,MS-DRG,,,,,Inpatient,,,,,,45260.325,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,45260.325,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,16458.3,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,7212.67,102,,,case rate,102% WV Medicaid DRG rate,27156.195,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,6591.73,100,,,case rate,100% PEIA with CHIP DRG base rate,26054.22,100,,,case rate,100% Highmark ACA DRG rate,32946.98,100,,,case rate,100% Highmark PPO DRG rate,32946.98,100,,,case rate,100% Highmark Trad DRG rate,7071.24,100,,,case rate,100% WV Medicaid DRG rate,16458.3,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,5606.91,100,,,case rate,100% PEIA DRG rate,24501.71,100,,,case rate,100% The Health Plan DRG rate,5606.91,45260.325,
FOOT PROCEDURES WITH MCC,503,MS-DRG,,,,,Inpatient,,,,,,35390.9875,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,35390.9875,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,12869.45,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,16825.71,102,,,case rate,102% WV Medicaid DRG rate,21234.5925,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,15377.17,100,,,case rate,100% PEIA with CHIP DRG base rate,50535.04,100,,,case rate,100% Highmark ACA DRG rate,63904.31,100,,,case rate,100% Highmark PPO DRG rate,63904.31,100,,,case rate,100% Highmark Trad DRG rate,16495.78,100,,,case rate,100% WV Medicaid DRG rate,12869.45,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,13079.8,100,,,case rate,100% PEIA DRG rate,47523.78,100,,,case rate,100% The Health Plan DRG rate,12869.45,63904.31,
FOOT PROCEDURES WITH CC,504,MS-DRG,,,,,Inpatient,,,,,,65228.1575,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,65228.1575,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,23719.33,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,7517.07,102,,,case rate,102% WV Medicaid DRG rate,39136.8945,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,6869.91,100,,,case rate,100% PEIA with CHIP DRG base rate,32543.75,100,,,case rate,100% Highmark ACA DRG rate,41153.34,100,,,case rate,100% Highmark PPO DRG rate,41153.34,100,,,case rate,100% Highmark Trad DRG rate,7369.66,100,,,case rate,100% WV Medicaid DRG rate,23719.33,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,5843.54,100,,,case rate,100% PEIA DRG rate,30604.54,100,,,case rate,100% The Health Plan DRG rate,5843.54,65228.1575,
FOOT PROCEDURES WITHOUT CC/MCC,505,MS-DRG,,,,,Inpatient,,,,,,45698.0425,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,45698.0425,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,16617.47,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,5524.04,102,,,case rate,102% WV Medicaid DRG rate,27418.8255,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,5048.47,100,,,case rate,100% PEIA with CHIP DRG base rate,32140.51,100,,,case rate,100% Highmark ACA DRG rate,40643.42,100,,,case rate,100% Highmark PPO DRG rate,40643.42,100,,,case rate,100% Highmark Trad DRG rate,5415.72,100,,,case rate,100% WV Medicaid DRG rate,16617.47,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,4294.22,100,,,case rate,100% PEIA DRG rate,30225.33,100,,,case rate,100% The Health Plan DRG rate,4294.22,45698.0425,
MAJOR THUMB OR JOINT PROCEDURES,506,MS-DRG,,,,,Inpatient,,,,,,45492.0675,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,45492.0675,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,16542.57,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,9363.91,102,,,case rate,102% WV Medicaid DRG rate,27295.2405,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,8557.76,100,,,case rate,100% PEIA with CHIP DRG base rate,27559.77,100,,,case rate,100% Highmark ACA DRG rate,34850.83,100,,,case rate,100% Highmark PPO DRG rate,34850.83,100,,,case rate,100% Highmark Trad DRG rate,9180.29,100,,,case rate,100% WV Medicaid DRG rate,16542.57,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,7279.22,100,,,case rate,100% PEIA DRG rate,25917.55,100,,,case rate,100% The Health Plan DRG rate,7279.22,45492.0675,
MAJOR SHOULDER OR ELBOW JOINT PROCEDURES WITH CC/MCC,507,MS-DRG,,,,,Inpatient,,,,,,36299.945,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,36299.945,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,13199.98,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,12318.68,102,,,case rate,102% WV Medicaid DRG rate,21779.967,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,11258.15,100,,,case rate,100% PEIA with CHIP DRG base rate,40167.62,100,,,case rate,100% Highmark ACA DRG rate,50794.15,100,,,case rate,100% Highmark PPO DRG rate,50794.15,100,,,case rate,100% Highmark Trad DRG rate,12077.13,100,,,case rate,100% WV Medicaid DRG rate,13199.98,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,9576.17,100,,,case rate,100% PEIA DRG rate,37774.13,100,,,case rate,100% The Health Plan DRG rate,9576.17,50794.15,
MAJOR SHOULDER OR ELBOW JOINT PROCEDURES WITHOUT CC/MCC,508,MS-DRG,,,,,Inpatient,,,,,,47757.9575,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,47757.9575,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,17366.53,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,9618.83,102,,,case rate,102% WV Medicaid DRG rate,28654.7745,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,8790.73,100,,,case rate,100% PEIA with CHIP DRG base rate,27020.86,100,,,case rate,100% Highmark ACA DRG rate,34169.35,100,,,case rate,100% Highmark PPO DRG rate,34169.35,100,,,case rate,100% Highmark Trad DRG rate,9430.22,100,,,case rate,100% WV Medicaid DRG rate,17366.53,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,7477.39,100,,,case rate,100% PEIA DRG rate,25410.75,100,,,case rate,100% The Health Plan DRG rate,7477.39,47757.9575,
ARTHROSCOPY,509,MS-DRG,,,,,Inpatient,,,,,,37288.6525,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,37288.6525,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,13559.51,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,9747.63,102,,,case rate,102% WV Medicaid DRG rate,22373.1915,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,8908.44,100,,,case rate,100% PEIA with CHIP DRG base rate,24989.59,100,,,case rate,100% Highmark ACA DRG rate,31600.69,100,,,case rate,100% Highmark PPO DRG rate,31600.69,100,,,case rate,100% Highmark Trad DRG rate,9556.49,100,,,case rate,100% WV Medicaid DRG rate,13559.51,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,7577.51,100,,,case rate,100% PEIA DRG rate,23500.52,100,,,case rate,100% The Health Plan DRG rate,7577.51,37288.6525,
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH MCC",510,MS-DRG,,,,,Inpatient,,,,,,39083.3575,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,39083.3575,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,14212.13,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,19181.95,102,,,case rate,102% WV Medicaid DRG rate,23450.0145,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,17530.56,100,,,case rate,100% PEIA with CHIP DRG base rate,51264.27,100,,,case rate,100% Highmark ACA DRG rate,64826.46,100,,,case rate,100% Highmark PPO DRG rate,64826.46,100,,,case rate,100% Highmark Trad DRG rate,18805.82,100,,,case rate,100% WV Medicaid DRG rate,14212.13,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,14911.47,100,,,case rate,100% PEIA DRG rate,48209.55,100,,,case rate,100% The Health Plan DRG rate,14212.13,64826.46,
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH CC",511,MS-DRG,,,,,Inpatient,,,,,,74363.63,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,74363.63,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,27041.32,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,9955.31,102,,,case rate,102% WV Medicaid DRG rate,44618.178,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,9098.25,100,,,case rate,100% PEIA with CHIP DRG base rate,37569.17,100,,,case rate,100% Highmark ACA DRG rate,47508.27,100,,,case rate,100% Highmark PPO DRG rate,47508.27,100,,,case rate,100% Highmark Trad DRG rate,9760.1,100,,,case rate,100% WV Medicaid DRG rate,27041.32,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,7738.96,100,,,case rate,100% PEIA DRG rate,35330.51,100,,,case rate,100% The Health Plan DRG rate,7738.96,74363.63,
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITHOUT CC/MCC",512,MS-DRG,,,,,Inpatient,,,,,,50955.85,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,50955.85,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,18529.4,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,7152.51,102,,,case rate,102% WV Medicaid DRG rate,30573.51,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,6536.74,100,,,case rate,100% PEIA with CHIP DRG base rate,30408.83,100,,,case rate,100% Highmark ACA DRG rate,38453.63,100,,,case rate,100% Highmark PPO DRG rate,38453.63,100,,,case rate,100% Highmark Trad DRG rate,7012.26,100,,,case rate,100% WV Medicaid DRG rate,18529.4,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,5560.14,100,,,case rate,100% PEIA DRG rate,28596.84,100,,,case rate,100% The Health Plan DRG rate,5560.14,50955.85,
"HAND OR WRIST PROCEDURES, EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITH CC/MCC",513,MS-DRG,,,,,Inpatient,,,,,,41364.6475,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,41364.6475,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,15041.69,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,5675.57,102,,,case rate,102% WV Medicaid DRG rate,24818.7885,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,5186.95,100,,,case rate,100% PEIA with CHIP DRG base rate,30544.5,100,,,case rate,100% Highmark ACA DRG rate,38625.19,100,,,case rate,100% Highmark PPO DRG rate,38625.19,100,,,case rate,100% Highmark Trad DRG rate,5564.28,100,,,case rate,100% WV Medicaid DRG rate,15041.69,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,4412.02,100,,,case rate,100% PEIA DRG rate,28724.43,100,,,case rate,100% The Health Plan DRG rate,4412.02,41364.6475,
"HAND OR WRIST PROCEDURES, EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITHOUT CC/MCC",514,MS-DRG,,,,,Inpatient,,,,,,41042.7875,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,41042.7875,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,14924.65,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,5113.58,102,,,case rate,102% WV Medicaid DRG rate,24625.6725,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,4673.35,100,,,case rate,100% PEIA with CHIP DRG base rate,19624.98,100,,,case rate,100% Highmark ACA DRG rate,24816.86,100,,,case rate,100% Highmark PPO DRG rate,24816.86,100,,,case rate,100% Highmark Trad DRG rate,5013.31,100,,,case rate,100% WV Medicaid DRG rate,14924.65,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,3975.14,100,,,case rate,100% PEIA DRG rate,18455.58,100,,,case rate,100% The Health Plan DRG rate,3975.14,41042.7875,
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH MCC,515,MS-DRG,,,,,Inpatient,,,,,,26590.2175,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,26590.2175,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,9669.17,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,17619.44,102,,,case rate,102% WV Medicaid DRG rate,15954.1305,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,16102.57,100,,,case rate,100% PEIA with CHIP DRG base rate,59572.14,100,,,case rate,100% Highmark ACA DRG rate,75332.22,100,,,case rate,100% Highmark PPO DRG rate,75332.22,100,,,case rate,100% Highmark Trad DRG rate,17273.95,100,,,case rate,100% WV Medicaid DRG rate,9669.17,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,13696.82,100,,,case rate,100% PEIA DRG rate,56022.38,100,,,case rate,100% The Health Plan DRG rate,9669.17,75332.22,
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH CC,516,MS-DRG,,,,,Inpatient,,,,,,80277.9725,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,80277.9725,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,29191.99,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,13716.74,102,,,case rate,102% WV Medicaid DRG rate,48166.7835,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,12535.85,100,,,case rate,100% PEIA with CHIP DRG base rate,38454.79,100,,,case rate,100% Highmark ACA DRG rate,48628.18,100,,,case rate,100% Highmark PPO DRG rate,48628.18,100,,,case rate,100% Highmark Trad DRG rate,13447.77,100,,,case rate,100% WV Medicaid DRG rate,29191.99,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,10662.98,100,,,case rate,100% PEIA DRG rate,36163.36,100,,,case rate,100% The Health Plan DRG rate,10662.98,80277.9725,
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITHOUT CC/MCC,517,MS-DRG,,,,,Inpatient,,,,,,52366.8475,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,52366.8475,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,19042.49,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,11034.71,102,,,case rate,102% WV Medicaid DRG rate,31420.1085,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,10084.72,100,,,case rate,100% PEIA with CHIP DRG base rate,28158.98,100,,,case rate,100% Highmark ACA DRG rate,35608.56,100,,,case rate,100% Highmark PPO DRG rate,35608.56,100,,,case rate,100% Highmark Trad DRG rate,10818.34,100,,,case rate,100% WV Medicaid DRG rate,19042.49,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,8578.05,100,,,case rate,100% PEIA DRG rate,26481.05,100,,,case rate,100% The Health Plan DRG rate,8578.05,52366.8475,
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH MCC OR DISC DEVICE OR NEUROSTIMULATOR,518,MS-DRG,,,,,Inpatient,,,,,,38877.3275,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,38877.3275,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,14137.21,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,17594.04,102,,,case rate,102% WV Medicaid DRG rate,23326.3965,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,16079.35,100,,,case rate,100% PEIA with CHIP DRG base rate,68810.87,100,,,case rate,100% Highmark ACA DRG rate,87015.09,100,,,case rate,100% Highmark PPO DRG rate,87015.09,100,,,case rate,100% Highmark Trad DRG rate,17249.04,100,,,case rate,100% WV Medicaid DRG rate,14137.21,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,13677.07,100,,,case rate,100% PEIA DRG rate,64710.59,100,,,case rate,100% The Health Plan DRG rate,13677.07,87015.09,
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH CC,519,MS-DRG,,,,,Inpatient,,,,,,95981.93,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,95981.93,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,34902.52,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,12395.34,102,,,case rate,102% WV Medicaid DRG rate,57589.158,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,11328.21,100,,,case rate,100% PEIA with CHIP DRG base rate,37094.33,100,,,case rate,100% Highmark ACA DRG rate,46907.8,100,,,case rate,100% Highmark PPO DRG rate,46907.8,100,,,case rate,100% Highmark Trad DRG rate,12152.28,100,,,case rate,100% WV Medicaid DRG rate,34902.52,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,9635.76,100,,,case rate,100% PEIA DRG rate,34883.97,100,,,case rate,100% The Health Plan DRG rate,9635.76,95981.93,
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITHOUT CC/MCC,520,MS-DRG,,,,,Inpatient,,,,,,51478.57,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,51478.57,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,18719.48,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,7513.5,102,,,case rate,102% WV Medicaid DRG rate,30887.142,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,6866.65,100,,,case rate,100% PEIA with CHIP DRG base rate,26973.75,100,,,case rate,100% Highmark ACA DRG rate,34109.78,100,,,case rate,100% Highmark PPO DRG rate,34109.78,100,,,case rate,100% Highmark Trad DRG rate,7366.17,100,,,case rate,100% WV Medicaid DRG rate,18719.48,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,5840.77,100,,,case rate,100% PEIA DRG rate,25366.45,100,,,case rate,100% The Health Plan DRG rate,5840.77,51478.57,
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITH MCC,521,MS-DRG,,,,,Inpatient,,,,,,38102.35,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,38102.35,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,13855.4,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,20051.9,102,,,case rate,102% WV Medicaid DRG rate,22861.41,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,18325.6,100,,,case rate,100% PEIA with CHIP DRG base rate,56419.71,100,,,case rate,100% Highmark ACA DRG rate,71345.8,100,,,case rate,100% Highmark PPO DRG rate,71345.8,100,,,case rate,100% Highmark Trad DRG rate,19658.7,100,,,case rate,100% WV Medicaid DRG rate,13855.4,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,15587.73,100,,,case rate,100% PEIA DRG rate,53057.79,100,,,case rate,100% The Health Plan DRG rate,13855.4,71345.8,
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITHOUT MCC,522,MS-DRG,,,,,Inpatient,,,,,,77739.255,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,77739.255,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,28268.82,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,9532.37,102,,,case rate,102% WV Medicaid DRG rate,46643.553,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,8711.72,100,,,case rate,100% PEIA with CHIP DRG base rate,39800.18,100,,,case rate,100% Highmark ACA DRG rate,50329.5,100,,,case rate,100% Highmark PPO DRG rate,50329.5,100,,,case rate,100% Highmark Trad DRG rate,9345.45,100,,,case rate,100% WV Medicaid DRG rate,28268.82,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,7410.18,100,,,case rate,100% PEIA DRG rate,37428.59,100,,,case rate,100% The Health Plan DRG rate,7410.18,77739.255,
FRACTURES OF FEMUR WITH MCC,533,MS-DRG,,,,,Inpatient,,,,,,55948.475,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,55948.475,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,20344.9,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,9473.1,102,,,case rate,102% WV Medicaid DRG rate,33569.085,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,8657.55,100,,,case rate,100% PEIA with CHIP DRG base rate,30740.47,100,,,case rate,100% Highmark ACA DRG rate,38873,100,,,case rate,100% Highmark PPO DRG rate,38873,100,,,case rate,100% Highmark Trad DRG rate,9287.34,100,,,case rate,100% WV Medicaid DRG rate,20344.9,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,7364.1,100,,,case rate,100% PEIA DRG rate,28908.72,100,,,case rate,100% The Health Plan DRG rate,7364.1,55948.475,
FRACTURES OF FEMUR WITHOUT MCC,534,MS-DRG,,,,,Inpatient,,,,,,36724.7375,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,36724.7375,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,13354.45,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,7254.57,102,,,case rate,102% WV Medicaid DRG rate,22034.8425,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,6630.01,100,,,case rate,100% PEIA with CHIP DRG base rate,15262.83,100,,,case rate,100% Highmark ACA DRG rate,19300.68,100,,,case rate,100% Highmark PPO DRG rate,19300.68,100,,,case rate,100% Highmark Trad DRG rate,7112.31,100,,,case rate,100% WV Medicaid DRG rate,13354.45,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,5639.48,100,,,case rate,100% PEIA DRG rate,14353.35,100,,,case rate,100% The Health Plan DRG rate,5639.48,36724.7375,
FRACTURES OF HIP AND PELVIS WITH MCC,535,MS-DRG,,,,,Inpatient,,,,,,20493.0275,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,20493.0275,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,7452.01,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,8564.83,102,,,case rate,102% WV Medicaid DRG rate,12295.8165,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,7827.47,100,,,case rate,100% PEIA with CHIP DRG base rate,24433.72,100,,,case rate,100% Highmark ACA DRG rate,30897.77,100,,,case rate,100% Highmark PPO DRG rate,30897.77,100,,,case rate,100% Highmark Trad DRG rate,8396.88,100,,,case rate,100% WV Medicaid DRG rate,7452.01,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,6658.04,100,,,case rate,100% PEIA DRG rate,22977.77,100,,,case rate,100% The Health Plan DRG rate,6658.04,30897.77,
FRACTURES OF HIP AND PELVIS WITHOUT MCC,536,MS-DRG,,,,,Inpatient,,,,,,33202.4,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,33202.4,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,12073.6,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,5732.17,102,,,case rate,102% WV Medicaid DRG rate,19921.44,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,5238.68,100,,,case rate,100% PEIA with CHIP DRG base rate,14831.33,100,,,case rate,100% Highmark ACA DRG rate,18755.02,100,,,case rate,100% Highmark PPO DRG rate,18755.02,100,,,case rate,100% Highmark Trad DRG rate,5619.77,100,,,case rate,100% WV Medicaid DRG rate,12073.6,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,4456.01,100,,,case rate,100% PEIA DRG rate,13947.56,100,,,case rate,100% The Health Plan DRG rate,4456.01,33202.4,
"SPRAINS, STRAINS, AND DISLOCATIONS OF HIP, PELVIS AND THIGH WITH CC/MCC",537,MS-DRG,,,,,Inpatient,,,,,,20009.0275,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,20009.0275,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,7276.01,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,6597.21,102,,,case rate,102% WV Medicaid DRG rate,12005.4165,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,6029.25,100,,,case rate,100% PEIA with CHIP DRG base rate,18221.18,100,,,case rate,100% Highmark ACA DRG rate,23041.68,100,,,case rate,100% Highmark PPO DRG rate,23041.68,100,,,case rate,100% Highmark Trad DRG rate,6467.85,100,,,case rate,100% WV Medicaid DRG rate,7276.01,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,5128.47,100,,,case rate,100% PEIA DRG rate,17135.42,100,,,case rate,100% The Health Plan DRG rate,5128.47,23041.68,
"SPRAINS, STRAINS, AND DISLOCATIONS OF HIP, PELVIS AND THIGH WITHOUT CC/MCC",538,MS-DRG,,,,,Inpatient,,,,,,25578.355,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,25578.355,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,9301.22,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,4470.49,102,,,case rate,102% WV Medicaid DRG rate,15347.013,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,4085.62,100,,,case rate,100% PEIA with CHIP DRG base rate,13361.57,100,,,case rate,100% Highmark ACA DRG rate,16896.43,100,,,case rate,100% Highmark PPO DRG rate,16896.43,100,,,case rate,100% Highmark Trad DRG rate,4382.82,100,,,case rate,100% WV Medicaid DRG rate,9301.22,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,3475.22,100,,,case rate,100% PEIA DRG rate,12565.39,100,,,case rate,100% The Health Plan DRG rate,3475.22,25578.355,
OSTEOMYELITIS WITH MCC,539,MS-DRG,,,,,Inpatient,,,,,,17925.9575,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,17925.9575,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,6518.53,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,8620.09,102,,,case rate,102% WV Medicaid DRG rate,10755.5745,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,7877.98,100,,,case rate,100% PEIA with CHIP DRG base rate,37392.05,100,,,case rate,100% Highmark ACA DRG rate,47284.28,100,,,case rate,100% Highmark PPO DRG rate,47284.28,100,,,case rate,100% Highmark Trad DRG rate,8451.06,100,,,case rate,100% WV Medicaid DRG rate,6518.53,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,6701,100,,,case rate,100% PEIA DRG rate,35163.95,100,,,case rate,100% The Health Plan DRG rate,6518.53,47284.28,
OSTEOMYELITIS WITH CC,540,MS-DRG,,,,,Inpatient,,,,,,51390.9825,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,51390.9825,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,18687.63,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,6289.7,102,,,case rate,102% WV Medicaid DRG rate,30834.5895,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,5748.21,100,,,case rate,100% PEIA with CHIP DRG base rate,24461.98,100,,,case rate,100% Highmark ACA DRG rate,30933.51,100,,,case rate,100% Highmark PPO DRG rate,30933.51,100,,,case rate,100% Highmark Trad DRG rate,6166.36,100,,,case rate,100% WV Medicaid DRG rate,18687.63,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,4889.42,100,,,case rate,100% PEIA DRG rate,23004.35,100,,,case rate,100% The Health Plan DRG rate,4889.42,51390.9825,
OSTEOMYELITIS WITHOUT CC/MCC,541,MS-DRG,,,,,Inpatient,,,,,,34672.66,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,34672.66,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,12608.24,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,4241.86,102,,,case rate,102% WV Medicaid DRG rate,20803.596,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,3876.67,100,,,case rate,100% PEIA with CHIP DRG base rate,16165.41,100,,,case rate,100% Highmark ACA DRG rate,20442.04,100,,,case rate,100% Highmark PPO DRG rate,20442.04,100,,,case rate,100% Highmark Trad DRG rate,4158.68,100,,,case rate,100% WV Medicaid DRG rate,12608.24,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,3297.49,100,,,case rate,100% PEIA DRG rate,15202.15,100,,,case rate,100% The Health Plan DRG rate,3297.49,34672.66,
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH MCC,542,MS-DRG,,,,,Inpatient,,,,,,21062.1125,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,21062.1125,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,7658.95,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,12803.57,102,,,case rate,102% WV Medicaid DRG rate,12637.2675,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,11701.29,100,,,case rate,100% PEIA with CHIP DRG base rate,34363.98,100,,,case rate,100% Highmark ACA DRG rate,43455.12,100,,,case rate,100% Highmark PPO DRG rate,43455.12,100,,,case rate,100% Highmark Trad DRG rate,12552.5,100,,,case rate,100% WV Medicaid DRG rate,7658.95,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,9953.1,100,,,case rate,100% PEIA DRG rate,32316.31,100,,,case rate,100% The Health Plan DRG rate,7658.95,43455.12,
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH CC,543,MS-DRG,,,,,Inpatient,,,,,,47067.8725,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,47067.8725,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,17115.59,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,5704.54,102,,,case rate,102% WV Medicaid DRG rate,28240.7235,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,5213.43,100,,,case rate,100% PEIA with CHIP DRG base rate,20552.06,100,,,case rate,100% Highmark ACA DRG rate,25989.2,100,,,case rate,100% Highmark PPO DRG rate,25989.2,100,,,case rate,100% Highmark Trad DRG rate,5592.68,100,,,case rate,100% WV Medicaid DRG rate,17115.59,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,4434.53,100,,,case rate,100% PEIA DRG rate,19327.41,100,,,case rate,100% The Health Plan DRG rate,4434.53,47067.8725,
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITHOUT CC/MCC,544,MS-DRG,,,,,Inpatient,,,,,,28039.88,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,28039.88,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,10196.32,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,5167.95,102,,,case rate,102% WV Medicaid DRG rate,16823.928,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,4723.04,100,,,case rate,100% PEIA with CHIP DRG base rate,14462,100,,,case rate,100% Highmark ACA DRG rate,18287.99,100,,,case rate,100% Highmark PPO DRG rate,18287.99,100,,,case rate,100% Highmark Trad DRG rate,5066.62,100,,,case rate,100% WV Medicaid DRG rate,10196.32,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,4017.41,100,,,case rate,100% PEIA DRG rate,13600.25,100,,,case rate,100% The Health Plan DRG rate,4017.41,28039.88,
CONNECTIVE TISSUE DISORDERS WITH MCC,545,MS-DRG,,,,,Inpatient,,,,,,20034.74,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,20034.74,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,7285.36,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,15758.34,102,,,case rate,102% WV Medicaid DRG rate,12020.844,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,14401.69,100,,,case rate,100% PEIA with CHIP DRG base rate,46979.37,100,,,case rate,100% Highmark ACA DRG rate,59407.97,100,,,case rate,100% Highmark PPO DRG rate,59407.97,100,,,case rate,100% Highmark Trad DRG rate,15449.34,100,,,case rate,100% WV Medicaid DRG rate,7285.36,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,12250.05,100,,,case rate,100% PEIA DRG rate,44179.98,100,,,case rate,100% The Health Plan DRG rate,7285.36,59407.97,
CONNECTIVE TISSUE DISORDERS WITH CC,546,MS-DRG,,,,,Inpatient,,,,,,64592.1925,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,64592.1925,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,23488.07,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,7558.07,102,,,case rate,102% WV Medicaid DRG rate,38755.3155,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,6907.38,100,,,case rate,100% PEIA with CHIP DRG base rate,22598.41,100,,,case rate,100% Highmark ACA DRG rate,28576.92,100,,,case rate,100% Highmark PPO DRG rate,28576.92,100,,,case rate,100% Highmark Trad DRG rate,7409.86,100,,,case rate,100% WV Medicaid DRG rate,23488.07,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,5875.41,100,,,case rate,100% PEIA DRG rate,21251.82,100,,,case rate,100% The Health Plan DRG rate,5875.41,64592.1925,
CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,547,MS-DRG,,,,,Inpatient,,,,,,31042.11,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,31042.11,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,11288.04,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,3486.01,102,,,case rate,102% WV Medicaid DRG rate,18625.266,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,3185.89,100,,,case rate,100% PEIA with CHIP DRG base rate,15326.9,100,,,case rate,100% Highmark ACA DRG rate,19381.7,100,,,case rate,100% Highmark PPO DRG rate,19381.7,100,,,case rate,100% Highmark Trad DRG rate,3417.65,100,,,case rate,100% WV Medicaid DRG rate,11288.04,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,2709.92,100,,,case rate,100% PEIA DRG rate,14413.6,100,,,case rate,100% The Health Plan DRG rate,2709.92,31042.11,
SEPTIC ARTHRITIS WITH MCC,548,MS-DRG,,,,,Inpatient,,,,,,23554.52,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,23554.52,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,8565.28,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,14009.54,102,,,case rate,102% WV Medicaid DRG rate,14132.712,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,12803.44,100,,,case rate,100% PEIA with CHIP DRG base rate,36740.08,100,,,case rate,100% Highmark ACA DRG rate,46459.83,100,,,case rate,100% Highmark PPO DRG rate,46459.83,100,,,case rate,100% Highmark Trad DRG rate,13734.83,100,,,case rate,100% WV Medicaid DRG rate,8565.28,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,10890.59,100,,,case rate,100% PEIA DRG rate,34550.83,100,,,case rate,100% The Health Plan DRG rate,8565.28,46459.83,
SEPTIC ARTHRITIS WITH CC,549,MS-DRG,,,,,Inpatient,,,,,,49949.1025,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,49949.1025,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,18163.31,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,6041.91,102,,,case rate,102% WV Medicaid DRG rate,29969.4615,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,5521.75,100,,,case rate,100% PEIA with CHIP DRG base rate,22728.43,100,,,case rate,100% Highmark ACA DRG rate,28741.33,100,,,case rate,100% Highmark PPO DRG rate,28741.33,100,,,case rate,100% Highmark Trad DRG rate,5923.43,100,,,case rate,100% WV Medicaid DRG rate,18163.31,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,4696.8,100,,,case rate,100% PEIA DRG rate,21374.09,100,,,case rate,100% The Health Plan DRG rate,4696.8,49949.1025,
SEPTIC ARTHRITIS WITHOUT CC/MCC,550,MS-DRG,,,,,Inpatient,,,,,,31199.2175,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,31199.2175,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,11345.17,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,4888.97,102,,,case rate,102% WV Medicaid DRG rate,18719.5305,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,4468.07,100,,,case rate,100% PEIA with CHIP DRG base rate,17350.63,100,,,case rate,100% Highmark ACA DRG rate,21940.82,100,,,case rate,100% Highmark PPO DRG rate,21940.82,100,,,case rate,100% Highmark Trad DRG rate,4793.1,100,,,case rate,100% WV Medicaid DRG rate,11345.17,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,3800.53,100,,,case rate,100% PEIA DRG rate,16316.75,100,,,case rate,100% The Health Plan DRG rate,3800.53,31199.2175,
MEDICAL BACK PROBLEMS WITH MCC,551,MS-DRG,,,,,Inpatient,,,,,,26991.9375,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,26991.9375,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,9815.25,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,9923.67,102,,,case rate,102% WV Medicaid DRG rate,16195.1625,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,9069.33,100,,,case rate,100% PEIA with CHIP DRG base rate,32068.9,100,,,case rate,100% Highmark ACA DRG rate,40552.87,100,,,case rate,100% Highmark PPO DRG rate,40552.87,100,,,case rate,100% Highmark Trad DRG rate,9729.08,100,,,case rate,100% WV Medicaid DRG rate,9815.25,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,7714.36,100,,,case rate,100% PEIA DRG rate,30157.99,100,,,case rate,100% The Health Plan DRG rate,7714.36,40552.87,
MEDICAL BACK PROBLEMS WITHOUT MCC,552,MS-DRG,,,,,Inpatient,,,,,,43087.165,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,43087.165,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,15668.06,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,9032.33,102,,,case rate,102% WV Medicaid DRG rate,25852.299,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,8254.73,100,,,case rate,100% PEIA with CHIP DRG base rate,18207.99,100,,,case rate,100% Highmark ACA DRG rate,23025,100,,,case rate,100% Highmark PPO DRG rate,23025,100,,,case rate,100% Highmark Trad DRG rate,8855.22,100,,,case rate,100% WV Medicaid DRG rate,15668.06,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,7021.46,100,,,case rate,100% PEIA DRG rate,17123.02,100,,,case rate,100% The Health Plan DRG rate,7021.46,43087.165,
BONE DISEASES AND ARTHROPATHIES WITH MCC,553,MS-DRG,,,,,Inpatient,,,,,,24731.19,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,24731.19,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,8993.16,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,11188.02,102,,,case rate,102% WV Medicaid DRG rate,14838.714,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,10224.83,100,,,case rate,100% PEIA with CHIP DRG base rate,25466.31,100,,,case rate,100% Highmark ACA DRG rate,32203.54,100,,,case rate,100% Highmark PPO DRG rate,32203.54,100,,,case rate,100% Highmark Trad DRG rate,10968.64,100,,,case rate,100% WV Medicaid DRG rate,8993.16,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,8697.23,100,,,case rate,100% PEIA DRG rate,23948.84,100,,,case rate,100% The Health Plan DRG rate,8697.23,32203.54,
BONE DISEASES AND ARTHROPATHIES WITHOUT MCC,554,MS-DRG,,,,,Inpatient,,,,,,34139.655,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,34139.655,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,12414.42,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,6612.36,102,,,case rate,102% WV Medicaid DRG rate,20483.793,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,6043.1,100,,,case rate,100% PEIA with CHIP DRG base rate,15485.18,100,,,case rate,100% Highmark ACA DRG rate,19581.85,100,,,case rate,100% Highmark PPO DRG rate,19581.85,100,,,case rate,100% Highmark Trad DRG rate,6482.7,100,,,case rate,100% WV Medicaid DRG rate,12414.42,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,5140.25,100,,,case rate,100% PEIA DRG rate,14562.45,100,,,case rate,100% The Health Plan DRG rate,5140.25,34139.655,
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,555,MS-DRG,,,,,Inpatient,,,,,,21118.7075,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,21118.7075,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,7679.53,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,7523.3,102,,,case rate,102% WV Medicaid DRG rate,12671.2245,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,6875.61,100,,,case rate,100% PEIA with CHIP DRG base rate,26361.36,100,,,case rate,100% Highmark ACA DRG rate,33335.37,100,,,case rate,100% Highmark PPO DRG rate,33335.37,100,,,case rate,100% Highmark Trad DRG rate,7375.78,100,,,case rate,100% WV Medicaid DRG rate,7679.53,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,5848.39,100,,,case rate,100% PEIA DRG rate,24790.55,100,,,case rate,100% The Health Plan DRG rate,5848.39,33335.37,
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT MCC,556,MS-DRG,,,,,Inpatient,,,,,,34276.11,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,34276.11,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,12464.04,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,3796.64,102,,,case rate,102% WV Medicaid DRG rate,20565.666,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,3469.78,100,,,case rate,100% PEIA with CHIP DRG base rate,15534.17,100,,,case rate,100% Highmark ACA DRG rate,19643.8,100,,,case rate,100% Highmark PPO DRG rate,19643.8,100,,,case rate,100% Highmark Trad DRG rate,3722.19,100,,,case rate,100% WV Medicaid DRG rate,12464.04,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,2951.39,100,,,case rate,100% PEIA DRG rate,14608.52,100,,,case rate,100% The Health Plan DRG rate,2951.39,34276.11,
"TENDONITIS, MYOSITIS AND BURSITIS WITH MCC",557,MS-DRG,,,,,Inpatient,,,,,,20804.63,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,20804.63,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,7565.32,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,5004.39,102,,,case rate,102% WV Medicaid DRG rate,12482.778,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,4573.56,100,,,case rate,100% PEIA with CHIP DRG base rate,29334.78,100,,,case rate,100% Highmark ACA DRG rate,37095.43,100,,,case rate,100% Highmark PPO DRG rate,37095.43,100,,,case rate,100% Highmark Trad DRG rate,4906.26,100,,,case rate,100% WV Medicaid DRG rate,7565.32,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,3890.26,100,,,case rate,100% PEIA DRG rate,27586.79,100,,,case rate,100% The Health Plan DRG rate,3890.26,37095.43,
"TENDONITIS, MYOSITIS AND BURSITIS WITHOUT MCC",558,MS-DRG,,,,,Inpatient,,,,,,36868.975,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,36868.975,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,13406.9,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,3832.74,102,,,case rate,102% WV Medicaid DRG rate,22121.385,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,3502.77,100,,,case rate,100% PEIA with CHIP DRG base rate,16551.69,100,,,case rate,100% Highmark ACA DRG rate,20930.52,100,,,case rate,100% Highmark PPO DRG rate,20930.52,100,,,case rate,100% Highmark Trad DRG rate,3757.58,100,,,case rate,100% WV Medicaid DRG rate,13406.9,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,2979.45,100,,,case rate,100% PEIA DRG rate,15565.41,100,,,case rate,100% The Health Plan DRG rate,2979.45,36868.975,
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC",559,MS-DRG,,,,,Inpatient,,,,,,22375.265,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,22375.265,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,8136.46,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,15318.47,102,,,case rate,102% WV Medicaid DRG rate,13425.159,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,13999.68,100,,,case rate,100% PEIA with CHIP DRG base rate,34868.97,100,,,case rate,100% Highmark ACA DRG rate,44093.71,100,,,case rate,100% Highmark PPO DRG rate,44093.71,100,,,case rate,100% Highmark Trad DRG rate,15018.09,100,,,case rate,100% WV Medicaid DRG rate,8136.46,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,11908.11,100,,,case rate,100% PEIA DRG rate,32791.21,100,,,case rate,100% The Health Plan DRG rate,8136.46,44093.71,
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC",560,MS-DRG,,,,,Inpatient,,,,,,45960.695,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,45960.695,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,16712.98,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,8825.54,102,,,case rate,102% WV Medicaid DRG rate,27576.417,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,8065.74,100,,,case rate,100% PEIA with CHIP DRG base rate,21332.16,100,,,case rate,100% Highmark ACA DRG rate,26975.68,100,,,case rate,100% Highmark PPO DRG rate,26975.68,100,,,case rate,100% Highmark Trad DRG rate,8652.49,100,,,case rate,100% WV Medicaid DRG rate,16712.98,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,6860.71,100,,,case rate,100% PEIA DRG rate,20061.03,100,,,case rate,100% The Health Plan DRG rate,6860.71,45960.695,
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC",561,MS-DRG,,,,,Inpatient,,,,,,28209.83,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,28209.83,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,10258.12,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,6344.07,102,,,case rate,102% WV Medicaid DRG rate,16925.898,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,5797.9,100,,,case rate,100% PEIA with CHIP DRG base rate,14701.31,100,,,case rate,100% Highmark ACA DRG rate,18590.61,100,,,case rate,100% Highmark PPO DRG rate,18590.61,100,,,case rate,100% Highmark Trad DRG rate,6219.67,100,,,case rate,100% WV Medicaid DRG rate,10258.12,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,4931.69,100,,,case rate,100% PEIA DRG rate,13825.29,100,,,case rate,100% The Health Plan DRG rate,4931.69,28209.83,
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITH MCC",562,MS-DRG,,,,,Inpatient,,,,,,20346.3425,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,20346.3425,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,7398.67,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,9657.16,102,,,case rate,102% WV Medicaid DRG rate,12207.8055,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,8825.76,100,,,case rate,100% PEIA with CHIP DRG base rate,28654.55,100,,,case rate,100% Highmark ACA DRG rate,36235.24,100,,,case rate,100% Highmark PPO DRG rate,36235.24,100,,,case rate,100% Highmark Trad DRG rate,9467.79,100,,,case rate,100% WV Medicaid DRG rate,7398.67,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,7507.18,100,,,case rate,100% PEIA DRG rate,26947.09,100,,,case rate,100% The Health Plan DRG rate,7398.67,36235.24,
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITHOUT MCC",563,MS-DRG,,,,,Inpatient,,,,,,37664.55,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,37664.55,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,13696.2,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,5963.92,102,,,case rate,102% WV Medicaid DRG rate,22598.73,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,5450.48,100,,,case rate,100% PEIA with CHIP DRG base rate,16875.79,100,,,case rate,100% Highmark ACA DRG rate,21340.36,100,,,case rate,100% Highmark PPO DRG rate,21340.36,100,,,case rate,100% Highmark Trad DRG rate,5846.97,100,,,case rate,100% WV Medicaid DRG rate,13696.2,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,4636.17,100,,,case rate,100% PEIA DRG rate,15870.2,100,,,case rate,100% The Health Plan DRG rate,4636.17,37664.55,
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH MCC,564,MS-DRG,,,,,Inpatient,,,,,,22174.4325,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,22174.4325,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,8063.43,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,7676.17,102,,,case rate,102% WV Medicaid DRG rate,13304.6595,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,7015.32,100,,,case rate,100% PEIA with CHIP DRG base rate,29430.88,100,,,case rate,100% Highmark ACA DRG rate,37216.95,100,,,case rate,100% Highmark PPO DRG rate,37216.95,100,,,case rate,100% Highmark Trad DRG rate,7525.65,100,,,case rate,100% WV Medicaid DRG rate,8063.43,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,5967.22,100,,,case rate,100% PEIA DRG rate,27677.16,100,,,case rate,100% The Health Plan DRG rate,5967.22,37216.95,
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH CC,565,MS-DRG,,,,,Inpatient,,,,,,39994.8175,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,39994.8175,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,14543.57,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,6548.63,102,,,case rate,102% WV Medicaid DRG rate,23996.8905,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,5984.85,100,,,case rate,100% PEIA with CHIP DRG base rate,18831.69,100,,,case rate,100% Highmark ACA DRG rate,23813.7,100,,,case rate,100% Highmark PPO DRG rate,23813.7,100,,,case rate,100% Highmark Trad DRG rate,6420.22,100,,,case rate,100% WV Medicaid DRG rate,14543.57,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,5090.71,100,,,case rate,100% PEIA DRG rate,17709.56,100,,,case rate,100% The Health Plan DRG rate,5090.71,39994.8175,
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITHOUT CC/MCC,566,MS-DRG,,,,,Inpatient,,,,,,25423.8325,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,25423.8325,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,9245.03,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,4707.13,102,,,case rate,102% WV Medicaid DRG rate,15254.2995,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,4301.89,100,,,case rate,100% PEIA with CHIP DRG base rate,14141.67,100,,,case rate,100% Highmark ACA DRG rate,17882.91,100,,,case rate,100% Highmark PPO DRG rate,17882.91,100,,,case rate,100% Highmark Trad DRG rate,4614.83,100,,,case rate,100% WV Medicaid DRG rate,9245.03,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,3659.18,100,,,case rate,100% PEIA DRG rate,13299,100,,,case rate,100% The Health Plan DRG rate,3659.18,25423.8325,
SKIN DEBRIDEMENT WITH MCC,570,MS-DRG,,,,,Inpatient,,,,,,19123.28,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,19123.28,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,6953.92,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,9219.07,102,,,case rate,102% WV Medicaid DRG rate,11473.968,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,8425.39,100,,,case rate,100% PEIA with CHIP DRG base rate,55063.01,100,,,case rate,100% Highmark ACA DRG rate,69630.18,100,,,case rate,100% Highmark PPO DRG rate,69630.18,100,,,case rate,100% Highmark Trad DRG rate,9038.29,100,,,case rate,100% WV Medicaid DRG rate,6953.92,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,7166.62,100,,,case rate,100% PEIA DRG rate,51781.94,100,,,case rate,100% The Health Plan DRG rate,6953.92,69630.18,
SKIN DEBRIDEMENT WITH CC,571,MS-DRG,,,,,Inpatient,,,,,,75110.31,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,75110.31,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,27312.84,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,6755.87,102,,,case rate,102% WV Medicaid DRG rate,45066.186,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,6174.25,100,,,case rate,100% PEIA with CHIP DRG base rate,31880.47,100,,,case rate,100% Highmark ACA DRG rate,40314.59,100,,,case rate,100% Highmark PPO DRG rate,40314.59,100,,,case rate,100% Highmark Trad DRG rate,6623.39,100,,,case rate,100% WV Medicaid DRG rate,27312.84,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,5251.81,100,,,case rate,100% PEIA DRG rate,29980.79,100,,,case rate,100% The Health Plan DRG rate,5251.81,75110.31,
SKIN DEBRIDEMENT WITHOUT CC/MCC,572,MS-DRG,,,,,Inpatient,,,,,,42448.6425,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,42448.6425,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,15435.87,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,4754.82,102,,,case rate,102% WV Medicaid DRG rate,25469.1855,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,4345.47,100,,,case rate,100% PEIA with CHIP DRG base rate,21473.48,100,,,case rate,100% Highmark ACA DRG rate,27154.39,100,,,case rate,100% Highmark PPO DRG rate,27154.39,100,,,case rate,100% Highmark Trad DRG rate,4661.58,100,,,case rate,100% WV Medicaid DRG rate,15435.87,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,3696.25,100,,,case rate,100% PEIA DRG rate,20193.93,100,,,case rate,100% The Health Plan DRG rate,3696.25,42448.6425,
SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITH MCC,573,MS-DRG,,,,,Inpatient,,,,,,30990.6575,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,30990.6575,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,11269.33,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,38989.18,102,,,case rate,102% WV Medicaid DRG rate,18594.3945,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,35632.55,100,,,case rate,100% PEIA with CHIP DRG base rate,117167.66,100,,,case rate,100% Highmark ACA DRG rate,148164.89,100,,,case rate,100% Highmark PPO DRG rate,148164.89,100,,,case rate,100% Highmark Trad DRG rate,38224.65,100,,,case rate,100% WV Medicaid DRG rate,11269.33,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,30309,100,,,case rate,100% PEIA DRG rate,110185.91,100,,,case rate,100% The Health Plan DRG rate,11269.33,148164.89,
SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITH CC,574,MS-DRG,,,,,Inpatient,,,,,,151155.3175,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,151155.3175,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,54965.57,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,12456.39,102,,,case rate,102% WV Medicaid DRG rate,90693.1905,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,11384.01,100,,,case rate,100% PEIA with CHIP DRG base rate,64175.49,100,,,case rate,100% Highmark ACA DRG rate,81153.4,100,,,case rate,100% Highmark PPO DRG rate,81153.4,100,,,case rate,100% Highmark Trad DRG rate,12212.14,100,,,case rate,100% WV Medicaid DRG rate,54965.57,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,9683.22,100,,,case rate,100% PEIA DRG rate,60351.42,100,,,case rate,100% The Health Plan DRG rate,9683.22,151155.3175,
SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITHOUT CC/MCC,575,MS-DRG,,,,,Inpatient,,,,,,92812.3075,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,92812.3075,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,33749.93,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,8954.79,102,,,case rate,102% WV Medicaid DRG rate,55687.3845,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,8183.86,100,,,case rate,100% PEIA with CHIP DRG base rate,38552.78,100,,,case rate,100% Highmark ACA DRG rate,48752.09,100,,,case rate,100% Highmark PPO DRG rate,48752.09,100,,,case rate,100% Highmark Trad DRG rate,8779.19,100,,,case rate,100% WV Medicaid DRG rate,33749.93,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,6961.18,100,,,case rate,100% PEIA DRG rate,36255.51,100,,,case rate,100% The Health Plan DRG rate,6961.18,92812.3075,
SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITH MCC,576,MS-DRG,,,,,Inpatient,,,,,,52773.7375,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,52773.7375,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,19190.45,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,37518.03,102,,,case rate,102% WV Medicaid DRG rate,31664.2425,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,34288.06,100,,,case rate,100% PEIA with CHIP DRG base rate,107086.65,100,,,case rate,100% Highmark ACA DRG rate,135416.91,100,,,case rate,100% Highmark PPO DRG rate,135416.91,100,,,case rate,100% Highmark Trad DRG rate,36782.35,100,,,case rate,100% WV Medicaid DRG rate,19190.45,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,29165.38,100,,,case rate,100% PEIA DRG rate,100705.61,100,,,case rate,100% The Health Plan DRG rate,19190.45,135416.91,
SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITH CC,577,MS-DRG,,,,,Inpatient,,,,,,145452.0375,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,145452.0375,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,52891.65,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,17392.15,102,,,case rate,102% WV Medicaid DRG rate,87271.2225,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,15894.84,100,,,case rate,100% PEIA with CHIP DRG base rate,49916.99,100,,,case rate,100% Highmark ACA DRG rate,63122.75,100,,,case rate,100% Highmark PPO DRG rate,63122.75,100,,,case rate,100% Highmark Trad DRG rate,17051.12,100,,,case rate,100% WV Medicaid DRG rate,52891.65,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,13520.13,100,,,case rate,100% PEIA DRG rate,46942.56,100,,,case rate,100% The Health Plan DRG rate,13520.13,145452.0375,
SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITHOUT CC/MCC,578,MS-DRG,,,,,Inpatient,,,,,,67427.0575,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,67427.0575,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,24518.93,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,11373.42,102,,,case rate,102% WV Medicaid DRG rate,40456.2345,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,10394.27,100,,,case rate,100% PEIA with CHIP DRG base rate,30346.65,100,,,case rate,100% Highmark ACA DRG rate,38374.99,100,,,case rate,100% Highmark PPO DRG rate,38374.99,100,,,case rate,100% Highmark Trad DRG rate,11150.4,100,,,case rate,100% WV Medicaid DRG rate,24518.93,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,8841.35,100,,,case rate,100% PEIA DRG rate,28538.37,100,,,case rate,100% The Health Plan DRG rate,8841.35,67427.0575,
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH MCC",579,MS-DRG,,,,,Inpatient,,,,,,44093.995,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,44093.995,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,16034.18,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,10881.41,102,,,case rate,102% WV Medicaid DRG rate,26456.397,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,9944.61,100,,,case rate,100% PEIA with CHIP DRG base rate,62977.07,100,,,case rate,100% Highmark ACA DRG rate,79637.94,100,,,case rate,100% Highmark PPO DRG rate,79637.94,100,,,case rate,100% Highmark Trad DRG rate,10668.03,100,,,case rate,100% WV Medicaid DRG rate,16034.18,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,8458.87,100,,,case rate,100% PEIA DRG rate,59224.42,100,,,case rate,100% The Health Plan DRG rate,8458.87,79637.94,
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH CC",580,MS-DRG,,,,,Inpatient,,,,,,81150.85,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,81150.85,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,29509.4,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,8548.78,102,,,case rate,102% WV Medicaid DRG rate,48690.51,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,7812.81,100,,,case rate,100% PEIA with CHIP DRG base rate,32911.18,100,,,case rate,100% Highmark ACA DRG rate,41617.98,100,,,case rate,100% Highmark PPO DRG rate,41617.98,100,,,case rate,100% Highmark Trad DRG rate,8381.15,100,,,case rate,100% WV Medicaid DRG rate,29509.4,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,6645.57,100,,,case rate,100% PEIA DRG rate,30950.08,100,,,case rate,100% The Health Plan DRG rate,6645.57,81150.85,
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITHOUT CC/MCC",581,MS-DRG,,,,,Inpatient,,,,,,44704.1925,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,44704.1925,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,16256.07,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,6145.3,102,,,case rate,102% WV Medicaid DRG rate,26822.5155,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,5616.25,100,,,case rate,100% PEIA with CHIP DRG base rate,25375.87,100,,,case rate,100% Highmark ACA DRG rate,32089.17,100,,,case rate,100% Highmark PPO DRG rate,32089.17,100,,,case rate,100% Highmark Trad DRG rate,6024.8,100,,,case rate,100% WV Medicaid DRG rate,16256.07,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,4777.17,100,,,case rate,100% PEIA DRG rate,23863.78,100,,,case rate,100% The Health Plan DRG rate,4777.17,44704.1925,
MASTECTOMY FOR MALIGNANCY WITH CC/MCC,582,MS-DRG,,,,,Inpatient,,,,,,36343.6975,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,36343.6975,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,13215.89,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,12849.92,102,,,case rate,102% WV Medicaid DRG rate,21806.2185,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,11743.65,100,,,case rate,100% PEIA with CHIP DRG base rate,31413.17,100,,,case rate,100% Highmark ACA DRG rate,39723.66,100,,,case rate,100% Highmark PPO DRG rate,39723.66,100,,,case rate,100% Highmark Trad DRG rate,12597.95,100,,,case rate,100% WV Medicaid DRG rate,13215.89,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,9989.14,100,,,case rate,100% PEIA DRG rate,29541.33,100,,,case rate,100% The Health Plan DRG rate,9989.14,39723.66,
MASTECTOMY FOR MALIGNANCY WITHOUT CC/MCC,583,MS-DRG,,,,,Inpatient,,,,,,49817.79,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,49817.79,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,18115.56,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,10034.64,102,,,case rate,102% WV Medicaid DRG rate,29890.674,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,9170.74,100,,,case rate,100% PEIA with CHIP DRG base rate,28677.16,100,,,case rate,100% Highmark ACA DRG rate,36263.83,100,,,case rate,100% Highmark PPO DRG rate,36263.83,100,,,case rate,100% Highmark Trad DRG rate,9837.87,100,,,case rate,100% WV Medicaid DRG rate,18115.56,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,7800.62,100,,,case rate,100% PEIA DRG rate,26968.36,100,,,case rate,100% The Health Plan DRG rate,7800.62,49817.79,
"BREAST BIOPSY, LOCAL EXCISION AND OTHER BREAST PROCEDURES WITH CC/MCC",584,MS-DRG,,,,,Inpatient,,,,,,38900.5375,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,38900.5375,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,14145.65,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,6676.54,102,,,case rate,102% WV Medicaid DRG rate,23340.3225,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,6101.75,100,,,case rate,100% PEIA with CHIP DRG base rate,36905.9,100,,,case rate,100% Highmark ACA DRG rate,46669.52,100,,,case rate,100% Highmark PPO DRG rate,46669.52,100,,,case rate,100% Highmark Trad DRG rate,6545.62,100,,,case rate,100% WV Medicaid DRG rate,14145.65,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,5190.14,100,,,case rate,100% PEIA DRG rate,34706.76,100,,,case rate,100% The Health Plan DRG rate,5190.14,46669.52,
"BREAST BIOPSY, LOCAL EXCISION AND OTHER BREAST PROCEDURES WITHOUT CC/MCC",585,MS-DRG,,,,,Inpatient,,,,,,54993.2075,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,54993.2075,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,19997.53,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,5656.41,102,,,case rate,102% WV Medicaid DRG rate,32995.9245,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,5169.44,100,,,case rate,100% PEIA with CHIP DRG base rate,31731.61,100,,,case rate,100% Highmark ACA DRG rate,40126.35,100,,,case rate,100% Highmark PPO DRG rate,40126.35,100,,,case rate,100% Highmark Trad DRG rate,5545.49,100,,,case rate,100% WV Medicaid DRG rate,19997.53,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,4397.12,100,,,case rate,100% PEIA DRG rate,29840.8,100,,,case rate,100% The Health Plan DRG rate,4397.12,54993.2075,
SKIN ULCERS WITH MCC,592,MS-DRG,,,,,Inpatient,,,,,,47405.1875,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,47405.1875,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,17238.25,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,8691.4,102,,,case rate,102% WV Medicaid DRG rate,28443.1125,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,7943.15,100,,,case rate,100% PEIA with CHIP DRG base rate,39383.75,100,,,case rate,100% Highmark ACA DRG rate,49802.9,100,,,case rate,100% Highmark PPO DRG rate,49802.9,100,,,case rate,100% Highmark Trad DRG rate,8520.97,100,,,case rate,100% WV Medicaid DRG rate,17238.25,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,6756.43,100,,,case rate,100% PEIA DRG rate,37036.97,100,,,case rate,100% The Health Plan DRG rate,6756.43,49802.9,
SKIN ULCERS WITH CC,593,MS-DRG,,,,,Inpatient,,,,,,45934.955,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,45934.955,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,16703.62,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,5820.86,102,,,case rate,102% WV Medicaid DRG rate,27560.973,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,5319.73,100,,,case rate,100% PEIA with CHIP DRG base rate,22798.15,100,,,case rate,100% Highmark ACA DRG rate,28829.5,100,,,case rate,100% Highmark PPO DRG rate,28829.5,100,,,case rate,100% Highmark Trad DRG rate,5706.72,100,,,case rate,100% WV Medicaid DRG rate,16703.62,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,4524.96,100,,,case rate,100% PEIA DRG rate,21439.66,100,,,case rate,100% The Health Plan DRG rate,4524.96,45934.955,
SKIN ULCERS WITHOUT CC/MCC,594,MS-DRG,,,,,Inpatient,,,,,,29659.4375,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,29659.4375,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,10785.25,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,5139.88,102,,,case rate,102% WV Medicaid DRG rate,17795.6625,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,4697.38,100,,,case rate,100% PEIA with CHIP DRG base rate,14836.98,100,,,case rate,100% Highmark ACA DRG rate,18762.17,100,,,case rate,100% Highmark PPO DRG rate,18762.17,100,,,case rate,100% Highmark Trad DRG rate,5039.09,100,,,case rate,100% WV Medicaid DRG rate,10785.25,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,3995.58,100,,,case rate,100% PEIA DRG rate,13952.88,100,,,case rate,100% The Health Plan DRG rate,3995.58,29659.4375,
MAJOR SKIN DISORDERS WITH MCC,595,MS-DRG,,,,,Inpatient,,,,,,19926.6375,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,19926.6375,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,7246.05,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,14222.13,102,,,case rate,102% WV Medicaid DRG rate,11955.9825,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,12997.73,100,,,case rate,100% PEIA with CHIP DRG base rate,40983.53,100,,,case rate,100% Highmark ACA DRG rate,51825.9,100,,,case rate,100% Highmark PPO DRG rate,51825.9,100,,,case rate,100% Highmark Trad DRG rate,13943.25,100,,,case rate,100% WV Medicaid DRG rate,7246.05,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,11055.85,100,,,case rate,100% PEIA DRG rate,38541.41,100,,,case rate,100% The Health Plan DRG rate,7246.05,51825.9,
MAJOR SKIN DISORDERS WITHOUT MCC,596,MS-DRG,,,,,Inpatient,,,,,,55137.39,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,55137.39,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,20049.96,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,6130.15,102,,,case rate,102% WV Medicaid DRG rate,33082.434,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,5602.4,100,,,case rate,100% PEIA with CHIP DRG base rate,19012.59,100,,,case rate,100% Highmark ACA DRG rate,24042.45,100,,,case rate,100% Highmark PPO DRG rate,24042.45,100,,,case rate,100% Highmark Trad DRG rate,6009.94,100,,,case rate,100% WV Medicaid DRG rate,20049.96,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,4765.39,100,,,case rate,100% PEIA DRG rate,17879.67,100,,,case rate,100% The Health Plan DRG rate,4765.39,55137.39,
MALIGNANT BREAST DISORDERS WITH MCC,597,MS-DRG,,,,,Inpatient,,,,,,28111.9575,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,28111.9575,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,10222.53,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,11184.46,102,,,case rate,102% WV Medicaid DRG rate,16867.1745,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,10221.58,100,,,case rate,100% PEIA with CHIP DRG base rate,30158.22,100,,,case rate,100% Highmark ACA DRG rate,38136.71,100,,,case rate,100% Highmark PPO DRG rate,38136.71,100,,,case rate,100% Highmark Trad DRG rate,10965.15,100,,,case rate,100% WV Medicaid DRG rate,10222.53,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,8694.46,100,,,case rate,100% PEIA DRG rate,28361.16,100,,,case rate,100% The Health Plan DRG rate,8694.46,38136.71,
MALIGNANT BREAST DISORDERS WITH CC,598,MS-DRG,,,,,Inpatient,,,,,,43360.075,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,43360.075,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,15767.3,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,5911.33,102,,,case rate,102% WV Medicaid DRG rate,26016.045,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,5402.41,100,,,case rate,100% PEIA with CHIP DRG base rate,22588.99,100,,,case rate,100% Highmark ACA DRG rate,28565.01,100,,,case rate,100% Highmark PPO DRG rate,28565.01,100,,,case rate,100% Highmark Trad DRG rate,5795.41,100,,,case rate,100% WV Medicaid DRG rate,15767.3,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,4595.29,100,,,case rate,100% PEIA DRG rate,21242.96,100,,,case rate,100% The Health Plan DRG rate,4595.29,43360.075,
MALIGNANT BREAST DISORDERS WITHOUT CC/MCC,599,MS-DRG,,,,,Inpatient,,,,,,27501.7325,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,27501.7325,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,10000.63,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,4964.73,102,,,case rate,102% WV Medicaid DRG rate,16501.0395,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,4537.31,100,,,case rate,100% PEIA with CHIP DRG base rate,11709.04,100,,,case rate,100% Highmark ACA DRG rate,14806.72,100,,,case rate,100% Highmark PPO DRG rate,14806.72,100,,,case rate,100% Highmark Trad DRG rate,4867.38,100,,,case rate,100% WV Medicaid DRG rate,10000.63,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,3859.43,100,,,case rate,100% PEIA DRG rate,11011.33,100,,,case rate,100% The Health Plan DRG rate,3859.43,27501.7325,
NON-MALIGNANT BREAST DISORDERS WITH CC/MCC,600,MS-DRG,,,,,Inpatient,,,,,,19249.395,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,19249.395,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,6999.78,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,4757.5,102,,,case rate,102% WV Medicaid DRG rate,11549.637,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,4347.92,100,,,case rate,100% PEIA with CHIP DRG base rate,19323.5,100,,,case rate,100% Highmark ACA DRG rate,24435.61,100,,,case rate,100% Highmark PPO DRG rate,24435.61,100,,,case rate,100% Highmark Trad DRG rate,4664.21,100,,,case rate,100% WV Medicaid DRG rate,6999.78,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,3698.33,100,,,case rate,100% PEIA DRG rate,18172.05,100,,,case rate,100% The Health Plan DRG rate,3698.33,24435.61,
NON-MALIGNANT BREAST DISORDERS WITHOUT CC/MCC,601,MS-DRG,,,,,Inpatient,,,,,,26806.5325,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,26806.5325,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,9747.83,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,2891.04,102,,,case rate,102% WV Medicaid DRG rate,16083.9195,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,2642.15,100,,,case rate,100% PEIA with CHIP DRG base rate,11731.65,100,,,case rate,100% Highmark ACA DRG rate,14835.31,100,,,case rate,100% Highmark PPO DRG rate,14835.31,100,,,case rate,100% Highmark Trad DRG rate,2834.35,100,,,case rate,100% WV Medicaid DRG rate,9747.83,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,2247.41,100,,,case rate,100% PEIA DRG rate,11032.59,100,,,case rate,100% The Health Plan DRG rate,2247.41,26806.5325,
CELLULITIS WITH MCC,602,MS-DRG,,,,,Inpatient,,,,,,18124.2325,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,18124.2325,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,6590.63,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,6045.03,102,,,case rate,102% WV Medicaid DRG rate,10874.5395,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,5524.6,100,,,case rate,100% PEIA with CHIP DRG base rate,28028.96,100,,,case rate,100% Highmark ACA DRG rate,35444.15,100,,,case rate,100% Highmark PPO DRG rate,35444.15,100,,,case rate,100% Highmark Trad DRG rate,5926.49,100,,,case rate,100% WV Medicaid DRG rate,6590.63,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,4699.22,100,,,case rate,100% PEIA DRG rate,26358.78,100,,,case rate,100% The Health Plan DRG rate,4699.22,35444.15,
CELLULITIS WITHOUT MCC,603,MS-DRG,,,,,Inpatient,,,,,,37108.4725,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,37108.4725,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,13493.99,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,3674.52,102,,,case rate,102% WV Medicaid DRG rate,22265.0835,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,3358.18,100,,,case rate,100% PEIA with CHIP DRG base rate,16670.4,100,,,case rate,100% Highmark ACA DRG rate,21080.63,100,,,case rate,100% Highmark PPO DRG rate,21080.63,100,,,case rate,100% Highmark Trad DRG rate,3602.47,100,,,case rate,100% WV Medicaid DRG rate,13493.99,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,2856.46,100,,,case rate,100% PEIA DRG rate,15677.05,100,,,case rate,100% The Health Plan DRG rate,2856.46,37108.4725,
"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITH MCC",604,MS-DRG,,,,,Inpatient,,,,,,22704.825,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,22704.825,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,8256.3,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,6869.07,102,,,case rate,102% WV Medicaid DRG rate,13622.895,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,6277.7,100,,,case rate,100% PEIA with CHIP DRG base rate,28381.33,100,,,case rate,100% Highmark ACA DRG rate,35889.73,100,,,case rate,100% Highmark PPO DRG rate,35889.73,100,,,case rate,100% Highmark Trad DRG rate,6734.37,100,,,case rate,100% WV Medicaid DRG rate,8256.3,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,5339.8,100,,,case rate,100% PEIA DRG rate,26690.15,100,,,case rate,100% The Health Plan DRG rate,5339.8,35889.73,
"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITHOUT MCC",605,MS-DRG,,,,,Inpatient,,,,,,38859.3425,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,38859.3425,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,14130.67,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,4218.68,102,,,case rate,102% WV Medicaid DRG rate,23315.6055,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,3855.49,100,,,case rate,100% PEIA with CHIP DRG base rate,17124.52,100,,,case rate,100% Highmark ACA DRG rate,21654.89,100,,,case rate,100% Highmark PPO DRG rate,21654.89,100,,,case rate,100% Highmark Trad DRG rate,4135.96,100,,,case rate,100% WV Medicaid DRG rate,14130.67,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,3279.48,100,,,case rate,100% PEIA DRG rate,16104.11,100,,,case rate,100% The Health Plan DRG rate,3279.48,38859.3425,
MINOR SKIN DISORDERS WITH MCC,606,MS-DRG,,,,,Inpatient,,,,,,23441.275,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,23441.275,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,8524.1,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,8754.68,102,,,case rate,102% WV Medicaid DRG rate,14064.765,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,8000.98,100,,,case rate,100% PEIA with CHIP DRG base rate,29881.23,100,,,case rate,100% Highmark ACA DRG rate,37786.44,100,,,case rate,100% Highmark PPO DRG rate,37786.44,100,,,case rate,100% Highmark Trad DRG rate,8583.01,100,,,case rate,100% WV Medicaid DRG rate,8524.1,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,6805.62,100,,,case rate,100% PEIA DRG rate,28100.68,100,,,case rate,100% The Health Plan DRG rate,6805.62,37786.44,
MINOR SKIN DISORDERS WITHOUT MCC,607,MS-DRG,,,,,Inpatient,,,,,,39521.0475,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,39521.0475,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,14371.29,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,3262.28,102,,,case rate,102% WV Medicaid DRG rate,23712.6285,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,2981.43,100,,,case rate,100% PEIA with CHIP DRG base rate,16836.22,100,,,case rate,100% Highmark ACA DRG rate,21290.32,100,,,case rate,100% Highmark PPO DRG rate,21290.32,100,,,case rate,100% Highmark Trad DRG rate,3198.31,100,,,case rate,100% WV Medicaid DRG rate,14371.29,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,2536,100,,,case rate,100% PEIA DRG rate,15832.99,100,,,case rate,100% The Health Plan DRG rate,2536,39521.0475,
ADRENAL AND PITUITARY PROCEDURES WITH CC/MCC,614,MS-DRG,,,,,Inpatient,,,,,,21839.7025,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,21839.7025,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,7941.71,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,17355.61,102,,,case rate,102% WV Medicaid DRG rate,13103.8215,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,15861.44,100,,,case rate,100% PEIA with CHIP DRG base rate,42441.97,100,,,case rate,100% Highmark ACA DRG rate,53670.19,100,,,case rate,100% Highmark PPO DRG rate,53670.19,100,,,case rate,100% Highmark Trad DRG rate,17015.29,100,,,case rate,100% WV Medicaid DRG rate,7941.71,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,13491.72,100,,,case rate,100% PEIA DRG rate,39912.96,100,,,case rate,100% The Health Plan DRG rate,7941.71,53670.19,
ADRENAL AND PITUITARY PROCEDURES WITHOUT CC/MCC,615,MS-DRG,,,,,Inpatient,,,,,,60505.885,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,60505.885,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,22002.14,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,12415.84,102,,,case rate,102% WV Medicaid DRG rate,36303.531,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,11346.94,100,,,case rate,100% PEIA with CHIP DRG base rate,27719.94,100,,,case rate,100% Highmark ACA DRG rate,35053.37,100,,,case rate,100% Highmark PPO DRG rate,35053.37,100,,,case rate,100% Highmark Trad DRG rate,12172.38,100,,,case rate,100% WV Medicaid DRG rate,22002.14,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,9651.69,100,,,case rate,100% PEIA DRG rate,26068.17,100,,,case rate,100% The Health Plan DRG rate,9651.69,60505.885,
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH MCC",616,MS-DRG,,,,,Inpatient,,,,,,37999.3075,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,37999.3075,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,13817.93,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,12643.13,102,,,case rate,102% WV Medicaid DRG rate,22799.5845,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,11554.67,100,,,case rate,100% PEIA with CHIP DRG base rate,74574.94,100,,,case rate,100% Highmark ACA DRG rate,94304.08,100,,,case rate,100% Highmark PPO DRG rate,94304.08,100,,,case rate,100% Highmark Trad DRG rate,12395.21,100,,,case rate,100% WV Medicaid DRG rate,13817.93,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,9828.38,100,,,case rate,100% PEIA DRG rate,70131.2,100,,,case rate,100% The Health Plan DRG rate,9828.38,94304.08,
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC",617,MS-DRG,,,,,Inpatient,,,,,,96929.4425,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,96929.4425,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,35247.07,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,9379.06,102,,,case rate,102% WV Medicaid DRG rate,58157.6655,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,8571.61,100,,,case rate,100% PEIA with CHIP DRG base rate,37393.93,100,,,case rate,100% Highmark ACA DRG rate,47286.67,100,,,case rate,100% Highmark PPO DRG rate,47286.67,100,,,case rate,100% Highmark Trad DRG rate,9195.15,100,,,case rate,100% WV Medicaid DRG rate,35247.07,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,7291,100,,,case rate,100% PEIA DRG rate,35165.72,100,,,case rate,100% The Health Plan DRG rate,7291,96929.4425,
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITHOUT CC/MCC",618,MS-DRG,,,,,Inpatient,,,,,,50054.7025,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,50054.7025,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,18201.71,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,7789.81,102,,,case rate,102% WV Medicaid DRG rate,30032.8215,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,7119.18,100,,,case rate,100% PEIA with CHIP DRG base rate,21886.14,100,,,case rate,100% Highmark ACA DRG rate,27676.22,100,,,case rate,100% Highmark PPO DRG rate,27676.22,100,,,case rate,100% Highmark Trad DRG rate,7637.06,100,,,case rate,100% WV Medicaid DRG rate,18201.71,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,6055.56,100,,,case rate,100% PEIA DRG rate,20582,100,,,case rate,100% The Health Plan DRG rate,6055.56,50054.7025,
O.R. PROCEDURES FOR OBESITY WITH MCC,619,MS-DRG,,,,,Inpatient,,,,,,30200.17,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,30200.17,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,10981.88,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,19205.13,102,,,case rate,102% WV Medicaid DRG rate,18120.102,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,17551.74,100,,,case rate,100% PEIA with CHIP DRG base rate,48775.11,100,,,case rate,100% Highmark ACA DRG rate,61678.78,100,,,case rate,100% Highmark PPO DRG rate,61678.78,100,,,case rate,100% Highmark Trad DRG rate,18828.54,100,,,case rate,100% WV Medicaid DRG rate,10981.88,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,14929.48,100,,,case rate,100% PEIA DRG rate,45868.71,100,,,case rate,100% The Health Plan DRG rate,10981.88,61678.78,
O.R. PROCEDURES FOR OBESITY WITH CC,620,MS-DRG,,,,,Inpatient,,,,,,74456.3325,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,74456.3325,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,27075.03,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,13140.49,102,,,case rate,102% WV Medicaid DRG rate,44673.7995,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,12009.21,100,,,case rate,100% PEIA with CHIP DRG base rate,30567.11,100,,,case rate,100% Highmark ACA DRG rate,38653.78,100,,,case rate,100% Highmark PPO DRG rate,38653.78,100,,,case rate,100% Highmark Trad DRG rate,12882.82,100,,,case rate,100% WV Medicaid DRG rate,27075.03,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,10215.02,100,,,case rate,100% PEIA DRG rate,28745.69,100,,,case rate,100% The Health Plan DRG rate,10215.02,74456.3325,
O.R. PROCEDURES FOR OBESITY WITHOUT CC/MCC,621,MS-DRG,,,,,Inpatient,,,,,,43401.27,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,43401.27,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,15782.28,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,10528.88,102,,,case rate,102% WV Medicaid DRG rate,26040.762,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,9622.44,100,,,case rate,100% PEIA with CHIP DRG base rate,28590.48,100,,,case rate,100% Highmark ACA DRG rate,36154.22,100,,,case rate,100% Highmark PPO DRG rate,36154.22,100,,,case rate,100% Highmark Trad DRG rate,10322.42,100,,,case rate,100% WV Medicaid DRG rate,15782.28,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,8184.83,100,,,case rate,100% PEIA DRG rate,26886.84,100,,,case rate,100% The Health Plan DRG rate,8184.83,43401.27,
"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH MCC",622,MS-DRG,,,,,Inpatient,,,,,,40038.5975,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,40038.5975,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,14559.49,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,13056.71,102,,,case rate,102% WV Medicaid DRG rate,24023.1585,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,11932.64,100,,,case rate,100% PEIA with CHIP DRG base rate,72085.78,100,,,case rate,100% Highmark ACA DRG rate,91156.4,100,,,case rate,100% Highmark PPO DRG rate,91156.4,100,,,case rate,100% Highmark Trad DRG rate,12800.68,100,,,case rate,100% WV Medicaid DRG rate,14559.49,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,10149.89,100,,,case rate,100% PEIA DRG rate,67790.36,100,,,case rate,100% The Health Plan DRG rate,10149.89,91156.4,
"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC",623,MS-DRG,,,,,Inpatient,,,,,,93237.1,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,93237.1,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,33904.4,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,8326.4,102,,,case rate,102% WV Medicaid DRG rate,55942.26,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,7609.57,100,,,case rate,100% PEIA with CHIP DRG base rate,35074.36,100,,,case rate,100% Highmark ACA DRG rate,44353.44,100,,,case rate,100% Highmark PPO DRG rate,44353.44,100,,,case rate,100% Highmark Trad DRG rate,8163.13,100,,,case rate,100% WV Medicaid DRG rate,33904.4,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,6472.69,100,,,case rate,100% PEIA DRG rate,32984.36,100,,,case rate,100% The Health Plan DRG rate,6472.69,93237.1,
"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITHOUT CC/MCC",624,MS-DRG,,,,,Inpatient,,,,,,48525.235,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,48525.235,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,17645.54,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,6567.79,102,,,case rate,102% WV Medicaid DRG rate,29115.141,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,6002.37,100,,,case rate,100% PEIA with CHIP DRG base rate,21000.52,100,,,case rate,100% Highmark ACA DRG rate,26556.31,100,,,case rate,100% Highmark PPO DRG rate,26556.31,100,,,case rate,100% Highmark Trad DRG rate,6439.01,100,,,case rate,100% WV Medicaid DRG rate,17645.54,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,5105.6,100,,,case rate,100% PEIA DRG rate,19749.15,100,,,case rate,100% The Health Plan DRG rate,5105.6,48525.235,
"THYROID, PARATHYROID AND THYROGLOSSAL PROCEDURES WITH MCC",625,MS-DRG,,,,,Inpatient,,,,,,25465.055,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,25465.055,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,9260.02,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,19108.86,102,,,case rate,102% WV Medicaid DRG rate,15279.033,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,17463.76,100,,,case rate,100% PEIA with CHIP DRG base rate,55044.17,100,,,case rate,100% Highmark ACA DRG rate,69606.35,100,,,case rate,100% Highmark PPO DRG rate,69606.35,100,,,case rate,100% Highmark Trad DRG rate,18734.16,100,,,case rate,100% WV Medicaid DRG rate,9260.02,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,14854.65,100,,,case rate,100% PEIA DRG rate,51764.22,100,,,case rate,100% The Health Plan DRG rate,9260.02,69606.35,
"THYROID, PARATHYROID AND THYROGLOSSAL PROCEDURES WITH CC",626,MS-DRG,,,,,Inpatient,,,,,,74083.02,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,74083.02,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,26939.28,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,11521.83,102,,,case rate,102% WV Medicaid DRG rate,44449.812,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,10529.9,100,,,case rate,100% PEIA with CHIP DRG base rate,28111.87,100,,,case rate,100% Highmark ACA DRG rate,35548.99,100,,,case rate,100% Highmark PPO DRG rate,35548.99,100,,,case rate,100% Highmark Trad DRG rate,11295.9,100,,,case rate,100% WV Medicaid DRG rate,26939.28,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,8956.72,100,,,case rate,100% PEIA DRG rate,26436.75,100,,,case rate,100% The Health Plan DRG rate,8956.72,74083.02,
"THYROID, PARATHYROID AND THYROGLOSSAL PROCEDURES WITHOUT CC/MCC",627,MS-DRG,,,,,Inpatient,,,,,,41691.65,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,41691.65,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,15160.6,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,8144.56,102,,,case rate,102% WV Medicaid DRG rate,25014.99,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,7443.39,100,,,case rate,100% PEIA with CHIP DRG base rate,23289.95,100,,,case rate,100% Highmark ACA DRG rate,29451.41,100,,,case rate,100% Highmark PPO DRG rate,29451.41,100,,,case rate,100% Highmark Trad DRG rate,7984.86,100,,,case rate,100% WV Medicaid DRG rate,15160.6,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,6331.34,100,,,case rate,100% PEIA DRG rate,21902.15,100,,,case rate,100% The Health Plan DRG rate,6331.34,41691.65,
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH MCC",628,MS-DRG,,,,,Inpatient,,,,,,32852.27,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,32852.27,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,11946.28,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,12042.81,102,,,case rate,102% WV Medicaid DRG rate,19711.362,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,11006.03,100,,,case rate,100% PEIA with CHIP DRG base rate,75645.22,100,,,case rate,100% Highmark ACA DRG rate,95657.51,100,,,case rate,100% Highmark PPO DRG rate,95657.51,100,,,case rate,100% Highmark Trad DRG rate,11806.67,100,,,case rate,100% WV Medicaid DRG rate,11946.28,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,9361.72,100,,,case rate,100% PEIA DRG rate,71137.7,100,,,case rate,100% The Health Plan DRG rate,9361.72,95657.51,
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH CC",629,MS-DRG,,,,,Inpatient,,,,,,93847.4075,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,93847.4075,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,34126.33,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,9680.78,102,,,case rate,102% WV Medicaid DRG rate,56308.4445,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,8847.35,100,,,case rate,100% PEIA with CHIP DRG base rate,42637.94,100,,,case rate,100% Highmark ACA DRG rate,53918,100,,,case rate,100% Highmark PPO DRG rate,53918,100,,,case rate,100% Highmark Trad DRG rate,9490.95,100,,,case rate,100% WV Medicaid DRG rate,34126.33,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,7525.54,100,,,case rate,100% PEIA DRG rate,40097.25,100,,,case rate,100% The Health Plan DRG rate,7525.54,93847.4075,
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITHOUT CC/MCC",630,MS-DRG,,,,,Inpatient,,,,,,57773.98,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,57773.98,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,21008.72,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,6958.2,102,,,case rate,102% WV Medicaid DRG rate,34664.388,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,6359.16,100,,,case rate,100% PEIA with CHIP DRG base rate,26310.48,100,,,case rate,100% Highmark ACA DRG rate,33271.04,100,,,case rate,100% Highmark PPO DRG rate,33271.04,100,,,case rate,100% Highmark Trad DRG rate,6821.76,100,,,case rate,100% WV Medicaid DRG rate,21008.72,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,5409.09,100,,,case rate,100% PEIA DRG rate,24742.7,100,,,case rate,100% The Health Plan DRG rate,5409.09,57773.98,
DIABETES WITH MCC,637,MS-DRG,,,,,Inpatient,,,,,,36155.735,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,36155.735,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,13147.54,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,6235.77,102,,,case rate,102% WV Medicaid DRG rate,21693.441,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,5698.93,100,,,case rate,100% PEIA with CHIP DRG base rate,27309.16,100,,,case rate,100% Highmark ACA DRG rate,34533.92,100,,,case rate,100% Highmark PPO DRG rate,34533.92,100,,,case rate,100% Highmark Trad DRG rate,6113.5,100,,,case rate,100% WV Medicaid DRG rate,13147.54,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,4847.5,100,,,case rate,100% PEIA DRG rate,25681.87,100,,,case rate,100% The Health Plan DRG rate,4847.5,36155.735,
DIABETES WITH CC,638,MS-DRG,,,,,Inpatient,,,,,,35936.9175,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,35936.9175,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,13067.97,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,3871.51,102,,,case rate,102% WV Medicaid DRG rate,21562.1505,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,3538.21,100,,,case rate,100% PEIA with CHIP DRG base rate,16947.39,100,,,case rate,100% Highmark ACA DRG rate,21430.9,100,,,case rate,100% Highmark PPO DRG rate,21430.9,100,,,case rate,100% Highmark Trad DRG rate,3795.59,100,,,case rate,100% WV Medicaid DRG rate,13067.97,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,3009.59,100,,,case rate,100% PEIA DRG rate,15937.54,100,,,case rate,100% The Health Plan DRG rate,3009.59,35936.9175,
DIABETES WITHOUT CC/MCC,639,MS-DRG,,,,,Inpatient,,,,,,22555.5,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,22555.5,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,8202,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,2847.81,102,,,case rate,102% WV Medicaid DRG rate,13533.3,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,2602.64,100,,,case rate,100% PEIA with CHIP DRG base rate,11729.77,100,,,case rate,100% Highmark ACA DRG rate,14832.93,100,,,case rate,100% Highmark PPO DRG rate,14832.93,100,,,case rate,100% Highmark Trad DRG rate,2791.97,100,,,case rate,100% WV Medicaid DRG rate,8202,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,2213.8,100,,,case rate,100% PEIA DRG rate,11030.82,100,,,case rate,100% The Health Plan DRG rate,2213.8,22555.5,
"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITH MCC",640,MS-DRG,,,,,Inpatient,,,,,,15469.5475,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,15469.5475,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,5625.29,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,6030.77,102,,,case rate,102% WV Medicaid DRG rate,9281.7285,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,5511.57,100,,,case rate,100% PEIA with CHIP DRG base rate,24782.31,100,,,case rate,100% Highmark ACA DRG rate,31338.59,100,,,case rate,100% Highmark PPO DRG rate,31338.59,100,,,case rate,100% Highmark Trad DRG rate,5912.51,100,,,case rate,100% WV Medicaid DRG rate,5625.29,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,4688.13,100,,,case rate,100% PEIA DRG rate,23305.59,100,,,case rate,100% The Health Plan DRG rate,4688.13,31338.59,
"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITHOUT MCC",641,MS-DRG,,,,,Inpatient,,,,,,32579.3325,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,32579.3325,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,11847.03,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,3569.79,102,,,case rate,102% WV Medicaid DRG rate,19547.5995,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,3262.46,100,,,case rate,100% PEIA with CHIP DRG base rate,14723.92,100,,,case rate,100% Highmark ACA DRG rate,18619.2,100,,,case rate,100% Highmark PPO DRG rate,18619.2,100,,,case rate,100% Highmark Trad DRG rate,3499.79,100,,,case rate,100% WV Medicaid DRG rate,11847.03,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,2775.05,100,,,case rate,100% PEIA DRG rate,13846.56,100,,,case rate,100% The Health Plan DRG rate,2775.05,32579.3325,
INBORN AND OTHER DISORDERS OF METABOLISM,642,MS-DRG,,,,,Inpatient,,,,,,19831.3225,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,19831.3225,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,7211.39,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,4105.04,102,,,case rate,102% WV Medicaid DRG rate,11898.7935,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,3751.63,100,,,case rate,100% PEIA with CHIP DRG base rate,24558.08,100,,,case rate,100% Highmark ACA DRG rate,31055.03,100,,,case rate,100% Highmark PPO DRG rate,31055.03,100,,,case rate,100% Highmark Trad DRG rate,4024.54,100,,,case rate,100% WV Medicaid DRG rate,7211.39,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,3191.13,100,,,case rate,100% PEIA DRG rate,23094.72,100,,,case rate,100% The Health Plan DRG rate,3191.13,31055.03,
ENDOCRINE DISORDERS WITH MCC,643,MS-DRG,,,,,Inpatient,,,,,,36132.525,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,36132.525,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,13139.1,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,6967.11,102,,,case rate,102% WV Medicaid DRG rate,21679.515,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,6367.31,100,,,case rate,100% PEIA with CHIP DRG base rate,30998.62,100,,,case rate,100% Highmark ACA DRG rate,39199.44,100,,,case rate,100% Highmark PPO DRG rate,39199.44,100,,,case rate,100% Highmark Trad DRG rate,6830.5,100,,,case rate,100% WV Medicaid DRG rate,13139.1,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,5416.02,100,,,case rate,100% PEIA DRG rate,29151.48,100,,,case rate,100% The Health Plan DRG rate,5416.02,39199.44,
ENDOCRINE DISORDERS WITH CC,644,MS-DRG,,,,,Inpatient,,,,,,42322.4725,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,42322.4725,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,15389.99,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,4992.81,102,,,case rate,102% WV Medicaid DRG rate,25393.4835,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,4562.97,100,,,case rate,100% PEIA with CHIP DRG base rate,20005.61,100,,,case rate,100% Highmark ACA DRG rate,25298.19,100,,,case rate,100% Highmark PPO DRG rate,25298.19,100,,,case rate,100% Highmark Trad DRG rate,4894.9,100,,,case rate,100% WV Medicaid DRG rate,15389.99,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,3881.26,100,,,case rate,100% PEIA DRG rate,18813.53,100,,,case rate,100% The Health Plan DRG rate,3881.26,42322.4725,
ENDOCRINE DISORDERS WITHOUT CC/MCC,645,MS-DRG,,,,,Inpatient,,,,,,26240.0875,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,26240.0875,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,9541.85,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,3280.55,102,,,case rate,102% WV Medicaid DRG rate,15744.0525,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,2998.13,100,,,case rate,100% PEIA with CHIP DRG base rate,14337.64,100,,,case rate,100% Highmark ACA DRG rate,18130.73,100,,,case rate,100% Highmark PPO DRG rate,18130.73,100,,,case rate,100% Highmark Trad DRG rate,3216.23,100,,,case rate,100% WV Medicaid DRG rate,9541.85,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,2550.2,100,,,case rate,100% PEIA DRG rate,13483.29,100,,,case rate,100% The Health Plan DRG rate,2550.2,26240.0875,
KIDNEY TRANSPLANT WITH HEMODIALYSIS WITH MCC,650,MS-DRG,,,,,Inpatient,,,,,,19120.7225,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,19120.7225,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,6952.99,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,20696.33,102,,,case rate,102% WV Medicaid DRG rate,11472.4335,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,18914.56,100,,,case rate,100% PEIA with CHIP DRG base rate,84746.39,100,,,case rate,100% Highmark ACA DRG rate,107166.43,100,,,case rate,100% Highmark PPO DRG rate,107166.43,100,,,case rate,100% Highmark Trad DRG rate,20290.5,100,,,case rate,100% WV Medicaid DRG rate,6952.99,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,16088.7,100,,,case rate,100% PEIA DRG rate,79696.55,100,,,case rate,100% The Health Plan DRG rate,6952.99,107166.43,
KIDNEY TRANSPLANT WITH HEMODIALYSIS WITHOUT MCC,651,MS-DRG,,,,,Inpatient,,,,,,119572.475,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,119572.475,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,43480.9,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,15804.24,102,,,case rate,102% WV Medicaid DRG rate,71743.485,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,14443.64,100,,,case rate,100% PEIA with CHIP DRG base rate,65166.63,100,,,case rate,100% Highmark ACA DRG rate,82406.76,100,,,case rate,100% Highmark PPO DRG rate,82406.76,100,,,case rate,100% Highmark Trad DRG rate,15494.34,100,,,case rate,100% WV Medicaid DRG rate,43480.9,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,12285.74,100,,,case rate,100% PEIA DRG rate,61283.51,100,,,case rate,100% The Health Plan DRG rate,12285.74,119572.475,
KIDNEY TRANSPLANT,652,MS-DRG,,,,,Inpatient,,,,,,91308.58,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,91308.58,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,33203.12,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,13749.27,102,,,case rate,102% WV Medicaid DRG rate,54785.148,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,12565.58,100,,,case rate,100% PEIA with CHIP DRG base rate,56611.91,100,,,case rate,100% Highmark ACA DRG rate,71588.84,100,,,case rate,100% Highmark PPO DRG rate,71588.84,100,,,case rate,100% Highmark Trad DRG rate,13479.67,100,,,case rate,100% WV Medicaid DRG rate,33203.12,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,10688.27,100,,,case rate,100% PEIA DRG rate,53238.54,100,,,case rate,100% The Health Plan DRG rate,10688.27,91308.58,
MAJOR BLADDER PROCEDURES WITH MCC,653,MS-DRG,,,,,Inpatient,,,,,,79436.0325,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,79436.0325,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,28885.83,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,36904.79,102,,,case rate,102% WV Medicaid DRG rate,47661.6195,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,33727.62,100,,,case rate,100% PEIA with CHIP DRG base rate,102008.46,100,,,case rate,100% Highmark ACA DRG rate,128995.26,100,,,case rate,100% Highmark PPO DRG rate,128995.26,100,,,case rate,100% Highmark Trad DRG rate,36181.13,100,,,case rate,100% WV Medicaid DRG rate,28885.83,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,28688.67,100,,,case rate,100% PEIA DRG rate,95930.02,100,,,case rate,100% The Health Plan DRG rate,28688.67,128995.26,
MAJOR BLADDER PROCEDURES WITH CC,654,MS-DRG,,,,,Inpatient,,,,,,143075.515,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,143075.515,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,52027.46,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,20596.95,102,,,case rate,102% WV Medicaid DRG rate,85845.309,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,18823.73,100,,,case rate,100% PEIA with CHIP DRG base rate,51582.71,100,,,case rate,100% Highmark ACA DRG rate,65229.15,100,,,case rate,100% Highmark PPO DRG rate,65229.15,100,,,case rate,100% Highmark Trad DRG rate,20193.06,100,,,case rate,100% WV Medicaid DRG rate,52027.46,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,16011.44,100,,,case rate,100% PEIA DRG rate,48509.02,100,,,case rate,100% The Health Plan DRG rate,16011.44,143075.515,
MAJOR BLADDER PROCEDURES WITHOUT CC/MCC,655,MS-DRG,,,,,Inpatient,,,,,,73189.5175,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,73189.5175,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,26614.37,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,14337.11,102,,,case rate,102% WV Medicaid DRG rate,43913.7105,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,13102.81,100,,,case rate,100% PEIA with CHIP DRG base rate,39717.28,100,,,case rate,100% Highmark ACA DRG rate,50224.66,100,,,case rate,100% Highmark PPO DRG rate,50224.66,100,,,case rate,100% Highmark Trad DRG rate,14055.97,100,,,case rate,100% WV Medicaid DRG rate,26614.37,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,11145.23,100,,,case rate,100% PEIA DRG rate,37350.62,100,,,case rate,100% The Health Plan DRG rate,11145.23,73189.5175,
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH MCC,656,MS-DRG,,,,,Inpatient,,,,,,55582.8075,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,55582.8075,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,20211.93,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,21548,102,,,case rate,102% WV Medicaid DRG rate,33349.6845,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,19692.91,100,,,case rate,100% PEIA with CHIP DRG base rate,59121.8,100,,,case rate,100% Highmark ACA DRG rate,74762.73,100,,,case rate,100% Highmark PPO DRG rate,74762.73,100,,,case rate,100% Highmark Trad DRG rate,21125.47,100,,,case rate,100% WV Medicaid DRG rate,20211.93,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,16750.76,100,,,case rate,100% PEIA DRG rate,55598.87,100,,,case rate,100% The Health Plan DRG rate,16750.76,74762.73,
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH CC,657,MS-DRG,,,,,Inpatient,,,,,,85105.845,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,85105.845,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,30947.58,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,12405.59,102,,,case rate,102% WV Medicaid DRG rate,51063.507,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,11337.57,100,,,case rate,100% PEIA with CHIP DRG base rate,34750.26,100,,,case rate,100% Highmark ACA DRG rate,43943.6,100,,,case rate,100% Highmark PPO DRG rate,43943.6,100,,,case rate,100% Highmark Trad DRG rate,12162.33,100,,,case rate,100% WV Medicaid DRG rate,30947.58,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,9643.73,100,,,case rate,100% PEIA DRG rate,32679.57,100,,,case rate,100% The Health Plan DRG rate,9643.73,85105.845,
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITHOUT CC/MCC,658,MS-DRG,,,,,Inpatient,,,,,,48355.285,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,48355.285,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,17583.74,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,11010.65,102,,,case rate,102% WV Medicaid DRG rate,29013.171,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,10062.73,100,,,case rate,100% PEIA with CHIP DRG base rate,27895.18,100,,,case rate,100% Highmark ACA DRG rate,35274.97,100,,,case rate,100% Highmark PPO DRG rate,35274.97,100,,,case rate,100% Highmark Trad DRG rate,10794.74,100,,,case rate,100% WV Medicaid DRG rate,17583.74,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,8559.34,100,,,case rate,100% PEIA DRG rate,26232.97,100,,,case rate,100% The Health Plan DRG rate,8559.34,48355.285,
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH MCC,659,MS-DRG,,,,,Inpatient,,,,,,40656.5225,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,40656.5225,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,14784.19,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,10749.93,102,,,case rate,102% WV Medicaid DRG rate,24393.9135,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,9824.46,100,,,case rate,100% PEIA with CHIP DRG base rate,48782.64,100,,,case rate,100% Highmark ACA DRG rate,61688.31,100,,,case rate,100% Highmark PPO DRG rate,61688.31,100,,,case rate,100% Highmark Trad DRG rate,10539.14,100,,,case rate,100% WV Medicaid DRG rate,14784.19,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,8356.67,100,,,case rate,100% PEIA DRG rate,45875.8,100,,,case rate,100% The Health Plan DRG rate,8356.67,61688.31,
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH CC,660,MS-DRG,,,,,Inpatient,,,,,,66350.735,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,66350.735,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,24127.54,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,7422.58,102,,,case rate,102% WV Medicaid DRG rate,39810.441,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,6783.56,100,,,case rate,100% PEIA with CHIP DRG base rate,25360.79,100,,,case rate,100% Highmark ACA DRG rate,32070.11,100,,,case rate,100% Highmark PPO DRG rate,32070.11,100,,,case rate,100% Highmark Trad DRG rate,7277.04,100,,,case rate,100% WV Medicaid DRG rate,24127.54,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,5770.09,100,,,case rate,100% PEIA DRG rate,23849.6,100,,,case rate,100% The Health Plan DRG rate,5770.09,66350.735,
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITHOUT CC/MCC,661,MS-DRG,,,,,Inpatient,,,,,,36335.97,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,36335.97,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,13213.08,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,5335.53,102,,,case rate,102% WV Medicaid DRG rate,21801.582,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,4876.18,100,,,case rate,100% PEIA with CHIP DRG base rate,19755,100,,,case rate,100% Highmark ACA DRG rate,24981.28,100,,,case rate,100% Highmark PPO DRG rate,24981.28,100,,,case rate,100% Highmark Trad DRG rate,5230.9,100,,,case rate,100% WV Medicaid DRG rate,13213.08,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,4147.68,100,,,case rate,100% PEIA DRG rate,18577.85,100,,,case rate,100% The Health Plan DRG rate,4147.68,36335.97,
MINOR BLADDER PROCEDURES WITH MCC,662,MS-DRG,,,,,Inpatient,,,,,,27754.1275,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,27754.1275,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,10092.41,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,19513.53,102,,,case rate,102% WV Medicaid DRG rate,16652.4765,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,17833.59,100,,,case rate,100% PEIA with CHIP DRG base rate,56466.82,100,,,case rate,100% Highmark ACA DRG rate,71405.37,100,,,case rate,100% Highmark PPO DRG rate,71405.37,100,,,case rate,100% Highmark Trad DRG rate,19130.89,100,,,case rate,100% WV Medicaid DRG rate,10092.41,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,15169.23,100,,,case rate,100% PEIA DRG rate,53102.09,100,,,case rate,100% The Health Plan DRG rate,10092.41,71405.37,
MINOR BLADDER PROCEDURES WITH CC,663,MS-DRG,,,,,Inpatient,,,,,,78241.35,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,78241.35,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,28451.4,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,10128.67,102,,,case rate,102% WV Medicaid DRG rate,46944.81,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,9256.68,100,,,case rate,100% PEIA with CHIP DRG base rate,27491.94,100,,,case rate,100% Highmark ACA DRG rate,34765.05,100,,,case rate,100% Highmark PPO DRG rate,34765.05,100,,,case rate,100% Highmark Trad DRG rate,9930.06,100,,,case rate,100% WV Medicaid DRG rate,28451.4,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,7873.72,100,,,case rate,100% PEIA DRG rate,25853.76,100,,,case rate,100% The Health Plan DRG rate,7873.72,78241.35,
MINOR BLADDER PROCEDURES WITHOUT CC/MCC,664,MS-DRG,,,,,Inpatient,,,,,,39266.1225,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,39266.1225,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,14278.59,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,7235.4,102,,,case rate,102% WV Medicaid DRG rate,23559.6735,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,6612.5,100,,,case rate,100% PEIA with CHIP DRG base rate,20003.73,100,,,case rate,100% Highmark ACA DRG rate,25295.8,100,,,case rate,100% Highmark PPO DRG rate,25295.8,100,,,case rate,100% Highmark Trad DRG rate,7093.53,100,,,case rate,100% WV Medicaid DRG rate,14278.59,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,5624.58,100,,,case rate,100% PEIA DRG rate,18811.75,100,,,case rate,100% The Health Plan DRG rate,5624.58,39266.1225,
PROSTATECTOMY WITH MCC,665,MS-DRG,,,,,Inpatient,,,,,,29010.575,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,29010.575,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,10549.3,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,20325.09,102,,,case rate,102% WV Medicaid DRG rate,17406.345,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,18575.28,100,,,case rate,100% PEIA with CHIP DRG base rate,58207.91,100,,,case rate,100% Highmark ACA DRG rate,73607.07,100,,,case rate,100% Highmark PPO DRG rate,73607.07,100,,,case rate,100% Highmark Trad DRG rate,19926.54,100,,,case rate,100% WV Medicaid DRG rate,10549.3,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,15800.11,100,,,case rate,100% PEIA DRG rate,54739.44,100,,,case rate,100% The Health Plan DRG rate,10549.3,73607.07,
PROSTATECTOMY WITH CC,666,MS-DRG,,,,,Inpatient,,,,,,78797.4275,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,78797.4275,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,28653.61,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,11435.82,102,,,case rate,102% WV Medicaid DRG rate,47278.4565,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,10451.29,100,,,case rate,100% PEIA with CHIP DRG base rate,32360.97,100,,,case rate,100% Highmark ACA DRG rate,40922.21,100,,,case rate,100% Highmark PPO DRG rate,40922.21,100,,,case rate,100% Highmark Trad DRG rate,11211.57,100,,,case rate,100% WV Medicaid DRG rate,28653.61,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,8889.86,100,,,case rate,100% PEIA DRG rate,30432.65,100,,,case rate,100% The Health Plan DRG rate,8889.86,78797.4275,
PROSTATECTOMY WITHOUT CC/MCC,667,MS-DRG,,,,,Inpatient,,,,,,44335.9675,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,44335.9675,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,16122.17,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,6318.22,102,,,case rate,102% WV Medicaid DRG rate,26601.5805,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,5774.28,100,,,case rate,100% PEIA with CHIP DRG base rate,19777.61,100,,,case rate,100% Highmark ACA DRG rate,25009.87,100,,,case rate,100% Highmark PPO DRG rate,25009.87,100,,,case rate,100% Highmark Trad DRG rate,6194.33,100,,,case rate,100% WV Medicaid DRG rate,16122.17,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,4911.59,100,,,case rate,100% PEIA DRG rate,18599.11,100,,,case rate,100% The Health Plan DRG rate,4911.59,44335.9675,
TRANSURETHRAL PROCEDURES WITH MCC,668,MS-DRG,,,,,Inpatient,,,,,,25333.7975,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,25333.7975,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,9212.29,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,18748.77,102,,,case rate,102% WV Medicaid DRG rate,15200.2785,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,17134.66,100,,,case rate,100% PEIA with CHIP DRG base rate,53099.57,100,,,case rate,100% Highmark ACA DRG rate,67147.3,100,,,case rate,100% Highmark PPO DRG rate,67147.3,100,,,case rate,100% Highmark Trad DRG rate,18381.12,100,,,case rate,100% WV Medicaid DRG rate,9212.29,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,14574.72,100,,,case rate,100% PEIA DRG rate,49935.5,100,,,case rate,100% The Health Plan DRG rate,9212.29,67147.3,
TRANSURETHRAL PROCEDURES WITH CC,669,MS-DRG,,,,,Inpatient,,,,,,72684.8375,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,72684.8375,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,26430.85,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,14219.01,102,,,case rate,102% WV Medicaid DRG rate,43610.9025,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,12994.87,100,,,case rate,100% PEIA with CHIP DRG base rate,28916.47,100,,,case rate,100% Highmark ACA DRG rate,36566.45,100,,,case rate,100% Highmark PPO DRG rate,36566.45,100,,,case rate,100% Highmark Trad DRG rate,13940.19,100,,,case rate,100% WV Medicaid DRG rate,26430.85,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,11053.42,100,,,case rate,100% PEIA DRG rate,27193.4,100,,,case rate,100% The Health Plan DRG rate,11053.42,72684.8375,
TRANSURETHRAL PROCEDURES WITHOUT CC/MCC,670,MS-DRG,,,,,Inpatient,,,,,,40532.965,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,40532.965,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,14739.26,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,6558.44,102,,,case rate,102% WV Medicaid DRG rate,24319.779,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,5993.81,100,,,case rate,100% PEIA with CHIP DRG base rate,18138.27,100,,,case rate,100% Highmark ACA DRG rate,22936.83,100,,,case rate,100% Highmark PPO DRG rate,22936.83,100,,,case rate,100% Highmark Trad DRG rate,6429.83,100,,,case rate,100% WV Medicaid DRG rate,14739.26,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,5098.33,100,,,case rate,100% PEIA DRG rate,17057.45,100,,,case rate,100% The Health Plan DRG rate,5098.33,40532.965,
URETHRAL PROCEDURES WITH CC/MCC,671,MS-DRG,,,,,Inpatient,,,,,,25426.445,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,25426.445,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,9245.98,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,11761.15,102,,,case rate,102% WV Medicaid DRG rate,15255.867,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,10748.62,100,,,case rate,100% PEIA with CHIP DRG base rate,32257.33,100,,,case rate,100% Highmark ACA DRG rate,40791.15,100,,,case rate,100% Highmark PPO DRG rate,40791.15,100,,,case rate,100% Highmark Trad DRG rate,11530.53,100,,,case rate,100% WV Medicaid DRG rate,9245.98,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,9142.76,100,,,case rate,100% PEIA DRG rate,30335.19,100,,,case rate,100% The Health Plan DRG rate,9142.76,40791.15,
URETHRAL PROCEDURES WITHOUT CC/MCC,672,MS-DRG,,,,,Inpatient,,,,,,47157.99,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,47157.99,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,17148.36,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,6689.02,102,,,case rate,102% WV Medicaid DRG rate,28294.794,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,6113.15,100,,,case rate,100% PEIA with CHIP DRG base rate,17386.44,100,,,case rate,100% Highmark ACA DRG rate,21986.1,100,,,case rate,100% Highmark PPO DRG rate,21986.1,100,,,case rate,100% Highmark Trad DRG rate,6557.85,100,,,case rate,100% WV Medicaid DRG rate,17148.36,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,5199.84,100,,,case rate,100% PEIA DRG rate,16350.42,100,,,case rate,100% The Health Plan DRG rate,5199.84,47157.99,
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH MCC,673,MS-DRG,,,,,Inpatient,,,,,,26821.9875,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,26821.9875,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,9753.45,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,13259.48,102,,,case rate,102% WV Medicaid DRG rate,16093.1925,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,12117.96,100,,,case rate,100% PEIA with CHIP DRG base rate,69681.41,100,,,case rate,100% Highmark ACA DRG rate,88115.94,100,,,case rate,100% Highmark PPO DRG rate,88115.94,100,,,case rate,100% Highmark Trad DRG rate,12999.48,100,,,case rate,100% WV Medicaid DRG rate,9753.45,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,10307.52,100,,,case rate,100% PEIA DRG rate,65529.26,100,,,case rate,100% The Health Plan DRG rate,9753.45,88115.94,
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH CC,674,MS-DRG,,,,,Inpatient,,,,,,89964.5175,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,89964.5175,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,32714.37,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,9834.09,102,,,case rate,102% WV Medicaid DRG rate,53978.7105,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,8987.46,100,,,case rate,100% PEIA with CHIP DRG base rate,44887.79,100,,,case rate,100% Highmark ACA DRG rate,56763.06,100,,,case rate,100% Highmark PPO DRG rate,56763.06,100,,,case rate,100% Highmark Trad DRG rate,9641.25,100,,,case rate,100% WV Medicaid DRG rate,32714.37,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,7644.72,100,,,case rate,100% PEIA DRG rate,42213.04,100,,,case rate,100% The Health Plan DRG rate,7644.72,89964.5175,
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITHOUT CC/MCC,675,MS-DRG,,,,,Inpatient,,,,,,61036.3325,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,61036.3325,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,22195.03,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,7068.72,102,,,case rate,102% WV Medicaid DRG rate,36621.7995,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,6460.17,100,,,case rate,100% PEIA with CHIP DRG base rate,29894.42,100,,,case rate,100% Highmark ACA DRG rate,37803.12,100,,,case rate,100% Highmark PPO DRG rate,37803.12,100,,,case rate,100% Highmark Trad DRG rate,6930.12,100,,,case rate,100% WV Medicaid DRG rate,22195.03,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,5495.01,100,,,case rate,100% PEIA DRG rate,28113.08,100,,,case rate,100% The Health Plan DRG rate,5495.01,61036.3325,
RENAL FAILURE WITH MCC,682,MS-DRG,,,,,Inpatient,,,,,,43421.9225,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,43421.9225,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,15789.79,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,6869.07,102,,,case rate,102% WV Medicaid DRG rate,26053.1535,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,6277.7,100,,,case rate,100% PEIA with CHIP DRG base rate,28279.57,100,,,case rate,100% Highmark ACA DRG rate,35761.06,100,,,case rate,100% Highmark PPO DRG rate,35761.06,100,,,case rate,100% Highmark Trad DRG rate,6734.37,100,,,case rate,100% WV Medicaid DRG rate,15789.79,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,5339.8,100,,,case rate,100% PEIA DRG rate,26594.46,100,,,case rate,100% The Health Plan DRG rate,5339.8,43421.9225,
RENAL FAILURE WITH CC,683,MS-DRG,,,,,Inpatient,,,,,,38277.415,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,38277.415,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,13919.06,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,4508.37,102,,,case rate,102% WV Medicaid DRG rate,22966.449,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,4120.24,100,,,case rate,100% PEIA with CHIP DRG base rate,16973.77,100,,,case rate,100% Highmark ACA DRG rate,21464.26,100,,,case rate,100% Highmark PPO DRG rate,21464.26,100,,,case rate,100% Highmark Trad DRG rate,4419.96,100,,,case rate,100% WV Medicaid DRG rate,13919.06,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,3504.67,100,,,case rate,100% PEIA DRG rate,15962.35,100,,,case rate,100% The Health Plan DRG rate,3504.67,38277.415,
RENAL FAILURE WITHOUT CC/MCC,684,MS-DRG,,,,,Inpatient,,,,,,23042.14,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,23042.14,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,8378.96,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,3703.94,102,,,case rate,102% WV Medicaid DRG rate,13825.284,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,3385.06,100,,,case rate,100% PEIA with CHIP DRG base rate,11465.97,100,,,case rate,100% Highmark ACA DRG rate,14499.34,100,,,case rate,100% Highmark PPO DRG rate,14499.34,100,,,case rate,100% Highmark Trad DRG rate,3631.31,100,,,case rate,100% WV Medicaid DRG rate,8378.96,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,2879.33,100,,,case rate,100% PEIA DRG rate,10782.74,100,,,case rate,100% The Health Plan DRG rate,2879.33,23042.14,
KIDNEY AND URINARY TRACT NEOPLASMS WITH MCC,686,MS-DRG,,,,,Inpatient,,,,,,15572.6175,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,15572.6175,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,5662.77,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,13310.74,102,,,case rate,102% WV Medicaid DRG rate,9343.5705,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,12164.8,100,,,case rate,100% PEIA with CHIP DRG base rate,34659.81,100,,,case rate,100% Highmark ACA DRG rate,43829.22,100,,,case rate,100% Highmark PPO DRG rate,43829.22,100,,,case rate,100% Highmark Trad DRG rate,13049.73,100,,,case rate,100% WV Medicaid DRG rate,5662.77,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,10347.36,100,,,case rate,100% PEIA DRG rate,32594.52,100,,,case rate,100% The Health Plan DRG rate,5662.77,43829.22,
KIDNEY AND URINARY TRACT NEOPLASMS WITH CC,687,MS-DRG,,,,,Inpatient,,,,,,43715.4575,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,43715.4575,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,15896.53,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,7668.59,102,,,case rate,102% WV Medicaid DRG rate,26229.2745,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,7008.39,100,,,case rate,100% PEIA with CHIP DRG base rate,19696.59,100,,,case rate,100% Highmark ACA DRG rate,24907.41,100,,,case rate,100% Highmark PPO DRG rate,24907.41,100,,,case rate,100% Highmark Trad DRG rate,7518.22,100,,,case rate,100% WV Medicaid DRG rate,15896.53,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,5961.33,100,,,case rate,100% PEIA DRG rate,18522.91,100,,,case rate,100% The Health Plan DRG rate,5961.33,43715.4575,
KIDNEY AND URINARY TRACT NEOPLASMS WITHOUT CC/MCC,688,MS-DRG,,,,,Inpatient,,,,,,26773.065,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,26773.065,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,9735.66,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,5753.56,102,,,case rate,102% WV Medicaid DRG rate,16063.839,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,5258.23,100,,,case rate,100% PEIA with CHIP DRG base rate,14714.5,100,,,case rate,100% Highmark ACA DRG rate,18607.29,100,,,case rate,100% Highmark PPO DRG rate,18607.29,100,,,case rate,100% Highmark Trad DRG rate,5640.74,100,,,case rate,100% WV Medicaid DRG rate,9735.66,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,4472.64,100,,,case rate,100% PEIA DRG rate,13837.7,100,,,case rate,100% The Health Plan DRG rate,4472.64,26773.065,
KIDNEY AND URINARY TRACT INFECTIONS WITH MCC,689,MS-DRG,,,,,Inpatient,,,,,,22308.33,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,22308.33,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,8112.12,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,5076.15,102,,,case rate,102% WV Medicaid DRG rate,13384.998,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,4639.14,100,,,case rate,100% PEIA with CHIP DRG base rate,22129.22,100,,,case rate,100% Highmark ACA DRG rate,27983.6,100,,,case rate,100% Highmark PPO DRG rate,27983.6,100,,,case rate,100% Highmark Trad DRG rate,4976.61,100,,,case rate,100% WV Medicaid DRG rate,8112.12,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,3946.04,100,,,case rate,100% PEIA DRG rate,20810.59,100,,,case rate,100% The Health Plan DRG rate,3946.04,27983.6,
KIDNEY AND URINARY TRACT INFECTIONS WITHOUT MCC,690,MS-DRG,,,,,Inpatient,,,,,,29535.825,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,29535.825,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,10740.3,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,3196.32,102,,,case rate,102% WV Medicaid DRG rate,17721.495,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,2921.15,100,,,case rate,100% PEIA with CHIP DRG base rate,15204.42,100,,,case rate,100% Highmark ACA DRG rate,19226.81,100,,,case rate,100% Highmark PPO DRG rate,19226.81,100,,,case rate,100% Highmark Trad DRG rate,3133.65,100,,,case rate,100% WV Medicaid DRG rate,10740.3,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,2484.73,100,,,case rate,100% PEIA DRG rate,14298.42,100,,,case rate,100% The Health Plan DRG rate,2484.73,29535.825,
URINARY STONES WITH MCC,693,MS-DRG,,,,,Inpatient,,,,,,20485.355,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,20485.355,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,7449.22,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,9502.96,102,,,case rate,102% WV Medicaid DRG rate,12291.213,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,8684.84,100,,,case rate,100% PEIA with CHIP DRG base rate,26687.34,100,,,case rate,100% Highmark ACA DRG rate,33747.6,100,,,case rate,100% Highmark PPO DRG rate,33747.6,100,,,case rate,100% Highmark Trad DRG rate,9316.62,100,,,case rate,100% WV Medicaid DRG rate,7449.22,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,7387.31,100,,,case rate,100% PEIA DRG rate,25097.11,100,,,case rate,100% The Health Plan DRG rate,7387.31,33747.6,
URINARY STONES WITHOUT MCC,694,MS-DRG,,,,,Inpatient,,,,,,36840.6225,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,36840.6225,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,13396.59,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,3925.43,102,,,case rate,102% WV Medicaid DRG rate,22104.3735,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,3587.49,100,,,case rate,100% PEIA with CHIP DRG base rate,14748.42,100,,,case rate,100% Highmark ACA DRG rate,18650.18,100,,,case rate,100% Highmark PPO DRG rate,18650.18,100,,,case rate,100% Highmark Trad DRG rate,3848.46,100,,,case rate,100% WV Medicaid DRG rate,13396.59,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,3051.51,100,,,case rate,100% PEIA DRG rate,13869.59,100,,,case rate,100% The Health Plan DRG rate,3051.51,36840.6225,
KIDNEY AND URINARY TRACT SIGNS AND SYMPTOMS WITH MCC,695,MS-DRG,,,,,Inpatient,,,,,,20523.965,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,20523.965,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,7463.26,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,7626.25,102,,,case rate,102% WV Medicaid DRG rate,12314.379,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,6969.7,100,,,case rate,100% PEIA with CHIP DRG base rate,22536.23,100,,,case rate,100% Highmark ACA DRG rate,28498.29,100,,,case rate,100% Highmark PPO DRG rate,28498.29,100,,,case rate,100% Highmark Trad DRG rate,7476.71,100,,,case rate,100% WV Medicaid DRG rate,7463.26,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,5928.42,100,,,case rate,100% PEIA DRG rate,21193.35,100,,,case rate,100% The Health Plan DRG rate,5928.42,28498.29,
KIDNEY AND URINARY TRACT SIGNS AND SYMPTOMS WITHOUT MCC,696,MS-DRG,,,,,Inpatient,,,,,,29566.79,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,29566.79,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,10751.56,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,3949.06,102,,,case rate,102% WV Medicaid DRG rate,17740.074,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,3609.08,100,,,case rate,100% PEIA with CHIP DRG base rate,13041.24,100,,,case rate,100% Highmark ACA DRG rate,16491.36,100,,,case rate,100% Highmark PPO DRG rate,16491.36,100,,,case rate,100% Highmark Trad DRG rate,3871.62,100,,,case rate,100% WV Medicaid DRG rate,10751.56,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,3069.88,100,,,case rate,100% PEIA DRG rate,12264.14,100,,,case rate,100% The Health Plan DRG rate,3069.88,29566.79,
URETHRAL STRICTURE,697,MS-DRG,,,,,Inpatient,,,,,,17843.595,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,17843.595,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,6488.58,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,6373.04,102,,,case rate,102% WV Medicaid DRG rate,10706.157,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,5824.38,100,,,case rate,100% PEIA with CHIP DRG base rate,20974.14,100,,,case rate,100% Highmark ACA DRG rate,26522.95,100,,,case rate,100% Highmark PPO DRG rate,26522.95,100,,,case rate,100% Highmark Trad DRG rate,6248.07,100,,,case rate,100% WV Medicaid DRG rate,6488.58,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,4954.21,100,,,case rate,100% PEIA DRG rate,19724.34,100,,,case rate,100% The Health Plan DRG rate,4954.21,26522.95,
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH MCC,698,MS-DRG,,,,,Inpatient,,,,,,25552.5875,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,25552.5875,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,9291.85,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,6681.89,102,,,case rate,102% WV Medicaid DRG rate,15331.5525,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,6106.63,100,,,case rate,100% PEIA with CHIP DRG base rate,31173.86,100,,,case rate,100% Highmark ACA DRG rate,39421.04,100,,,case rate,100% Highmark PPO DRG rate,39421.04,100,,,case rate,100% Highmark Trad DRG rate,6550.86,100,,,case rate,100% WV Medicaid DRG rate,9291.85,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,5194.29,100,,,case rate,100% PEIA DRG rate,29316.28,100,,,case rate,100% The Health Plan DRG rate,5194.29,39421.04,
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH CC,699,MS-DRG,,,,,Inpatient,,,,,,41261.6325,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,41261.6325,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,15004.23,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,4712.48,102,,,case rate,102% WV Medicaid DRG rate,24756.9795,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,4306.78,100,,,case rate,100% PEIA with CHIP DRG base rate,19234.93,100,,,case rate,100% Highmark ACA DRG rate,24323.62,100,,,case rate,100% Highmark PPO DRG rate,24323.62,100,,,case rate,100% Highmark Trad DRG rate,4620.08,100,,,case rate,100% WV Medicaid DRG rate,15004.23,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,3663.34,100,,,case rate,100% PEIA DRG rate,18088.77,100,,,case rate,100% The Health Plan DRG rate,3663.34,41261.6325,
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITHOUT CC/MCC,700,MS-DRG,,,,,Inpatient,,,,,,26059.8525,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,26059.8525,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,9476.31,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,3387.51,102,,,case rate,102% WV Medicaid DRG rate,15635.9115,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,3095.88,100,,,case rate,100% PEIA with CHIP DRG base rate,13346.5,100,,,case rate,100% Highmark ACA DRG rate,16877.37,100,,,case rate,100% Highmark PPO DRG rate,16877.37,100,,,case rate,100% Highmark Trad DRG rate,3321.09,100,,,case rate,100% WV Medicaid DRG rate,9476.31,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,2633.35,100,,,case rate,100% PEIA DRG rate,12551.21,100,,,case rate,100% The Health Plan DRG rate,2633.35,26059.8525,
MAJOR MALE PELVIC PROCEDURES WITH CC/MCC,707,MS-DRG,,,,,Inpatient,,,,,,19074.33,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,19074.33,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,6936.12,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,25548.31,102,,,case rate,102% WV Medicaid DRG rate,11444.598,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,23348.82,100,,,case rate,100% PEIA with CHIP DRG base rate,36968.08,100,,,case rate,100% Highmark ACA DRG rate,46748.15,100,,,case rate,100% Highmark PPO DRG rate,46748.15,100,,,case rate,100% Highmark Trad DRG rate,25047.33,100,,,case rate,100% WV Medicaid DRG rate,6936.12,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,19860.48,100,,,case rate,100% PEIA DRG rate,34765.24,100,,,case rate,100% The Health Plan DRG rate,6936.12,46748.15,
MAJOR MALE PELVIC PROCEDURES WITHOUT CC/MCC,708,MS-DRG,,,,,Inpatient,,,,,,51375.5275,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,51375.5275,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,18682.01,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,15523.92,102,,,case rate,102% WV Medicaid DRG rate,30825.3165,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,14187.45,100,,,case rate,100% PEIA with CHIP DRG base rate,27482.52,100,,,case rate,100% Highmark ACA DRG rate,34753.14,100,,,case rate,100% Highmark PPO DRG rate,34753.14,100,,,case rate,100% Highmark Trad DRG rate,15219.51,100,,,case rate,100% WV Medicaid DRG rate,18682.01,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,12067.82,100,,,case rate,100% PEIA DRG rate,25844.9,100,,,case rate,100% The Health Plan DRG rate,12067.82,51375.5275,
PENIS PROCEDURES WITH CC/MCC,709,MS-DRG,,,,,Inpatient,,,,,,38228.4925,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,38228.4925,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,13901.27,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,16019.5,102,,,case rate,102% WV Medicaid DRG rate,22937.0955,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,14640.36,100,,,case rate,100% PEIA with CHIP DRG base rate,39947.16,100,,,case rate,100% Highmark ACA DRG rate,50515.36,100,,,case rate,100% Highmark PPO DRG rate,50515.36,100,,,case rate,100% Highmark Trad DRG rate,15705.38,100,,,case rate,100% WV Medicaid DRG rate,13901.27,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,12453.07,100,,,case rate,100% PEIA DRG rate,37566.8,100,,,case rate,100% The Health Plan DRG rate,12453.07,50515.36,
PENIS PROCEDURES WITHOUT CC/MCC,710,MS-DRG,,,,,Inpatient,,,,,,62104.845,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,62104.845,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,22583.58,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,9573.37,102,,,case rate,102% WV Medicaid DRG rate,37262.907,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,8749.19,100,,,case rate,100% PEIA with CHIP DRG base rate,23257.91,100,,,case rate,100% Highmark ACA DRG rate,29410.9,100,,,case rate,100% Highmark PPO DRG rate,29410.9,100,,,case rate,100% Highmark Trad DRG rate,9385.65,100,,,case rate,100% WV Medicaid DRG rate,22583.58,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,7442.05,100,,,case rate,100% PEIA DRG rate,21872.03,100,,,case rate,100% The Health Plan DRG rate,7442.05,62104.845,
TESTES PROCEDURES WITH CC/MCC,711,MS-DRG,,,,,Inpatient,,,,,,37113.615,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,37113.615,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,13495.86,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,13571.9,102,,,case rate,102% WV Medicaid DRG rate,22268.169,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,12403.48,100,,,case rate,100% PEIA with CHIP DRG base rate,40001.8,100,,,case rate,100% Highmark ACA DRG rate,50584.46,100,,,case rate,100% Highmark PPO DRG rate,50584.46,100,,,case rate,100% Highmark Trad DRG rate,13305.77,100,,,case rate,100% WV Medicaid DRG rate,13495.86,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,10550.38,100,,,case rate,100% PEIA DRG rate,37618.19,100,,,case rate,100% The Health Plan DRG rate,10550.38,50584.46,
TESTES PROCEDURES WITHOUT CC/MCC,712,MS-DRG,,,,,Inpatient,,,,,,52614.1,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,52614.1,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,19132.4,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,8245.73,102,,,case rate,102% WV Medicaid DRG rate,31568.46,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,7535.85,100,,,case rate,100% PEIA with CHIP DRG base rate,22393.02,100,,,case rate,100% Highmark ACA DRG rate,28317.2,100,,,case rate,100% Highmark PPO DRG rate,28317.2,100,,,case rate,100% Highmark Trad DRG rate,8084.04,100,,,case rate,100% WV Medicaid DRG rate,19132.4,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,6409.98,100,,,case rate,100% PEIA DRG rate,21058.67,100,,,case rate,100% The Health Plan DRG rate,6409.98,52614.1,
TRANSURETHRAL PROSTATECTOMY WITH CC/MCC,713,MS-DRG,,,,,Inpatient,,,,,,31969.1075,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,31969.1075,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,11625.13,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,9842.56,102,,,case rate,102% WV Medicaid DRG rate,19181.4645,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,8995.2,100,,,case rate,100% PEIA with CHIP DRG base rate,27335.54,100,,,case rate,100% Highmark ACA DRG rate,34567.28,100,,,case rate,100% Highmark PPO DRG rate,34567.28,100,,,case rate,100% Highmark Trad DRG rate,9649.55,100,,,case rate,100% WV Medicaid DRG rate,11625.13,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,7651.3,100,,,case rate,100% PEIA DRG rate,25706.68,100,,,case rate,100% The Health Plan DRG rate,7651.3,34567.28,
TRANSURETHRAL PROSTATECTOMY WITHOUT CC/MCC,714,MS-DRG,,,,,Inpatient,,,,,,38156.36,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,38156.36,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,13875.04,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,6363.68,102,,,case rate,102% WV Medicaid DRG rate,22893.816,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,5815.82,100,,,case rate,100% PEIA with CHIP DRG base rate,18061.02,100,,,case rate,100% Highmark ACA DRG rate,22839.14,100,,,case rate,100% Highmark PPO DRG rate,22839.14,100,,,case rate,100% Highmark Trad DRG rate,6238.89,100,,,case rate,100% WV Medicaid DRG rate,13875.04,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,4946.93,100,,,case rate,100% PEIA DRG rate,16984.8,100,,,case rate,100% The Health Plan DRG rate,4946.93,38156.36,
OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES FOR MALIGNANCY WITH CC/MCC,715,MS-DRG,,,,,Inpatient,,,,,,24671.9825,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,24671.9825,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,8971.63,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,14341.12,102,,,case rate,102% WV Medicaid DRG rate,14803.1895,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,13106.47,100,,,case rate,100% PEIA with CHIP DRG base rate,41595.92,100,,,case rate,100% Highmark ACA DRG rate,52600.31,100,,,case rate,100% Highmark PPO DRG rate,52600.31,100,,,case rate,100% Highmark Trad DRG rate,14059.91,100,,,case rate,100% WV Medicaid DRG rate,8971.63,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,11148.35,100,,,case rate,100% PEIA DRG rate,39117.32,100,,,case rate,100% The Health Plan DRG rate,8971.63,52600.31,
OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES FOR MALIGNANCY WITHOUT CC/MCC,716,MS-DRG,,,,,Inpatient,,,,,,57501.0975,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,57501.0975,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,20909.49,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,8439.6,102,,,case rate,102% WV Medicaid DRG rate,34500.6585,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,7713.02,100,,,case rate,100% PEIA with CHIP DRG base rate,26798.51,100,,,case rate,100% Highmark ACA DRG rate,33888.18,100,,,case rate,100% Highmark PPO DRG rate,33888.18,100,,,case rate,100% Highmark Trad DRG rate,8274.11,100,,,case rate,100% WV Medicaid DRG rate,20909.49,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,6560.69,100,,,case rate,100% PEIA DRG rate,25201.65,100,,,case rate,100% The Health Plan DRG rate,6560.69,57501.0975,
OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES EXCEPT MALIGNANCY WITH CC/MCC,717,MS-DRG,,,,,Inpatient,,,,,,33840.95,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,33840.95,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,12305.8,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,9196.78,102,,,case rate,102% WV Medicaid DRG rate,20304.57,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,8405.02,100,,,case rate,100% PEIA with CHIP DRG base rate,34175.55,100,,,case rate,100% Highmark ACA DRG rate,43216.84,100,,,case rate,100% Highmark PPO DRG rate,43216.84,100,,,case rate,100% Highmark Trad DRG rate,9016.45,100,,,case rate,100% WV Medicaid DRG rate,12305.8,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,7149.3,100,,,case rate,100% PEIA DRG rate,32139.11,100,,,case rate,100% The Health Plan DRG rate,7149.3,43216.84,
OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES EXCEPT MALIGNANCY WITHOUT CC/MCC,718,MS-DRG,,,,,Inpatient,,,,,,45582.185,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,45582.185,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,16575.34,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,5587.33,102,,,case rate,102% WV Medicaid DRG rate,27349.311,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,5106.31,100,,,case rate,100% PEIA with CHIP DRG base rate,22155.6,100,,,case rate,100% Highmark ACA DRG rate,28016.96,100,,,case rate,100% Highmark PPO DRG rate,28016.96,100,,,case rate,100% Highmark Trad DRG rate,5477.77,100,,,case rate,100% WV Medicaid DRG rate,16575.34,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,4343.42,100,,,case rate,100% PEIA DRG rate,20835.4,100,,,case rate,100% The Health Plan DRG rate,4343.42,45582.185,
"MALIGNANCY, MALE REPRODUCTIVE SYSTEM WITH MCC",722,MS-DRG,,,,,Inpatient,,,,,,32674.565,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,32674.565,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,11881.66,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,10901.91,102,,,case rate,102% WV Medicaid DRG rate,19604.739,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,9963.35,100,,,case rate,100% PEIA with CHIP DRG base rate,35326.86,100,,,case rate,100% Highmark ACA DRG rate,44672.73,100,,,case rate,100% Highmark PPO DRG rate,44672.73,100,,,case rate,100% Highmark Trad DRG rate,10688.13,100,,,case rate,100% WV Medicaid DRG rate,11881.66,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,8474.81,100,,,case rate,100% PEIA DRG rate,33221.81,100,,,case rate,100% The Health Plan DRG rate,8474.81,44672.73,
"MALIGNANCY, MALE REPRODUCTIVE SYSTEM WITH CC",723,MS-DRG,,,,,Inpatient,,,,,,43712.8725,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,43712.8725,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,15895.59,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,7653.44,102,,,case rate,102% WV Medicaid DRG rate,26227.7235,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,6994.55,100,,,case rate,100% PEIA with CHIP DRG base rate,20996.75,100,,,case rate,100% Highmark ACA DRG rate,26551.54,100,,,case rate,100% Highmark PPO DRG rate,26551.54,100,,,case rate,100% Highmark Trad DRG rate,7503.36,100,,,case rate,100% WV Medicaid DRG rate,15895.59,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,5949.55,100,,,case rate,100% PEIA DRG rate,19745.61,100,,,case rate,100% The Health Plan DRG rate,5949.55,43712.8725,
"MALIGNANCY, MALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC",724,MS-DRG,,,,,Inpatient,,,,,,29672.335,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,29672.335,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,10789.94,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,4913.03,102,,,case rate,102% WV Medicaid DRG rate,17803.401,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,4490.06,100,,,case rate,100% PEIA with CHIP DRG base rate,15253.41,100,,,case rate,100% Highmark ACA DRG rate,19288.77,100,,,case rate,100% Highmark PPO DRG rate,19288.77,100,,,case rate,100% Highmark Trad DRG rate,4816.69,100,,,case rate,100% WV Medicaid DRG rate,10789.94,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,3819.24,100,,,case rate,100% PEIA DRG rate,14344.49,100,,,case rate,100% The Health Plan DRG rate,3819.24,29672.335,
BENIGN PROSTATIC HYPERTROPHY WITH MCC,725,MS-DRG,,,,,Inpatient,,,,,,19700.01,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,19700.01,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,7163.64,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,8022.01,102,,,case rate,102% WV Medicaid DRG rate,11820.006,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,7331.38,100,,,case rate,100% PEIA with CHIP DRG base rate,23382.28,100,,,case rate,100% Highmark ACA DRG rate,29568.17,100,,,case rate,100% Highmark PPO DRG rate,29568.17,100,,,case rate,100% Highmark Trad DRG rate,7864.7,100,,,case rate,100% WV Medicaid DRG rate,7163.64,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,6236.06,100,,,case rate,100% PEIA DRG rate,21988.98,100,,,case rate,100% The Health Plan DRG rate,6236.06,29568.17,
BENIGN PROSTATIC HYPERTROPHY WITHOUT MCC,726,MS-DRG,,,,,Inpatient,,,,,,32167.355,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,32167.355,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,11697.22,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,5124.28,102,,,case rate,102% WV Medicaid DRG rate,19300.413,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,4683.12,100,,,case rate,100% PEIA with CHIP DRG base rate,13772.35,100,,,case rate,100% Highmark ACA DRG rate,17415.89,100,,,case rate,100% Highmark PPO DRG rate,17415.89,100,,,case rate,100% Highmark Trad DRG rate,5023.8,100,,,case rate,100% WV Medicaid DRG rate,11697.22,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,3983.46,100,,,case rate,100% PEIA DRG rate,12951.69,100,,,case rate,100% The Health Plan DRG rate,3983.46,32167.355,
INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITH MCC,727,MS-DRG,,,,,Inpatient,,,,,,19867.375,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,19867.375,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,7224.5,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,9542.62,102,,,case rate,102% WV Medicaid DRG rate,11920.425,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,8721.09,100,,,case rate,100% PEIA with CHIP DRG base rate,30544.5,100,,,case rate,100% Highmark ACA DRG rate,38625.19,100,,,case rate,100% Highmark PPO DRG rate,38625.19,100,,,case rate,100% Highmark Trad DRG rate,9355.5,100,,,case rate,100% WV Medicaid DRG rate,7224.5,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,7418.14,100,,,case rate,100% PEIA DRG rate,28724.43,100,,,case rate,100% The Health Plan DRG rate,7224.5,38625.19,
INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITHOUT MCC,728,MS-DRG,,,,,Inpatient,,,,,,36995.145,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,36995.145,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,13452.78,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,3551.07,102,,,case rate,102% WV Medicaid DRG rate,22197.087,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,3245.36,100,,,case rate,100% PEIA with CHIP DRG base rate,15076.28,100,,,case rate,100% Highmark ACA DRG rate,19064.78,100,,,case rate,100% Highmark PPO DRG rate,19064.78,100,,,case rate,100% Highmark Trad DRG rate,3481.44,100,,,case rate,100% WV Medicaid DRG rate,13452.78,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,2760.5,100,,,case rate,100% PEIA DRG rate,14177.92,100,,,case rate,100% The Health Plan DRG rate,2760.5,36995.145,
OTHER MALE REPRODUCTIVE SYSTEM DIAGNOSES WITH CC/MCC,729,MS-DRG,,,,,Inpatient,,,,,,21157.3725,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,21157.3725,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,7693.59,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,7157.86,102,,,case rate,102% WV Medicaid DRG rate,12694.4235,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,6541.63,100,,,case rate,100% PEIA with CHIP DRG base rate,18916.49,100,,,case rate,100% Highmark ACA DRG rate,23920.93,100,,,case rate,100% Highmark PPO DRG rate,23920.93,100,,,case rate,100% Highmark Trad DRG rate,7017.5,100,,,case rate,100% WV Medicaid DRG rate,7693.59,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,5564.3,100,,,case rate,100% PEIA DRG rate,17789.3,100,,,case rate,100% The Health Plan DRG rate,5564.3,23920.93,
OTHER MALE REPRODUCTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC,730,MS-DRG,,,,,Inpatient,,,,,,27751.4875,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,27751.4875,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,10091.45,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,4355.5,102,,,case rate,102% WV Medicaid DRG rate,16650.8925,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,3980.53,100,,,case rate,100% PEIA with CHIP DRG base rate,11712.81,100,,,case rate,100% Highmark ACA DRG rate,14811.48,100,,,case rate,100% Highmark PPO DRG rate,14811.48,100,,,case rate,100% Highmark Trad DRG rate,4270.1,100,,,case rate,100% WV Medicaid DRG rate,10091.45,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,3385.84,100,,,case rate,100% PEIA DRG rate,11014.87,100,,,case rate,100% The Health Plan DRG rate,3385.84,27751.4875,
"PELVIC EVISCERATION, RADICAL HYSTERECTOMY AND RADICAL VULVECTOMY WITH CC/MCC",734,MS-DRG,,,,,Inpatient,,,,,,16885.7425,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,16885.7425,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,6140.27,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,14513.59,102,,,case rate,102% WV Medicaid DRG rate,10131.4455,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,13264.1,100,,,case rate,100% PEIA with CHIP DRG base rate,40957.14,100,,,case rate,100% Highmark ACA DRG rate,51792.54,100,,,case rate,100% Highmark PPO DRG rate,51792.54,100,,,case rate,100% Highmark Trad DRG rate,14229,100,,,case rate,100% WV Medicaid DRG rate,6140.27,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,11282.43,100,,,case rate,100% PEIA DRG rate,38516.6,100,,,case rate,100% The Health Plan DRG rate,6140.27,51792.54,
"PELVIC EVISCERATION, RADICAL HYSTERECTOMY AND RADICAL VULVECTOMY WITHOUT CC/MCC",735,MS-DRG,,,,,Inpatient,,,,,,56265.165,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,56265.165,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,20460.06,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,8169.08,102,,,case rate,102% WV Medicaid DRG rate,33759.099,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,7465.79,100,,,case rate,100% PEIA with CHIP DRG base rate,23745.95,100,,,case rate,100% Highmark ACA DRG rate,30028.05,100,,,case rate,100% Highmark PPO DRG rate,30028.05,100,,,case rate,100% Highmark Trad DRG rate,8008.89,100,,,case rate,100% WV Medicaid DRG rate,20460.06,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,6350.39,100,,,case rate,100% PEIA DRG rate,22330.98,100,,,case rate,100% The Health Plan DRG rate,6350.39,56265.165,
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH MCC,736,MS-DRG,,,,,Inpatient,,,,,,32756.955,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,32756.955,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,11911.62,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,28327.93,102,,,case rate,102% WV Medicaid DRG rate,19654.173,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,25889.15,100,,,case rate,100% PEIA with CHIP DRG base rate,73246.51,100,,,case rate,100% Highmark ACA DRG rate,92624.2,100,,,case rate,100% Highmark PPO DRG rate,92624.2,100,,,case rate,100% Highmark Trad DRG rate,27772.45,100,,,case rate,100% WV Medicaid DRG rate,11911.62,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,22021.27,100,,,case rate,100% PEIA DRG rate,68881.92,100,,,case rate,100% The Health Plan DRG rate,11911.62,92624.2,
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH CC,737,MS-DRG,,,,,Inpatient,,,,,,109821.6075,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,109821.6075,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,39935.13,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,10374.68,102,,,case rate,102% WV Medicaid DRG rate,65892.9645,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,9481.51,100,,,case rate,100% PEIA with CHIP DRG base rate,37192.31,100,,,case rate,100% Highmark ACA DRG rate,47031.71,100,,,case rate,100% Highmark PPO DRG rate,47031.71,100,,,case rate,100% Highmark Trad DRG rate,10171.25,100,,,case rate,100% WV Medicaid DRG rate,39935.13,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,8064.96,100,,,case rate,100% PEIA DRG rate,34976.11,100,,,case rate,100% The Health Plan DRG rate,8064.96,109821.6075,
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITHOUT CC/MCC,738,MS-DRG,,,,,Inpatient,,,,,,52101.61,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,52101.61,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,18946.04,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,7457.79,102,,,case rate,102% WV Medicaid DRG rate,31260.966,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,6815.74,100,,,case rate,100% PEIA with CHIP DRG base rate,25713.16,100,,,case rate,100% Highmark ACA DRG rate,32515.69,100,,,case rate,100% Highmark PPO DRG rate,32515.69,100,,,case rate,100% Highmark Trad DRG rate,7311.55,100,,,case rate,100% WV Medicaid DRG rate,18946.04,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,5797.46,100,,,case rate,100% PEIA DRG rate,24180.97,100,,,case rate,100% The Health Plan DRG rate,5797.46,52101.61,
UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITH MCC,739,MS-DRG,,,,,Inpatient,,,,,,36145.45,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,36145.45,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,13143.8,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,25058.96,102,,,case rate,102% WV Medicaid DRG rate,21687.27,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,22901.61,100,,,case rate,100% PEIA with CHIP DRG base rate,68141.94,100,,,case rate,100% Highmark ACA DRG rate,86169.2,100,,,case rate,100% Highmark PPO DRG rate,86169.2,100,,,case rate,100% Highmark Trad DRG rate,24567.59,100,,,case rate,100% WV Medicaid DRG rate,13143.8,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,19480.08,100,,,case rate,100% PEIA DRG rate,64081.52,100,,,case rate,100% The Health Plan DRG rate,13143.8,86169.2,
UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITH CC,740,MS-DRG,,,,,Inpatient,,,,,,100477.5475,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,100477.5475,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,36537.29,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,8686.94,102,,,case rate,102% WV Medicaid DRG rate,60286.5285,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,7939.07,100,,,case rate,100% PEIA with CHIP DRG base rate,33672.44,100,,,case rate,100% Highmark ACA DRG rate,42580.64,100,,,case rate,100% Highmark PPO DRG rate,42580.64,100,,,case rate,100% Highmark Trad DRG rate,8516.6,100,,,case rate,100% WV Medicaid DRG rate,36537.29,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,6752.96,100,,,case rate,100% PEIA DRG rate,31665.98,100,,,case rate,100% The Health Plan DRG rate,6752.96,100477.5475,
UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITHOUT CC/MCC,741,MS-DRG,,,,,Inpatient,,,,,,46408.7525,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,46408.7525,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,16875.91,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,7492.11,102,,,case rate,102% WV Medicaid DRG rate,27845.2515,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,6847.1,100,,,case rate,100% PEIA with CHIP DRG base rate,24482.71,100,,,case rate,100% Highmark ACA DRG rate,30959.72,100,,,case rate,100% Highmark PPO DRG rate,30959.72,100,,,case rate,100% Highmark Trad DRG rate,7345.2,100,,,case rate,100% WV Medicaid DRG rate,16875.91,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,5824.14,100,,,case rate,100% PEIA DRG rate,23023.84,100,,,case rate,100% The Health Plan DRG rate,5824.14,46408.7525,
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITH CC/MCC,742,MS-DRG,,,,,Inpatient,,,,,,33804.925,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,33804.925,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,12292.7,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,9101.86,102,,,case rate,102% WV Medicaid DRG rate,20282.955,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,8318.27,100,,,case rate,100% PEIA with CHIP DRG base rate,33576.34,100,,,case rate,100% Highmark ACA DRG rate,42459.11,100,,,case rate,100% Highmark PPO DRG rate,42459.11,100,,,case rate,100% Highmark Trad DRG rate,8923.38,100,,,case rate,100% WV Medicaid DRG rate,12292.7,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,7075.51,100,,,case rate,100% PEIA DRG rate,31575.61,100,,,case rate,100% The Health Plan DRG rate,7075.51,42459.11,
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITHOUT CC/MCC,743,MS-DRG,,,,,Inpatient,,,,,,46401.025,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,46401.025,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,16873.1,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,6461.28,102,,,case rate,102% WV Medicaid DRG rate,27840.615,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,5905.02,100,,,case rate,100% PEIA with CHIP DRG base rate,21895.57,100,,,case rate,100% Highmark ACA DRG rate,27688.14,100,,,case rate,100% Highmark PPO DRG rate,27688.14,100,,,case rate,100% Highmark Trad DRG rate,6334.58,100,,,case rate,100% WV Medicaid DRG rate,16873.1,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,5022.8,100,,,case rate,100% PEIA DRG rate,20590.86,100,,,case rate,100% The Health Plan DRG rate,5022.8,46401.025,
"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITH CC/MCC",744,MS-DRG,,,,,Inpatient,,,,,,30140.9625,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,30140.9625,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,10960.35,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,6796.42,102,,,case rate,102% WV Medicaid DRG rate,18084.5775,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,6211.31,100,,,case rate,100% PEIA with CHIP DRG base rate,35470.06,100,,,case rate,100% Highmark ACA DRG rate,44853.83,100,,,case rate,100% Highmark PPO DRG rate,44853.83,100,,,case rate,100% Highmark Trad DRG rate,6663.15,100,,,case rate,100% WV Medicaid DRG rate,10960.35,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,5283.33,100,,,case rate,100% PEIA DRG rate,33356.49,100,,,case rate,100% The Health Plan DRG rate,5283.33,44853.83,
"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITHOUT CC/MCC",745,MS-DRG,,,,,Inpatient,,,,,,48878.005,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,48878.005,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,17773.82,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,4130,102,,,case rate,102% WV Medicaid DRG rate,29326.803,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,3774.44,100,,,case rate,100% PEIA with CHIP DRG base rate,19519.46,100,,,case rate,100% Highmark ACA DRG rate,24683.43,100,,,case rate,100% Highmark PPO DRG rate,24683.43,100,,,case rate,100% Highmark Trad DRG rate,4049.01,100,,,case rate,100% WV Medicaid DRG rate,17773.82,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,3210.53,100,,,case rate,100% PEIA DRG rate,18356.34,100,,,case rate,100% The Health Plan DRG rate,3210.53,48878.005,
"VAGINA, CERVIX AND VULVA PROCEDURES WITH CC/MCC",746,MS-DRG,,,,,Inpatient,,,,,,29631.1675,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,29631.1675,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,10774.97,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,6590.97,102,,,case rate,102% WV Medicaid DRG rate,17778.7005,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,6023.54,100,,,case rate,100% PEIA with CHIP DRG base rate,31582.75,100,,,case rate,100% Highmark ACA DRG rate,39938.11,100,,,case rate,100% Highmark PPO DRG rate,39938.11,100,,,case rate,100% Highmark Trad DRG rate,6461.73,100,,,case rate,100% WV Medicaid DRG rate,10774.97,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,5123.62,100,,,case rate,100% PEIA DRG rate,29700.81,100,,,case rate,100% The Health Plan DRG rate,5123.62,39938.11,
"VAGINA, CERVIX AND VULVA PROCEDURES WITHOUT CC/MCC",747,MS-DRG,,,,,Inpatient,,,,,,40254.8575,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,40254.8575,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,14638.13,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,4004.76,102,,,case rate,102% WV Medicaid DRG rate,24152.9145,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,3659.99,100,,,case rate,100% PEIA with CHIP DRG base rate,16717.51,100,,,case rate,100% Highmark ACA DRG rate,21140.2,100,,,case rate,100% Highmark PPO DRG rate,21140.2,100,,,case rate,100% Highmark Trad DRG rate,3926.24,100,,,case rate,100% WV Medicaid DRG rate,14638.13,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,3113.18,100,,,case rate,100% PEIA DRG rate,15721.35,100,,,case rate,100% The Health Plan DRG rate,3113.18,40254.8575,
FEMALE REPRODUCTIVE SYSTEM RECONSTRUCTIVE PROCEDURES,748,MS-DRG,,,,,Inpatient,,,,,,25197.2875,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,25197.2875,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,9162.65,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,9412.49,102,,,case rate,102% WV Medicaid DRG rate,15118.3725,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,8602.15,100,,,case rate,100% PEIA with CHIP DRG base rate,26472.53,100,,,case rate,100% Highmark ACA DRG rate,33475.96,100,,,case rate,100% Highmark PPO DRG rate,33475.96,100,,,case rate,100% Highmark Trad DRG rate,9227.92,100,,,case rate,100% WV Medicaid DRG rate,9162.65,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,7316.98,100,,,case rate,100% PEIA DRG rate,24895.09,100,,,case rate,100% The Health Plan DRG rate,7316.98,33475.96,
OTHER FEMALE REPRODUCTIVE SYSTEM O.R. PROCEDURES WITH CC/MCC,749,MS-DRG,,,,,Inpatient,,,,,,36490.465,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,36490.465,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,13269.26,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,10521.75,102,,,case rate,102% WV Medicaid DRG rate,21894.279,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,9615.92,100,,,case rate,100% PEIA with CHIP DRG base rate,47431.6,100,,,case rate,100% Highmark ACA DRG rate,59979.84,100,,,case rate,100% Highmark PPO DRG rate,59979.84,100,,,case rate,100% Highmark Trad DRG rate,10315.43,100,,,case rate,100% WV Medicaid DRG rate,13269.26,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,8179.29,100,,,case rate,100% PEIA DRG rate,44605.26,100,,,case rate,100% The Health Plan DRG rate,8179.29,59979.84,
OTHER FEMALE REPRODUCTIVE SYSTEM O.R. PROCEDURES WITHOUT CC/MCC,750,MS-DRG,,,,,Inpatient,,,,,,65045.3375,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,65045.3375,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,23652.85,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,9478.45,102,,,case rate,102% WV Medicaid DRG rate,39027.2025,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,8662.44,100,,,case rate,100% PEIA with CHIP DRG base rate,25626.48,100,,,case rate,100% Highmark ACA DRG rate,32406.08,100,,,case rate,100% Highmark PPO DRG rate,32406.08,100,,,case rate,100% Highmark Trad DRG rate,9292.58,100,,,case rate,100% WV Medicaid DRG rate,23652.85,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,7368.26,100,,,case rate,100% PEIA DRG rate,24099.46,100,,,case rate,100% The Health Plan DRG rate,7368.26,65045.3375,
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITH MCC",754,MS-DRG,,,,,Inpatient,,,,,,36742.805,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,36742.805,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,13361.02,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,12488.04,102,,,case rate,102% WV Medicaid DRG rate,22045.683,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,11412.93,100,,,case rate,100% PEIA with CHIP DRG base rate,34906.66,100,,,case rate,100% Highmark ACA DRG rate,44141.37,100,,,case rate,100% Highmark PPO DRG rate,44141.37,100,,,case rate,100% Highmark Trad DRG rate,12243.16,100,,,case rate,100% WV Medicaid DRG rate,13361.02,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,9707.82,100,,,case rate,100% PEIA DRG rate,32826.65,100,,,case rate,100% The Health Plan DRG rate,9707.82,44141.37,
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITH CC",755,MS-DRG,,,,,Inpatient,,,,,,44722.205,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,44722.205,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,16262.62,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,8243.5,102,,,case rate,102% WV Medicaid DRG rate,26833.323,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,7533.81,100,,,case rate,100% PEIA with CHIP DRG base rate,20439,100,,,case rate,100% Highmark ACA DRG rate,25846.23,100,,,case rate,100% Highmark PPO DRG rate,25846.23,100,,,case rate,100% Highmark Trad DRG rate,8081.86,100,,,case rate,100% WV Medicaid DRG rate,16262.62,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,6408.25,100,,,case rate,100% PEIA DRG rate,19221.09,100,,,case rate,100% The Health Plan DRG rate,6408.25,44722.205,
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC",756,MS-DRG,,,,,Inpatient,,,,,,27836.49,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,27836.49,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,10122.36,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,6619.94,102,,,case rate,102% WV Medicaid DRG rate,16701.894,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,6050.02,100,,,case rate,100% PEIA with CHIP DRG base rate,18648.92,100,,,case rate,100% Highmark ACA DRG rate,23582.57,100,,,case rate,100% Highmark PPO DRG rate,23582.57,100,,,case rate,100% Highmark Trad DRG rate,6490.13,100,,,case rate,100% WV Medicaid DRG rate,10122.36,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,5146.14,100,,,case rate,100% PEIA DRG rate,17537.67,100,,,case rate,100% The Health Plan DRG rate,5146.14,27836.49,
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH MCC",757,MS-DRG,,,,,Inpatient,,,,,,25665.8875,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,25665.8875,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,9333.05,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,9114.34,102,,,case rate,102% WV Medicaid DRG rate,15399.5325,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,8329.67,100,,,case rate,100% PEIA with CHIP DRG base rate,28106.22,100,,,case rate,100% Highmark ACA DRG rate,35541.84,100,,,case rate,100% Highmark PPO DRG rate,35541.84,100,,,case rate,100% Highmark Trad DRG rate,8935.61,100,,,case rate,100% WV Medicaid DRG rate,9333.05,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,7085.21,100,,,case rate,100% PEIA DRG rate,26431.44,100,,,case rate,100% The Health Plan DRG rate,7085.21,35541.84,
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH CC",758,MS-DRG,,,,,Inpatient,,,,,,35331.8075,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,35331.8075,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,12847.93,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,3760.54,102,,,case rate,102% WV Medicaid DRG rate,21199.0845,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,3436.79,100,,,case rate,100% PEIA with CHIP DRG base rate,18703.56,100,,,case rate,100% Highmark ACA DRG rate,23651.67,100,,,case rate,100% Highmark PPO DRG rate,23651.67,100,,,case rate,100% Highmark Trad DRG rate,3686.8,100,,,case rate,100% WV Medicaid DRG rate,12847.93,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,2923.33,100,,,case rate,100% PEIA DRG rate,17589.06,100,,,case rate,100% The Health Plan DRG rate,2923.33,35331.8075,
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC",759,MS-DRG,,,,,Inpatient,,,,,,24602.49,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,24602.49,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,8946.36,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,3000.23,102,,,case rate,102% WV Medicaid DRG rate,14761.494,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,2741.94,100,,,case rate,100% PEIA with CHIP DRG base rate,12176.35,100,,,case rate,100% Highmark ACA DRG rate,15397.65,100,,,case rate,100% Highmark PPO DRG rate,15397.65,100,,,case rate,100% Highmark Trad DRG rate,2941.4,100,,,case rate,100% WV Medicaid DRG rate,8946.36,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,2332.29,100,,,case rate,100% PEIA DRG rate,11450.79,100,,,case rate,100% The Health Plan DRG rate,2332.29,24602.49,
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITH CC/MCC,760,MS-DRG,,,,,Inpatient,,,,,,15974.2825,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,15974.2825,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,5808.83,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,5215.2,102,,,case rate,102% WV Medicaid DRG rate,9584.5695,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,4766.21,100,,,case rate,100% PEIA with CHIP DRG base rate,18756.32,100,,,case rate,100% Highmark ACA DRG rate,23718.39,100,,,case rate,100% Highmark PPO DRG rate,23718.39,100,,,case rate,100% Highmark Trad DRG rate,5112.93,100,,,case rate,100% WV Medicaid DRG rate,5808.83,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,4054.13,100,,,case rate,100% PEIA DRG rate,17638.68,100,,,case rate,100% The Health Plan DRG rate,4054.13,23718.39,
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITHOUT CC/MCC,761,MS-DRG,,,,,Inpatient,,,,,,24888.2975,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,24888.2975,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,9050.29,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,4876.93,102,,,case rate,102% WV Medicaid DRG rate,14932.9785,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,4457.07,100,,,case rate,100% PEIA with CHIP DRG base rate,11411.32,100,,,case rate,100% Highmark ACA DRG rate,14430.24,100,,,case rate,100% Highmark PPO DRG rate,14430.24,100,,,case rate,100% Highmark Trad DRG rate,4781.3,100,,,case rate,100% WV Medicaid DRG rate,9050.29,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,3791.18,100,,,case rate,100% PEIA DRG rate,10731.35,100,,,case rate,100% The Health Plan DRG rate,3791.18,24888.2975,
VAGINAL DELIVERY WITH O.R. PROCEDURES EXCEPT STERILIZATION AND/OR D&C,768,MS-DRG,,,,,Inpatient,,,,,,14565.7875,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,14565.7875,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,5296.65,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,3135.27,102,,,case rate,102% WV Medicaid DRG rate,8739.4725,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,2865.35,100,,,case rate,100% PEIA with CHIP DRG base rate,22952.66,100,,,case rate,100% Highmark ACA DRG rate,29024.89,100,,,case rate,100% Highmark PPO DRG rate,29024.89,100,,,case rate,100% Highmark Trad DRG rate,3073.79,100,,,case rate,100% WV Medicaid DRG rate,5296.65,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,2437.26,100,,,case rate,100% PEIA DRG rate,21584.96,100,,,case rate,100% The Health Plan DRG rate,2437.26,29024.89,
POSTPARTUM AND POST ABORTION DIAGNOSES WITH O.R. PROCEDURES,769,MS-DRG,,,,,Inpatient,,,,,,29528.1525,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,29528.1525,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,10737.51,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,5286.95,102,,,case rate,102% WV Medicaid DRG rate,17716.8915,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,4831.79,100,,,case rate,100% PEIA with CHIP DRG base rate,29091.71,100,,,case rate,100% Highmark ACA DRG rate,36788.05,100,,,case rate,100% Highmark PPO DRG rate,36788.05,100,,,case rate,100% Highmark Trad DRG rate,5183.28,100,,,case rate,100% WV Medicaid DRG rate,10737.51,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,4109.91,100,,,case rate,100% PEIA DRG rate,27358.2,100,,,case rate,100% The Health Plan DRG rate,4109.91,36788.05,
"ABORTION WITH D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY",770,MS-DRG,,,,,Inpatient,,,,,,42775.645,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,42775.645,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,15554.78,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,3467.73,102,,,case rate,102% WV Medicaid DRG rate,25665.387,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,3169.19,100,,,case rate,100% PEIA with CHIP DRG base rate,15049.9,100,,,case rate,100% Highmark ACA DRG rate,19031.42,100,,,case rate,100% Highmark PPO DRG rate,19031.42,100,,,case rate,100% Highmark Trad DRG rate,3399.74,100,,,case rate,100% WV Medicaid DRG rate,15554.78,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,2695.71,100,,,case rate,100% PEIA DRG rate,14153.12,100,,,case rate,100% The Health Plan DRG rate,2695.71,42775.645,
POSTPARTUM AND POST ABORTION DIAGNOSES WITHOUT O.R. PROCEDURES,776,MS-DRG,,,,,Inpatient,,,,,,22292.875,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,22292.875,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,8106.5,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,2779.63,102,,,case rate,102% WV Medicaid DRG rate,13375.725,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,2540.32,100,,,case rate,100% PEIA with CHIP DRG base rate,13504.78,100,,,case rate,100% Highmark ACA DRG rate,17077.53,100,,,case rate,100% Highmark PPO DRG rate,17077.53,100,,,case rate,100% Highmark Trad DRG rate,2725.12,100,,,case rate,100% WV Medicaid DRG rate,8106.5,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,2160.8,100,,,case rate,100% PEIA DRG rate,12700.06,100,,,case rate,100% The Health Plan DRG rate,2160.8,22292.875,
ABORTION WITHOUT D&C,779,MS-DRG,,,,,Inpatient,,,,,,17949.1125,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,17949.1125,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,6526.95,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,3555.53,102,,,case rate,102% WV Medicaid DRG rate,10769.4675,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,3249.43,100,,,case rate,100% PEIA with CHIP DRG base rate,18639.5,100,,,case rate,100% Highmark ACA DRG rate,23570.66,100,,,case rate,100% Highmark PPO DRG rate,23570.66,100,,,case rate,100% Highmark Trad DRG rate,3485.81,100,,,case rate,100% WV Medicaid DRG rate,6526.95,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,2763.96,100,,,case rate,100% PEIA DRG rate,17528.81,100,,,case rate,100% The Health Plan DRG rate,2763.96,23570.66,
CESAREAN SECTION WITH STERILIZATION WITH MCC,783,MS-DRG,,,,,Inpatient,,,,,,26227.2175,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,26227.2175,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,9537.17,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,4940.22,102,,,case rate,102% WV Medicaid DRG rate,15736.3305,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,4514.91,100,,,case rate,100% PEIA with CHIP DRG base rate,33386.03,100,,,case rate,100% Highmark ACA DRG rate,42218.45,100,,,case rate,100% Highmark PPO DRG rate,42218.45,100,,,case rate,100% Highmark Trad DRG rate,4843.35,100,,,case rate,100% WV Medicaid DRG rate,9537.17,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,3840.38,100,,,case rate,100% PEIA DRG rate,31396.63,100,,,case rate,100% The Health Plan DRG rate,3840.38,42218.45,
CESAREAN SECTION WITH STERILIZATION WITH CC,784,MS-DRG,,,,,Inpatient,,,,,,49686.505,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,49686.505,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,18067.82,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,4257.9,102,,,case rate,102% WV Medicaid DRG rate,29811.903,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,3891.33,100,,,case rate,100% PEIA with CHIP DRG base rate,19297.12,100,,,case rate,100% Highmark ACA DRG rate,24402.25,100,,,case rate,100% Highmark PPO DRG rate,24402.25,100,,,case rate,100% Highmark Trad DRG rate,4174.41,100,,,case rate,100% WV Medicaid DRG rate,18067.82,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,3309.96,100,,,case rate,100% PEIA DRG rate,18147.25,100,,,case rate,100% The Health Plan DRG rate,3309.96,49686.505,
CESAREAN SECTION WITH STERILIZATION WITHOUT CC/MCC,785,MS-DRG,,,,,Inpatient,,,,,,26881.25,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,26881.25,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,9775,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,3060.4,102,,,case rate,102% WV Medicaid DRG rate,16128.75,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,2796.92,100,,,case rate,100% PEIA with CHIP DRG base rate,16323.69,100,,,case rate,100% Highmark ACA DRG rate,20642.2,100,,,case rate,100% Highmark PPO DRG rate,20642.2,100,,,case rate,100% Highmark Trad DRG rate,3000.38,100,,,case rate,100% WV Medicaid DRG rate,9775,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,2379.06,100,,,case rate,100% PEIA DRG rate,15351,100,,,case rate,100% The Health Plan DRG rate,2379.06,26881.25,
CESAREAN SECTION WITHOUT STERILIZATION WITH MCC,786,MS-DRG,,,,,Inpatient,,,,,,23485.0275,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,23485.0275,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,8540.01,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,4614.44,102,,,case rate,102% WV Medicaid DRG rate,14091.0165,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,4217.17,100,,,case rate,100% PEIA with CHIP DRG base rate,32965.83,100,,,case rate,100% Highmark ACA DRG rate,41687.09,100,,,case rate,100% Highmark PPO DRG rate,41687.09,100,,,case rate,100% Highmark Trad DRG rate,4523.95,100,,,case rate,100% WV Medicaid DRG rate,8540.01,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,3587.12,100,,,case rate,100% PEIA DRG rate,31001.47,100,,,case rate,100% The Health Plan DRG rate,3587.12,41687.09,
CESAREAN SECTION WITHOUT STERILIZATION WITH CC,787,MS-DRG,,,,,Inpatient,,,,,,41583.5475,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,41583.5475,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,15121.29,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,3851.9,102,,,case rate,102% WV Medicaid DRG rate,24950.1285,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,3520.29,100,,,case rate,100% PEIA with CHIP DRG base rate,19805.88,100,,,case rate,100% Highmark ACA DRG rate,25045.61,100,,,case rate,100% Highmark PPO DRG rate,25045.61,100,,,case rate,100% Highmark Trad DRG rate,3776.37,100,,,case rate,100% WV Medicaid DRG rate,15121.29,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,2994.35,100,,,case rate,100% PEIA DRG rate,18625.69,100,,,case rate,100% The Health Plan DRG rate,2994.35,41583.5475,
CESAREAN SECTION WITHOUT STERILIZATION WITHOUT CC/MCC,788,MS-DRG,,,,,Inpatient,,,,,,27429.655,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,27429.655,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,9974.42,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,3537.26,102,,,case rate,102% WV Medicaid DRG rate,16457.793,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,3232.73,100,,,case rate,100% PEIA with CHIP DRG base rate,16110.77,100,,,case rate,100% Highmark ACA DRG rate,20372.94,100,,,case rate,100% Highmark PPO DRG rate,20372.94,100,,,case rate,100% Highmark Trad DRG rate,3467.9,100,,,case rate,100% WV Medicaid DRG rate,9974.42,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,2749.76,100,,,case rate,100% PEIA DRG rate,15150.76,100,,,case rate,100% The Health Plan DRG rate,2749.76,27429.655,
"NEONATES, DIED OR TRANSFERRED TO ANOTHER ACUTE CARE FACILITY",789,MS-DRG,,,,,Inpatient,,,,,,22462.825,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,22462.825,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,8168.3,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,1092.78,102,,,case rate,102% WV Medicaid DRG rate,13477.695,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,998.7,100,,,case rate,100% PEIA with CHIP DRG base rate,34282.95,100,,,case rate,100% Highmark ACA DRG rate,43352.66,100,,,case rate,100% Highmark PPO DRG rate,43352.66,100,,,case rate,100% Highmark Trad DRG rate,1071.35,100,,,case rate,100% WV Medicaid DRG rate,8168.3,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,849.49,100,,,case rate,100% PEIA DRG rate,32240.11,100,,,case rate,100% The Health Plan DRG rate,849.49,43352.66,
"EXTREME IMMATURITY OR RESPIRATORY DISTRESS SYNDROME, NEONATE",790,MS-DRG,,,,,Inpatient,,,,,,47011.2225,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,47011.2225,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,17094.99,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,6072.21,102,,,case rate,102% WV Medicaid DRG rate,28206.7335,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,5549.45,100,,,case rate,100% PEIA with CHIP DRG base rate,113059.88,100,,,case rate,100% Highmark ACA DRG rate,142970.38,100,,,case rate,100% Highmark PPO DRG rate,142970.38,100,,,case rate,100% Highmark Trad DRG rate,5953.14,100,,,case rate,100% WV Medicaid DRG rate,17094.99,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,4720.35,100,,,case rate,100% PEIA DRG rate,106322.91,100,,,case rate,100% The Health Plan DRG rate,4720.35,142970.38,
PREMATURITY WITH MAJOR PROBLEMS,791,MS-DRG,,,,,Inpatient,,,,,,155033.01,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,155033.01,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,56375.64,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,4109.05,102,,,case rate,102% WV Medicaid DRG rate,93019.806,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,3755.3,100,,,case rate,100% PEIA with CHIP DRG base rate,77212.96,100,,,case rate,100% Highmark ACA DRG rate,97640,100,,,case rate,100% Highmark PPO DRG rate,97640,100,,,case rate,100% Highmark Trad DRG rate,4028.48,100,,,case rate,100% WV Medicaid DRG rate,56375.64,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,3194.25,100,,,case rate,100% PEIA DRG rate,72612.02,100,,,case rate,100% The Health Plan DRG rate,3194.25,155033.01,
PREMATURITY WITHOUT MAJOR PROBLEMS,792,MS-DRG,,,,,Inpatient,,,,,,105879.51,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,105879.51,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,38501.64,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,1361.07,102,,,case rate,102% WV Medicaid DRG rate,63527.706,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,1243.89,100,,,case rate,100% PEIA with CHIP DRG base rate,46589.32,100,,,case rate,100% Highmark ACA DRG rate,58914.73,100,,,case rate,100% Highmark PPO DRG rate,58914.73,100,,,case rate,100% Highmark Trad DRG rate,1334.38,100,,,case rate,100% WV Medicaid DRG rate,38501.64,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,1058.05,100,,,case rate,100% PEIA DRG rate,43813.17,100,,,case rate,100% The Health Plan DRG rate,1058.05,105879.51,
FULL TERM NEONATE WITH MAJOR PROBLEMS,793,MS-DRG,,,,,Inpatient,,,,,,63886.6525,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,63886.6525,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,23231.51,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,1994.81,102,,,case rate,102% WV Medicaid DRG rate,38331.9915,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,1823.07,100,,,case rate,100% PEIA with CHIP DRG base rate,79315.84,100,,,case rate,100% Highmark ACA DRG rate,100299.2,100,,,case rate,100% Highmark PPO DRG rate,100299.2,100,,,case rate,100% Highmark Trad DRG rate,1955.69,100,,,case rate,100% WV Medicaid DRG rate,23231.51,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,1550.7,100,,,case rate,100% PEIA DRG rate,74589.6,100,,,case rate,100% The Health Plan DRG rate,1550.7,100299.2,
NEONATE WITH OTHER SIGNIFICANT PROBLEMS,794,MS-DRG,,,,,Inpatient,,,,,,108760.7675,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,108760.7675,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,39549.37,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,852.56,102,,,case rate,102% WV Medicaid DRG rate,65256.4605,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,779.16,100,,,case rate,100% PEIA with CHIP DRG base rate,28074.19,100,,,case rate,100% Highmark ACA DRG rate,35501.34,100,,,case rate,100% Highmark PPO DRG rate,35501.34,100,,,case rate,100% Highmark Trad DRG rate,835.84,100,,,case rate,100% WV Medicaid DRG rate,39549.37,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,662.76,100,,,case rate,100% PEIA DRG rate,26401.31,100,,,case rate,100% The Health Plan DRG rate,662.76,108760.7675,
NORMAL NEWBORN,795,MS-DRG,,,,,Inpatient,,,,,,38496.315,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,38496.315,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,13998.66,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,742.93,102,,,case rate,102% WV Medicaid DRG rate,23097.789,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,678.97,100,,,case rate,100% PEIA with CHIP DRG base rate,3800.63,100,,,case rate,100% Highmark ACA DRG rate,4806.11,100,,,case rate,100% Highmark PPO DRG rate,4806.11,100,,,case rate,100% Highmark Trad DRG rate,728.36,100,,,case rate,100% WV Medicaid DRG rate,13998.66,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,577.53,100,,,case rate,100% PEIA DRG rate,3574.16,100,,,case rate,100% The Health Plan DRG rate,577.53,38496.315,
VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITH MCC,796,MS-DRG,,,,,Inpatient,,,,,,5564.3775,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,5564.3775,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,2023.41,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,7039.31,102,,,case rate,102% WV Medicaid DRG rate,3338.6265,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,6433.29,100,,,case rate,100% PEIA with CHIP DRG base rate,26726.91,100,,,case rate,100% Highmark ACA DRG rate,33797.64,100,,,case rate,100% Highmark PPO DRG rate,33797.64,100,,,case rate,100% Highmark Trad DRG rate,6901.28,100,,,case rate,100% WV Medicaid DRG rate,2023.41,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,5472.15,100,,,case rate,100% PEIA DRG rate,25134.32,100,,,case rate,100% The Health Plan DRG rate,2023.41,33797.64,
VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITH CC,797,MS-DRG,,,,,Inpatient,,,,,,33807.5375,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,33807.5375,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,12293.65,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,4056.46,102,,,case rate,102% WV Medicaid DRG rate,20284.5225,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,3707.24,100,,,case rate,100% PEIA with CHIP DRG base rate,18765.74,100,,,case rate,100% Highmark ACA DRG rate,23730.31,100,,,case rate,100% Highmark PPO DRG rate,23730.31,100,,,case rate,100% Highmark Trad DRG rate,3976.92,100,,,case rate,100% WV Medicaid DRG rate,12293.65,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,3153.37,100,,,case rate,100% PEIA DRG rate,17647.54,100,,,case rate,100% The Health Plan DRG rate,3153.37,33807.5375,
VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITHOUT CC/MCC,798,MS-DRG,,,,,Inpatient,,,,,,23891.8075,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,23891.8075,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,8687.93,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,2915.55,102,,,case rate,102% WV Medicaid DRG rate,14335.0845,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,2664.55,100,,,case rate,100% PEIA with CHIP DRG base rate,15285.44,100,,,case rate,100% Highmark ACA DRG rate,19329.27,100,,,case rate,100% Highmark PPO DRG rate,19329.27,100,,,case rate,100% Highmark Trad DRG rate,2858.38,100,,,case rate,100% WV Medicaid DRG rate,8687.93,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,2266.46,100,,,case rate,100% PEIA DRG rate,14374.62,100,,,case rate,100% The Health Plan DRG rate,2266.46,23891.8075,
SPLENIC PROCEDURES WITH MCC,799,MS-DRG,,,,,Inpatient,,,,,,23891.8075,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,23891.8075,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,8687.93,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,15485.59,102,,,case rate,102% WV Medicaid DRG rate,14335.0845,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,14152.42,100,,,case rate,100% PEIA with CHIP DRG base rate,93359.53,100,,,case rate,100% Highmark ACA DRG rate,118058.21,100,,,case rate,100% Highmark PPO DRG rate,118058.21,100,,,case rate,100% Highmark Trad DRG rate,15181.94,100,,,case rate,100% WV Medicaid DRG rate,8687.93,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,12038.03,100,,,case rate,100% PEIA DRG rate,87796.45,100,,,case rate,100% The Health Plan DRG rate,8687.93,118058.21,
SPLENIC PROCEDURES WITH CC,800,MS-DRG,,,,,Inpatient,,,,,,134089.395,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,134089.395,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,48759.78,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,11188.02,102,,,case rate,102% WV Medicaid DRG rate,80453.637,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,10224.83,100,,,case rate,100% PEIA with CHIP DRG base rate,53093.92,100,,,case rate,100% Highmark ACA DRG rate,67140.16,100,,,case rate,100% Highmark PPO DRG rate,67140.16,100,,,case rate,100% Highmark Trad DRG rate,10968.64,100,,,case rate,100% WV Medicaid DRG rate,48759.78,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,8697.23,100,,,case rate,100% PEIA DRG rate,49930.18,100,,,case rate,100% The Health Plan DRG rate,8697.23,134089.395,
SPLENIC PROCEDURES WITHOUT CC/MCC,801,MS-DRG,,,,,Inpatient,,,,,,68451.7625,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,68451.7625,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,24891.55,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,8041.62,102,,,case rate,102% WV Medicaid DRG rate,41071.0575,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,7349.3,100,,,case rate,100% PEIA with CHIP DRG base rate,33723.32,100,,,case rate,100% Highmark ACA DRG rate,42644.97,100,,,case rate,100% Highmark PPO DRG rate,42644.97,100,,,case rate,100% Highmark Trad DRG rate,7883.93,100,,,case rate,100% WV Medicaid DRG rate,24891.55,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,6251.31,100,,,case rate,100% PEIA DRG rate,31713.82,100,,,case rate,100% The Health Plan DRG rate,6251.31,68451.7625,
OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITH MCC,802,MS-DRG,,,,,Inpatient,,,,,,46243.9175,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,46243.9175,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,16815.97,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,25317.45,102,,,case rate,102% WV Medicaid DRG rate,27746.3505,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,23137.84,100,,,case rate,100% PEIA with CHIP DRG base rate,63883.42,100,,,case rate,100% Highmark ACA DRG rate,80784.07,100,,,case rate,100% Highmark PPO DRG rate,80784.07,100,,,case rate,100% Highmark Trad DRG rate,24821.01,100,,,case rate,100% WV Medicaid DRG rate,16815.97,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,19681.02,100,,,case rate,100% PEIA DRG rate,60076.76,100,,,case rate,100% The Health Plan DRG rate,16815.97,80784.07,
OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITH CC,803,MS-DRG,,,,,Inpatient,,,,,,98152.4775,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,98152.4775,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,35691.81,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,12518.79,102,,,case rate,102% WV Medicaid DRG rate,58891.4865,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,11441.03,100,,,case rate,100% PEIA with CHIP DRG base rate,35014.06,100,,,case rate,100% Highmark ACA DRG rate,44277.19,100,,,case rate,100% Highmark PPO DRG rate,44277.19,100,,,case rate,100% Highmark Trad DRG rate,12273.31,100,,,case rate,100% WV Medicaid DRG rate,35691.81,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,9731.72,100,,,case rate,100% PEIA DRG rate,32927.66,100,,,case rate,100% The Health Plan DRG rate,9731.72,98152.4775,
OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITHOUT CC/MCC,804,MS-DRG,,,,,Inpatient,,,,,,52868.9425,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,52868.9425,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,19225.07,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,8379.88,102,,,case rate,102% WV Medicaid DRG rate,31721.3655,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,7658.44,100,,,case rate,100% PEIA with CHIP DRG base rate,22807.57,100,,,case rate,100% Highmark ACA DRG rate,28841.41,100,,,case rate,100% Highmark PPO DRG rate,28841.41,100,,,case rate,100% Highmark Trad DRG rate,8215.56,100,,,case rate,100% WV Medicaid DRG rate,19225.07,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,6514.26,100,,,case rate,100% PEIA DRG rate,21448.52,100,,,case rate,100% The Health Plan DRG rate,6514.26,52868.9425,
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH MCC,805,MS-DRG,,,,,Inpatient,,,,,,32489.215,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,32489.215,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,11814.26,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,4362.19,102,,,case rate,102% WV Medicaid DRG rate,19493.529,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,3986.64,100,,,case rate,100% PEIA with CHIP DRG base rate,18997.51,100,,,case rate,100% Highmark ACA DRG rate,24023.39,100,,,case rate,100% Highmark PPO DRG rate,24023.39,100,,,case rate,100% Highmark Trad DRG rate,4276.65,100,,,case rate,100% WV Medicaid DRG rate,11814.26,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,3391.03,100,,,case rate,100% PEIA DRG rate,17865.5,100,,,case rate,100% The Health Plan DRG rate,3391.03,32489.215,
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH CC,806,MS-DRG,,,,,Inpatient,,,,,,25892.46,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,25892.46,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,9415.44,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,2513.12,102,,,case rate,102% WV Medicaid DRG rate,15535.476,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,2296.76,100,,,case rate,100% PEIA with CHIP DRG base rate,14070.07,100,,,case rate,100% Highmark ACA DRG rate,17792.37,100,,,case rate,100% Highmark PPO DRG rate,17792.37,100,,,case rate,100% Highmark Trad DRG rate,2463.84,100,,,case rate,100% WV Medicaid DRG rate,9415.44,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,1953.62,100,,,case rate,100% PEIA DRG rate,13231.67,100,,,case rate,100% The Health Plan DRG rate,1953.62,25892.46,
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITHOUT CC/MCC,807,MS-DRG,,,,,Inpatient,,,,,,17967.1525,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,17967.1525,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,6533.51,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,2124.94,102,,,case rate,102% WV Medicaid DRG rate,10780.2915,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,1942,100,,,case rate,100% PEIA with CHIP DRG base rate,12328.97,100,,,case rate,100% Highmark ACA DRG rate,15590.66,100,,,case rate,100% Highmark PPO DRG rate,15590.66,100,,,case rate,100% Highmark Trad DRG rate,2083.27,100,,,case rate,100% WV Medicaid DRG rate,6533.51,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,1651.86,100,,,case rate,100% PEIA DRG rate,11594.32,100,,,case rate,100% The Health Plan DRG rate,1651.86,17967.1525,
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH MCC,808,MS-DRG,,,,,Inpatient,,,,,,16257.505,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,16257.505,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,5911.82,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,7182.82,102,,,case rate,102% WV Medicaid DRG rate,9754.503,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,6564.44,100,,,case rate,100% PEIA with CHIP DRG base rate,41268.05,100,,,case rate,100% Highmark ACA DRG rate,52185.7,100,,,case rate,100% Highmark PPO DRG rate,52185.7,100,,,case rate,100% Highmark Trad DRG rate,7041.97,100,,,case rate,100% WV Medicaid DRG rate,5911.82,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,5583.7,100,,,case rate,100% PEIA DRG rate,38808.99,100,,,case rate,100% The Health Plan DRG rate,5583.7,52185.7,
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH CC,809,MS-DRG,,,,,Inpatient,,,,,,55127.105,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,55127.105,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,20046.22,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,5839.13,102,,,case rate,102% WV Medicaid DRG rate,33076.263,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,5336.43,100,,,case rate,100% PEIA with CHIP DRG base rate,22694.51,100,,,case rate,100% Highmark ACA DRG rate,28698.44,100,,,case rate,100% Highmark PPO DRG rate,28698.44,100,,,case rate,100% Highmark Trad DRG rate,5724.63,100,,,case rate,100% WV Medicaid DRG rate,20046.22,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,4539.16,100,,,case rate,100% PEIA DRG rate,21342.2,100,,,case rate,100% The Health Plan DRG rate,4539.16,55127.105,
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITHOUT CC/MCC,810,MS-DRG,,,,,Inpatient,,,,,,31302.1775,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,31302.1775,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,11382.61,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,4481.63,102,,,case rate,102% WV Medicaid DRG rate,18781.3065,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,4095.8,100,,,case rate,100% PEIA with CHIP DRG base rate,18927.79,100,,,case rate,100% Highmark ACA DRG rate,23935.23,100,,,case rate,100% Highmark PPO DRG rate,23935.23,100,,,case rate,100% Highmark Trad DRG rate,4393.75,100,,,case rate,100% WV Medicaid DRG rate,11382.61,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,3483.88,100,,,case rate,100% PEIA DRG rate,17799.93,100,,,case rate,100% The Health Plan DRG rate,3483.88,31302.1775,
RED BLOOD CELL DISORDERS WITH MCC,811,MS-DRG,,,,,Inpatient,,,,,,24172.4725,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,24172.4725,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,8789.99,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,7320.97,102,,,case rate,102% WV Medicaid DRG rate,14503.4835,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,6690.7,100,,,case rate,100% PEIA with CHIP DRG base rate,26448.03,100,,,case rate,100% Highmark ACA DRG rate,33444.98,100,,,case rate,100% Highmark PPO DRG rate,33444.98,100,,,case rate,100% Highmark Trad DRG rate,7177.42,100,,,case rate,100% WV Medicaid DRG rate,8789.99,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,5691.1,100,,,case rate,100% PEIA DRG rate,24872.06,100,,,case rate,100% The Health Plan DRG rate,5691.1,33444.98,
RED BLOOD CELL DISORDERS WITHOUT MCC,812,MS-DRG,,,,,Inpatient,,,,,,35797.8775,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,35797.8775,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,13017.41,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,4559.17,102,,,case rate,102% WV Medicaid DRG rate,21478.7265,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,4166.67,100,,,case rate,100% PEIA with CHIP DRG base rate,16971.89,100,,,case rate,100% Highmark ACA DRG rate,21461.88,100,,,case rate,100% Highmark PPO DRG rate,21461.88,100,,,case rate,100% Highmark Trad DRG rate,4469.77,100,,,case rate,100% WV Medicaid DRG rate,13017.41,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,3544.16,100,,,case rate,100% PEIA DRG rate,15960.58,100,,,case rate,100% The Health Plan DRG rate,3544.16,35797.8775,
COAGULATION DISORDERS,813,MS-DRG,,,,,Inpatient,,,,,,23121.9725,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,23121.9725,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,8407.99,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,8057.21,102,,,case rate,102% WV Medicaid DRG rate,13873.1835,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,7363.56,100,,,case rate,100% PEIA with CHIP DRG base rate,29395.08,100,,,case rate,100% Highmark ACA DRG rate,37171.68,100,,,case rate,100% Highmark PPO DRG rate,37171.68,100,,,case rate,100% Highmark Trad DRG rate,7899.22,100,,,case rate,100% WV Medicaid DRG rate,8407.99,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,6263.43,100,,,case rate,100% PEIA DRG rate,27643.5,100,,,case rate,100% The Health Plan DRG rate,6263.43,37171.68,
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH MCC,814,MS-DRG,,,,,Inpatient,,,,,,40298.6375,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,40298.6375,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,14654.05,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,9101.86,102,,,case rate,102% WV Medicaid DRG rate,24179.1825,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,8318.27,100,,,case rate,100% PEIA with CHIP DRG base rate,40099.79,100,,,case rate,100% Highmark ACA DRG rate,50708.37,100,,,case rate,100% Highmark PPO DRG rate,50708.37,100,,,case rate,100% Highmark Trad DRG rate,8923.38,100,,,case rate,100% WV Medicaid DRG rate,14654.05,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,7075.51,100,,,case rate,100% PEIA DRG rate,37710.34,100,,,case rate,100% The Health Plan DRG rate,7075.51,50708.37,
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH CC,815,MS-DRG,,,,,Inpatient,,,,,,48383.61,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,48383.61,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,17594.04,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,5557.47,102,,,case rate,102% WV Medicaid DRG rate,29030.166,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,5079.02,100,,,case rate,100% PEIA with CHIP DRG base rate,18733.71,100,,,case rate,100% Highmark ACA DRG rate,23689.8,100,,,case rate,100% Highmark PPO DRG rate,23689.8,100,,,case rate,100% Highmark Trad DRG rate,5448.49,100,,,case rate,100% WV Medicaid DRG rate,17594.04,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,4320.21,100,,,case rate,100% PEIA DRG rate,17617.41,100,,,case rate,100% The Health Plan DRG rate,4320.21,48383.61,
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITHOUT CC/MCC,816,MS-DRG,,,,,Inpatient,,,,,,26549.05,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,26549.05,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,9654.2,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,4031.06,102,,,case rate,102% WV Medicaid DRG rate,15929.43,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,3684.02,100,,,case rate,100% PEIA with CHIP DRG base rate,13382.3,100,,,case rate,100% Highmark ACA DRG rate,16922.65,100,,,case rate,100% Highmark PPO DRG rate,16922.65,100,,,case rate,100% Highmark Trad DRG rate,3952.01,100,,,case rate,100% WV Medicaid DRG rate,9654.2,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,3133.62,100,,,case rate,100% PEIA DRG rate,12584.88,100,,,case rate,100% The Health Plan DRG rate,3133.62,26549.05,
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH MCC,817,MS-DRG,,,,,Inpatient,,,,,,18770.455,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,18770.455,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,6825.62,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,5959.9,102,,,case rate,102% WV Medicaid DRG rate,11262.273,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,5446.81,100,,,case rate,100% PEIA with CHIP DRG base rate,42490.97,100,,,case rate,100% Highmark ACA DRG rate,53732.14,100,,,case rate,100% Highmark PPO DRG rate,53732.14,100,,,case rate,100% Highmark Trad DRG rate,5843.04,100,,,case rate,100% WV Medicaid DRG rate,6825.62,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,4633.05,100,,,case rate,100% PEIA DRG rate,39959.03,100,,,case rate,100% The Health Plan DRG rate,4633.05,53732.14,
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH CC,818,MS-DRG,,,,,Inpatient,,,,,,80587.0175,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,80587.0175,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,29304.37,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,5663.54,102,,,case rate,102% WV Medicaid DRG rate,48352.2105,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,5175.96,100,,,case rate,100% PEIA with CHIP DRG base rate,22104.72,100,,,case rate,100% Highmark ACA DRG rate,27952.63,100,,,case rate,100% Highmark PPO DRG rate,27952.63,100,,,case rate,100% Highmark Trad DRG rate,5552.48,100,,,case rate,100% WV Medicaid DRG rate,29304.37,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,4402.66,100,,,case rate,100% PEIA DRG rate,20787.55,100,,,case rate,100% The Health Plan DRG rate,4402.66,80587.0175,
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITHOUT CC/MCC,819,MS-DRG,,,,,Inpatient,,,,,,40942.385,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,40942.385,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,14888.14,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,4071.17,102,,,case rate,102% WV Medicaid DRG rate,24565.431,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,3720.68,100,,,case rate,100% PEIA with CHIP DRG base rate,17094.37,100,,,case rate,100% Highmark ACA DRG rate,21616.76,100,,,case rate,100% Highmark PPO DRG rate,21616.76,100,,,case rate,100% Highmark Trad DRG rate,3991.34,100,,,case rate,100% WV Medicaid DRG rate,14888.14,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,3164.8,100,,,case rate,100% PEIA DRG rate,16075.76,100,,,case rate,100% The Health Plan DRG rate,3164.8,40942.385,
LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITH MCC,820,MS-DRG,,,,,Inpatient,,,,,,22877.3875,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,22877.3875,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,8319.05,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,24604.38,102,,,case rate,102% WV Medicaid DRG rate,13726.4325,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,22486.16,100,,,case rate,100% PEIA with CHIP DRG base rate,113937.97,100,,,case rate,100% Highmark ACA DRG rate,144080.77,100,,,case rate,100% Highmark PPO DRG rate,144080.77,100,,,case rate,100% Highmark Trad DRG rate,24121.92,100,,,case rate,100% WV Medicaid DRG rate,8319.05,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,19126.7,100,,,case rate,100% PEIA DRG rate,107148.67,100,,,case rate,100% The Health Plan DRG rate,8319.05,144080.77,
LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITH CC,821,MS-DRG,,,,,Inpatient,,,,,,136919.09,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,136919.09,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,49788.76,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,14362.06,102,,,case rate,102% WV Medicaid DRG rate,82151.454,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,13125.62,100,,,case rate,100% PEIA with CHIP DRG base rate,42059.46,100,,,case rate,100% Highmark ACA DRG rate,53186.48,100,,,case rate,100% Highmark PPO DRG rate,53186.48,100,,,case rate,100% Highmark Trad DRG rate,14080.44,100,,,case rate,100% WV Medicaid DRG rate,49788.76,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,11164.63,100,,,case rate,100% PEIA DRG rate,39553.24,100,,,case rate,100% The Health Plan DRG rate,11164.63,136919.09,
LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC,822,MS-DRG,,,,,Inpatient,,,,,,55678.1225,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,55678.1225,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,20246.59,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,13238.09,102,,,case rate,102% WV Medicaid DRG rate,33406.8735,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,12098.41,100,,,case rate,100% PEIA with CHIP DRG base rate,23342.71,100,,,case rate,100% Highmark ACA DRG rate,29518.13,100,,,case rate,100% Highmark PPO DRG rate,29518.13,100,,,case rate,100% Highmark Trad DRG rate,12978.51,100,,,case rate,100% WV Medicaid DRG rate,20246.59,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,10290.89,100,,,case rate,100% PEIA DRG rate,21951.77,100,,,case rate,100% The Health Plan DRG rate,10290.89,55678.1225,
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH MCC,823,MS-DRG,,,,,Inpatient,,,,,,31026.655,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,31026.655,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,11282.42,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,25095.06,102,,,case rate,102% WV Medicaid DRG rate,18615.993,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,22934.6,100,,,case rate,100% PEIA with CHIP DRG base rate,84829.3,100,,,case rate,100% Highmark ACA DRG rate,107271.27,100,,,case rate,100% Highmark PPO DRG rate,107271.27,100,,,case rate,100% Highmark Trad DRG rate,24602.98,100,,,case rate,100% WV Medicaid DRG rate,11282.42,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,19508.14,100,,,case rate,100% PEIA DRG rate,79774.52,100,,,case rate,100% The Health Plan DRG rate,11282.42,107271.27,
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH CC,824,MS-DRG,,,,,Inpatient,,,,,,111397.385,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,111397.385,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,40508.14,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,15210.61,102,,,case rate,102% WV Medicaid DRG rate,66838.431,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,13901.11,100,,,case rate,100% PEIA with CHIP DRG base rate,42074.53,100,,,case rate,100% Highmark ACA DRG rate,53205.54,100,,,case rate,100% Highmark PPO DRG rate,53205.54,100,,,case rate,100% Highmark Trad DRG rate,14912.35,100,,,case rate,100% WV Medicaid DRG rate,40508.14,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,11824.27,100,,,case rate,100% PEIA DRG rate,39567.41,100,,,case rate,100% The Health Plan DRG rate,11824.27,111397.385,
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITHOUT CC/MCC,825,MS-DRG,,,,,Inpatient,,,,,,58971.33,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,58971.33,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,21444.12,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,8744.88,102,,,case rate,102% WV Medicaid DRG rate,35382.798,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,7992.02,100,,,case rate,100% PEIA with CHIP DRG base rate,24333.85,100,,,case rate,100% Highmark ACA DRG rate,30771.48,100,,,case rate,100% Highmark PPO DRG rate,30771.48,100,,,case rate,100% Highmark Trad DRG rate,8573.4,100,,,case rate,100% WV Medicaid DRG rate,21444.12,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,6798,100,,,case rate,100% PEIA DRG rate,22883.85,100,,,case rate,100% The Health Plan DRG rate,6798,58971.33,
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH MCC,826,MS-DRG,,,,,Inpatient,,,,,,33900.185,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,33900.185,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,12327.34,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,34150.57,102,,,case rate,102% WV Medicaid DRG rate,20340.111,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,31210.51,100,,,case rate,100% PEIA with CHIP DRG base rate,82698.16,100,,,case rate,100% Highmark ACA DRG rate,104576.33,100,,,case rate,100% Highmark PPO DRG rate,104576.33,100,,,case rate,100% Highmark Trad DRG rate,33480.92,100,,,case rate,100% WV Medicaid DRG rate,12327.34,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,26547.62,100,,,case rate,100% PEIA DRG rate,77770.37,100,,,case rate,100% The Health Plan DRG rate,12327.34,104576.33,
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH CC,827,MS-DRG,,,,,Inpatient,,,,,,132395.12,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,132395.12,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,48143.68,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,17055.68,102,,,case rate,102% WV Medicaid DRG rate,79437.072,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,15587.33,100,,,case rate,100% PEIA with CHIP DRG base rate,43663,100,,,case rate,100% Highmark ACA DRG rate,55214.24,100,,,case rate,100% Highmark PPO DRG rate,55214.24,100,,,case rate,100% Highmark Trad DRG rate,16721.23,100,,,case rate,100% WV Medicaid DRG rate,48143.68,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,13258.56,100,,,case rate,100% PEIA DRG rate,41061.22,100,,,case rate,100% The Health Plan DRG rate,13258.56,132395.12,
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC,828,MS-DRG,,,,,Inpatient,,,,,,62689.33,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,62689.33,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,22796.12,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,11550.35,102,,,case rate,102% WV Medicaid DRG rate,37613.598,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,10555.97,100,,,case rate,100% PEIA with CHIP DRG base rate,30910.06,100,,,case rate,100% Highmark ACA DRG rate,39087.45,100,,,case rate,100% Highmark PPO DRG rate,39087.45,100,,,case rate,100% Highmark Trad DRG rate,11323.86,100,,,case rate,100% WV Medicaid DRG rate,22796.12,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,8978.89,100,,,case rate,100% PEIA DRG rate,29068.2,100,,,case rate,100% The Health Plan DRG rate,8978.89,62689.33,
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITH CC/MCC,829,MS-DRG,,,,,Inpatient,,,,,,44778.8825,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,44778.8825,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,16283.23,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,10955.39,102,,,case rate,102% WV Medicaid DRG rate,26867.3295,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,10012.22,100,,,case rate,100% PEIA with CHIP DRG base rate,59427.05,100,,,case rate,100% Highmark ACA DRG rate,75148.75,100,,,case rate,100% Highmark PPO DRG rate,75148.75,100,,,case rate,100% Highmark Trad DRG rate,10740.56,100,,,case rate,100% WV Medicaid DRG rate,16283.23,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,8516.38,100,,,case rate,100% PEIA DRG rate,55885.94,100,,,case rate,100% The Health Plan DRG rate,8516.38,75148.75,
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITHOUT CC/MCC,830,MS-DRG,,,,,Inpatient,,,,,,81485.635,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,81485.635,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,29631.14,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,6656.48,102,,,case rate,102% WV Medicaid DRG rate,48891.381,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,6083.42,100,,,case rate,100% PEIA with CHIP DRG base rate,29794.55,100,,,case rate,100% Highmark ACA DRG rate,37676.83,100,,,case rate,100% Highmark PPO DRG rate,37676.83,100,,,case rate,100% Highmark Trad DRG rate,6525.96,100,,,case rate,100% WV Medicaid DRG rate,29631.14,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,5174.55,100,,,case rate,100% PEIA DRG rate,28019.16,100,,,case rate,100% The Health Plan DRG rate,5174.55,81485.635,
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH MCC,831,MS-DRG,,,,,Inpatient,,,,,,37862.88,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,37862.88,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,13768.32,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,4218.68,102,,,case rate,102% WV Medicaid DRG rate,22717.728,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,3855.49,100,,,case rate,100% PEIA with CHIP DRG base rate,19027.66,100,,,case rate,100% Highmark ACA DRG rate,24061.51,100,,,case rate,100% Highmark PPO DRG rate,24061.51,100,,,case rate,100% Highmark Trad DRG rate,4135.96,100,,,case rate,100% WV Medicaid DRG rate,13768.32,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,3279.48,100,,,case rate,100% PEIA DRG rate,17893.85,100,,,case rate,100% The Health Plan DRG rate,3279.48,37862.88,
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH CC,832,MS-DRG,,,,,Inpatient,,,,,,30764.03,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,30764.03,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,11186.92,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,2781.41,102,,,case rate,102% WV Medicaid DRG rate,18458.418,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,2541.95,100,,,case rate,100% PEIA with CHIP DRG base rate,13900.48,100,,,case rate,100% Highmark ACA DRG rate,17577.92,100,,,case rate,100% Highmark PPO DRG rate,17577.92,100,,,case rate,100% Highmark Trad DRG rate,2726.87,100,,,case rate,100% WV Medicaid DRG rate,11186.92,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,2162.18,100,,,case rate,100% PEIA DRG rate,13072.18,100,,,case rate,100% The Health Plan DRG rate,2162.18,30764.03,
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITHOUT CC/MCC,833,MS-DRG,,,,,Inpatient,,,,,,18036.6725,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,18036.6725,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,6558.79,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,2433.79,102,,,case rate,102% WV Medicaid DRG rate,10822.0035,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,2224.26,100,,,case rate,100% PEIA with CHIP DRG base rate,9643.85,100,,,case rate,100% Highmark ACA DRG rate,12195.17,100,,,case rate,100% Highmark PPO DRG rate,12195.17,100,,,case rate,100% Highmark Trad DRG rate,2386.06,100,,,case rate,100% WV Medicaid DRG rate,6558.79,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,1891.95,100,,,case rate,100% PEIA DRG rate,9069.19,100,,,case rate,100% The Health Plan DRG rate,1891.95,18036.6725,
ACUTE LEUKEMIA WITHOUT MAJOR O.R. PROCEDURES WITH MCC,834,MS-DRG,,,,,Inpatient,,,,,,12977.085,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,12977.085,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,4718.94,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,31929.37,102,,,case rate,102% WV Medicaid DRG rate,7786.251,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,29180.53,100,,,case rate,100% PEIA with CHIP DRG base rate,105501.96,100,,,case rate,100% Highmark ACA DRG rate,133412.97,100,,,case rate,100% Highmark PPO DRG rate,133412.97,100,,,case rate,100% Highmark Trad DRG rate,31303.27,100,,,case rate,100% WV Medicaid DRG rate,4718.94,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,24820.92,100,,,case rate,100% PEIA DRG rate,99215.34,100,,,case rate,100% The Health Plan DRG rate,4718.94,133412.97,
ACUTE LEUKEMIA WITHOUT MAJOR O.R. PROCEDURES WITH CC,835,MS-DRG,,,,,Inpatient,,,,,,142388.015,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,142388.015,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,51777.46,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,13904.81,102,,,case rate,102% WV Medicaid DRG rate,85432.809,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,12707.73,100,,,case rate,100% PEIA with CHIP DRG base rate,42123.53,100,,,case rate,100% Highmark ACA DRG rate,53267.49,100,,,case rate,100% Highmark PPO DRG rate,53267.49,100,,,case rate,100% Highmark Trad DRG rate,13632.15,100,,,case rate,100% WV Medicaid DRG rate,51777.46,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,10809.18,100,,,case rate,100% PEIA DRG rate,39613.48,100,,,case rate,100% The Health Plan DRG rate,10809.18,142388.015,
ACUTE LEUKEMIA WITHOUT MAJOR O.R. PROCEDURES WITHOUT CC/MCC,836,MS-DRG,,,,,Inpatient,,,,,,53996.7175,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,53996.7175,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,19635.17,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,10419.25,102,,,case rate,102% WV Medicaid DRG rate,32398.0305,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,9522.24,100,,,case rate,100% PEIA with CHIP DRG base rate,22560.72,100,,,case rate,100% Highmark ACA DRG rate,28529.26,100,,,case rate,100% Highmark PPO DRG rate,28529.26,100,,,case rate,100% Highmark Trad DRG rate,10214.94,100,,,case rate,100% WV Medicaid DRG rate,19635.17,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,8099.61,100,,,case rate,100% PEIA DRG rate,21216.38,100,,,case rate,100% The Health Plan DRG rate,8099.61,53996.7175,
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS OR WITH HIGH DOSE CHEMOTHERAPY AGENT WITH MCC,837,MS-DRG,,,,,Inpatient,,,,,,40393.925,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,40393.925,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,14688.7,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,9899.16,102,,,case rate,102% WV Medicaid DRG rate,24236.355,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,9046.93,100,,,case rate,100% PEIA with CHIP DRG base rate,89628.61,100,,,case rate,100% Highmark ACA DRG rate,113340.26,100,,,case rate,100% Highmark PPO DRG rate,113340.26,100,,,case rate,100% Highmark Trad DRG rate,9705.04,100,,,case rate,100% WV Medicaid DRG rate,14688.7,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,7695.3,100,,,case rate,100% PEIA DRG rate,84287.86,100,,,case rate,100% The Health Plan DRG rate,7695.3,113340.26,
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC OR HIGH DOSE CHEMOTHERAPY AGENT,838,MS-DRG,,,,,Inpatient,,,,,,138582.4275,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,138582.4275,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,50393.61,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,6213.04,102,,,case rate,102% WV Medicaid DRG rate,83149.4565,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,5678.16,100,,,case rate,100% PEIA with CHIP DRG base rate,36789.07,100,,,case rate,100% Highmark ACA DRG rate,46521.79,100,,,case rate,100% Highmark PPO DRG rate,46521.79,100,,,case rate,100% Highmark Trad DRG rate,6091.21,100,,,case rate,100% WV Medicaid DRG rate,50393.61,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,4829.83,100,,,case rate,100% PEIA DRG rate,34596.9,100,,,case rate,100% The Health Plan DRG rate,4829.83,138582.4275,
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITHOUT CC/MCC,839,MS-DRG,,,,,Inpatient,,,,,,57266.77,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,57266.77,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,20824.28,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,4466.03,102,,,case rate,102% WV Medicaid DRG rate,34360.062,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,4081.54,100,,,case rate,100% PEIA with CHIP DRG base rate,24554.31,100,,,case rate,100% Highmark ACA DRG rate,31050.27,100,,,case rate,100% Highmark PPO DRG rate,31050.27,100,,,case rate,100% Highmark Trad DRG rate,4378.46,100,,,case rate,100% WV Medicaid DRG rate,20824.28,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,3471.76,100,,,case rate,100% PEIA DRG rate,23091.18,100,,,case rate,100% The Health Plan DRG rate,3471.76,57266.77,
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH MCC,840,MS-DRG,,,,,Inpatient,,,,,,35396.1575,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,35396.1575,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,12871.33,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,15701.74,102,,,case rate,102% WV Medicaid DRG rate,21237.6945,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,14349.96,100,,,case rate,100% PEIA with CHIP DRG base rate,58888.14,100,,,case rate,100% Highmark ACA DRG rate,74467.27,100,,,case rate,100% Highmark PPO DRG rate,74467.27,100,,,case rate,100% Highmark Trad DRG rate,15393.85,100,,,case rate,100% WV Medicaid DRG rate,12871.33,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,12206.06,100,,,case rate,100% PEIA DRG rate,55379.14,100,,,case rate,100% The Health Plan DRG rate,12206.06,74467.27,
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH CC,841,MS-DRG,,,,,Inpatient,,,,,,79999.9475,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,79999.9475,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,29090.89,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,6418.94,102,,,case rate,102% WV Medicaid DRG rate,47999.9685,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,5866.33,100,,,case rate,100% PEIA with CHIP DRG base rate,29649.46,100,,,case rate,100% Highmark ACA DRG rate,37493.36,100,,,case rate,100% Highmark PPO DRG rate,37493.36,100,,,case rate,100% Highmark Trad DRG rate,6293.07,100,,,case rate,100% WV Medicaid DRG rate,29090.89,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,4989.89,100,,,case rate,100% PEIA DRG rate,27882.72,100,,,case rate,100% The Health Plan DRG rate,4989.89,79999.9475,
LYMPHOMA AND NON-ACUTE LEUKEMIA WITHOUT CC/MCC,842,MS-DRG,,,,,Inpatient,,,,,,41063.33,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,41063.33,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,14932.12,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,5357.81,102,,,case rate,102% WV Medicaid DRG rate,24637.998,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,4896.55,100,,,case rate,100% PEIA with CHIP DRG base rate,20094.18,100,,,case rate,100% Highmark ACA DRG rate,25410.18,100,,,case rate,100% Highmark PPO DRG rate,25410.18,100,,,case rate,100% Highmark Trad DRG rate,5252.75,100,,,case rate,100% WV Medicaid DRG rate,14932.12,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,4165,100,,,case rate,100% PEIA DRG rate,18896.81,100,,,case rate,100% The Health Plan DRG rate,4165,41063.33,
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH MCC,843,MS-DRG,,,,,Inpatient,,,,,,28418.3625,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,28418.3625,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,10333.95,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,13161.44,102,,,case rate,102% WV Medicaid DRG rate,17051.0175,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,12028.35,100,,,case rate,100% PEIA with CHIP DRG base rate,35059.29,100,,,case rate,100% Highmark ACA DRG rate,44334.38,100,,,case rate,100% Highmark PPO DRG rate,44334.38,100,,,case rate,100% Highmark Trad DRG rate,12903.36,100,,,case rate,100% WV Medicaid DRG rate,10333.95,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,10231.3,100,,,case rate,100% PEIA DRG rate,32970.19,100,,,case rate,100% The Health Plan DRG rate,10231.3,44334.38,
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH CC,844,MS-DRG,,,,,Inpatient,,,,,,49884.725,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,49884.725,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,18139.9,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,6308.42,102,,,case rate,102% WV Medicaid DRG rate,29930.835,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,5765.32,100,,,case rate,100% PEIA with CHIP DRG base rate,21805.12,100,,,case rate,100% Highmark ACA DRG rate,27573.76,100,,,case rate,100% Highmark PPO DRG rate,27573.76,100,,,case rate,100% Highmark Trad DRG rate,6184.72,100,,,case rate,100% WV Medicaid DRG rate,18139.9,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,4903.97,100,,,case rate,100% PEIA DRG rate,20505.8,100,,,case rate,100% The Health Plan DRG rate,4903.97,49884.725,
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITHOUT CC/MCC,845,MS-DRG,,,,,Inpatient,,,,,,29368.515,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,29368.515,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,10679.46,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,4535.11,102,,,case rate,102% WV Medicaid DRG rate,17621.109,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,4144.67,100,,,case rate,100% PEIA with CHIP DRG base rate,16297.31,100,,,case rate,100% Highmark ACA DRG rate,20608.84,100,,,case rate,100% Highmark PPO DRG rate,20608.84,100,,,case rate,100% Highmark Trad DRG rate,4446.18,100,,,case rate,100% WV Medicaid DRG rate,10679.46,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,3525.45,100,,,case rate,100% PEIA DRG rate,15326.19,100,,,case rate,100% The Health Plan DRG rate,3525.45,29368.515,
CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH MCC,846,MS-DRG,,,,,Inpatient,,,,,,21770.21,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,21770.21,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,7916.44,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,7899.89,102,,,case rate,102% WV Medicaid DRG rate,13062.126,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,7219.78,100,,,case rate,100% PEIA with CHIP DRG base rate,46052.29,100,,,case rate,100% Highmark ACA DRG rate,58235.63,100,,,case rate,100% Highmark PPO DRG rate,58235.63,100,,,case rate,100% Highmark Trad DRG rate,7744.99,100,,,case rate,100% WV Medicaid DRG rate,7916.44,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,6141.14,100,,,case rate,100% PEIA DRG rate,43308.14,100,,,case rate,100% The Health Plan DRG rate,6141.14,58235.63,
CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC,847,MS-DRG,,,,,Inpatient,,,,,,62027.625,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,62027.625,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,22555.5,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,4551.15,102,,,case rate,102% WV Medicaid DRG rate,37216.575,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,4159.34,100,,,case rate,100% PEIA with CHIP DRG base rate,22849.02,100,,,case rate,100% Highmark ACA DRG rate,28893.83,100,,,case rate,100% Highmark PPO DRG rate,28893.83,100,,,case rate,100% Highmark Trad DRG rate,4461.91,100,,,case rate,100% WV Medicaid DRG rate,22555.5,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,3537.93,100,,,case rate,100% PEIA DRG rate,21487.5,100,,,case rate,100% The Health Plan DRG rate,3537.93,62027.625,
CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITHOUT CC/MCC,848,MS-DRG,,,,,Inpatient,,,,,,31363.97,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,31363.97,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,11405.08,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,3272.09,102,,,case rate,102% WV Medicaid DRG rate,18818.382,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,2990.39,100,,,case rate,100% PEIA with CHIP DRG base rate,14311.26,100,,,case rate,100% Highmark ACA DRG rate,18097.37,100,,,case rate,100% Highmark PPO DRG rate,18097.37,100,,,case rate,100% Highmark Trad DRG rate,3207.93,100,,,case rate,100% WV Medicaid DRG rate,11405.08,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,2543.62,100,,,case rate,100% PEIA DRG rate,13458.48,100,,,case rate,100% The Health Plan DRG rate,2543.62,31363.97,
RADIOTHERAPY,849,MS-DRG,,,,,Inpatient,,,,,,23922.745,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,23922.745,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,8699.18,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,15533.72,102,,,case rate,102% WV Medicaid DRG rate,14353.647,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,14196.41,100,,,case rate,100% PEIA with CHIP DRG base rate,50714.05,100,,,case rate,100% Highmark ACA DRG rate,64130.68,100,,,case rate,100% Highmark PPO DRG rate,64130.68,100,,,case rate,100% Highmark Trad DRG rate,15229.13,100,,,case rate,100% WV Medicaid DRG rate,8699.18,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,12075.45,100,,,case rate,100% PEIA DRG rate,47692.12,100,,,case rate,100% The Health Plan DRG rate,8699.18,64130.68,
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH MCC,853,MS-DRG,,,,,Inpatient,,,,,,60222.69,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,60222.69,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,21899.16,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,25382.96,102,,,case rate,102% WV Medicaid DRG rate,36133.614,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,23197.71,100,,,case rate,100% PEIA with CHIP DRG base rate,94201.81,100,,,case rate,100% Highmark ACA DRG rate,119123.32,100,,,case rate,100% Highmark PPO DRG rate,119123.32,100,,,case rate,100% Highmark Trad DRG rate,24885.23,100,,,case rate,100% WV Medicaid DRG rate,21899.16,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,19731.95,100,,,case rate,100% PEIA DRG rate,88588.55,100,,,case rate,100% The Health Plan DRG rate,19731.95,119123.32,
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH CC,854,MS-DRG,,,,,Inpatient,,,,,,126192.385,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,126192.385,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,45888.14,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,10550.27,102,,,case rate,102% WV Medicaid DRG rate,75715.431,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,9641.99,100,,,case rate,100% PEIA with CHIP DRG base rate,38405.8,100,,,case rate,100% Highmark ACA DRG rate,48566.23,100,,,case rate,100% Highmark PPO DRG rate,48566.23,100,,,case rate,100% Highmark Trad DRG rate,10343.4,100,,,case rate,100% WV Medicaid DRG rate,45888.14,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,8201.46,100,,,case rate,100% PEIA DRG rate,36117.29,100,,,case rate,100% The Health Plan DRG rate,8201.46,126192.385,
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITHOUT CC/MCC,855,MS-DRG,,,,,Inpatient,,,,,,52928.1775,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,52928.1775,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,19246.61,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,7583.02,102,,,case rate,102% WV Medicaid DRG rate,31756.9065,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,6930.19,100,,,case rate,100% PEIA with CHIP DRG base rate,32067.02,100,,,case rate,100% Highmark ACA DRG rate,40550.49,100,,,case rate,100% Highmark PPO DRG rate,40550.49,100,,,case rate,100% Highmark Trad DRG rate,7434.33,100,,,case rate,100% WV Medicaid DRG rate,19246.61,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,5894.81,100,,,case rate,100% PEIA DRG rate,30156.22,100,,,case rate,100% The Health Plan DRG rate,5894.81,52928.1775,
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH MCC,856,MS-DRG,,,,,Inpatient,,,,,,39335.6425,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,39335.6425,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,14303.87,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,19155.66,102,,,case rate,102% WV Medicaid DRG rate,23601.3855,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,17506.53,100,,,case rate,100% PEIA with CHIP DRG base rate,83444.34,100,,,case rate,100% Highmark ACA DRG rate,105519.92,100,,,case rate,100% Highmark PPO DRG rate,105519.92,100,,,case rate,100% Highmark Trad DRG rate,18780.04,100,,,case rate,100% WV Medicaid DRG rate,14303.87,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,14891.03,100,,,case rate,100% PEIA DRG rate,78472.09,100,,,case rate,100% The Health Plan DRG rate,14303.87,105519.92,
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH CC,857,MS-DRG,,,,,Inpatient,,,,,,113619.4675,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,113619.4675,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,41316.17,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,9725.35,102,,,case rate,102% WV Medicaid DRG rate,68171.6805,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,8888.08,100,,,case rate,100% PEIA with CHIP DRG base rate,40243,100,,,case rate,100% Highmark ACA DRG rate,50889.46,100,,,case rate,100% Highmark PPO DRG rate,50889.46,100,,,case rate,100% Highmark Trad DRG rate,9534.64,100,,,case rate,100% WV Medicaid DRG rate,41316.17,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,7560.19,100,,,case rate,100% PEIA DRG rate,37845.01,100,,,case rate,100% The Health Plan DRG rate,7560.19,113619.4675,
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITHOUT CC/MCC,858,MS-DRG,,,,,Inpatient,,,,,,54303.1225,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,54303.1225,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,19746.59,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,6242.9,102,,,case rate,102% WV Medicaid DRG rate,32581.8735,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,5705.44,100,,,case rate,100% PEIA with CHIP DRG base rate,24183.11,100,,,case rate,100% Highmark ACA DRG rate,30580.86,100,,,case rate,100% Highmark PPO DRG rate,30580.86,100,,,case rate,100% Highmark Trad DRG rate,6120.49,100,,,case rate,100% WV Medicaid DRG rate,19746.59,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,4853.04,100,,,case rate,100% PEIA DRG rate,22742.09,100,,,case rate,100% The Health Plan DRG rate,4853.04,54303.1225,
POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITH MCC,862,MS-DRG,,,,,Inpatient,,,,,,36423.5575,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,36423.5575,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,13244.93,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,6965.33,102,,,case rate,102% WV Medicaid DRG rate,21854.1345,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,6365.68,100,,,case rate,100% PEIA with CHIP DRG base rate,34708.81,100,,,case rate,100% Highmark ACA DRG rate,43891.18,100,,,case rate,100% Highmark PPO DRG rate,43891.18,100,,,case rate,100% Highmark Trad DRG rate,6828.75,100,,,case rate,100% WV Medicaid DRG rate,13244.93,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,5414.64,100,,,case rate,100% PEIA DRG rate,32640.59,100,,,case rate,100% The Health Plan DRG rate,5414.64,43891.18,
POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITHOUT MCC,863,MS-DRG,,,,,Inpatient,,,,,,47096.1975,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,47096.1975,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,17125.89,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,4335.45,102,,,case rate,102% WV Medicaid DRG rate,28257.7185,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,3962.2,100,,,case rate,100% PEIA with CHIP DRG base rate,18946.64,100,,,case rate,100% Highmark ACA DRG rate,23959.05,100,,,case rate,100% Highmark PPO DRG rate,23959.05,100,,,case rate,100% Highmark Trad DRG rate,4250.44,100,,,case rate,100% WV Medicaid DRG rate,17125.89,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,3370.25,100,,,case rate,100% PEIA DRG rate,17817.65,100,,,case rate,100% The Health Plan DRG rate,3370.25,47096.1975,
FEVER AND INFLAMMATORY CONDITIONS,864,MS-DRG,,,,,Inpatient,,,,,,25900.16,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,25900.16,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,9418.24,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,4083.65,102,,,case rate,102% WV Medicaid DRG rate,15540.096,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,3732.08,100,,,case rate,100% PEIA with CHIP DRG base rate,16634.6,100,,,case rate,100% Highmark ACA DRG rate,21035.36,100,,,case rate,100% Highmark PPO DRG rate,21035.36,100,,,case rate,100% Highmark Trad DRG rate,4003.57,100,,,case rate,100% WV Medicaid DRG rate,9418.24,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,3174.5,100,,,case rate,100% PEIA DRG rate,15643.38,100,,,case rate,100% The Health Plan DRG rate,3174.5,25900.16,
VIRAL ILLNESS WITH MCC,865,MS-DRG,,,,,Inpatient,,,,,,21839.7025,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,21839.7025,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,7941.71,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,11110.03,102,,,case rate,102% WV Medicaid DRG rate,13103.8215,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,10153.56,100,,,case rate,100% PEIA with CHIP DRG base rate,30900.64,100,,,case rate,100% Highmark ACA DRG rate,39075.54,100,,,case rate,100% Highmark PPO DRG rate,39075.54,100,,,case rate,100% Highmark Trad DRG rate,10892.18,100,,,case rate,100% WV Medicaid DRG rate,7941.71,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,8636.6,100,,,case rate,100% PEIA DRG rate,29059.34,100,,,case rate,100% The Health Plan DRG rate,7941.71,39075.54,
VIRAL ILLNESS WITHOUT MCC,866,MS-DRG,,,,,Inpatient,,,,,,43071.71,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,43071.71,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,15662.44,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,3215.49,102,,,case rate,102% WV Medicaid DRG rate,25843.026,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,2938.66,100,,,case rate,100% PEIA with CHIP DRG base rate,17292.22,100,,,case rate,100% Highmark ACA DRG rate,21866.96,100,,,case rate,100% Highmark PPO DRG rate,21866.96,100,,,case rate,100% Highmark Trad DRG rate,3152.44,100,,,case rate,100% WV Medicaid DRG rate,15662.44,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,2499.62,100,,,case rate,100% PEIA DRG rate,16261.82,100,,,case rate,100% The Health Plan DRG rate,2499.62,43071.71,
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH MCC,867,MS-DRG,,,,,Inpatient,,,,,,23165.725,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,23165.725,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,8423.9,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,7477.4,102,,,case rate,102% WV Medicaid DRG rate,13899.435,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,6833.66,100,,,case rate,100% PEIA with CHIP DRG base rate,39425.21,100,,,case rate,100% Highmark ACA DRG rate,49855.32,100,,,case rate,100% Highmark PPO DRG rate,49855.32,100,,,case rate,100% Highmark Trad DRG rate,7330.78,100,,,case rate,100% WV Medicaid DRG rate,8423.9,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,5812.7,100,,,case rate,100% PEIA DRG rate,37075.95,100,,,case rate,100% The Health Plan DRG rate,5812.7,49855.32,
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH CC,868,MS-DRG,,,,,Inpatient,,,,,,54416.4225,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,54416.4225,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,19787.79,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,5529.39,102,,,case rate,102% WV Medicaid DRG rate,32649.8535,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,5053.36,100,,,case rate,100% PEIA with CHIP DRG base rate,20454.08,100,,,case rate,100% Highmark ACA DRG rate,25865.29,100,,,case rate,100% Highmark PPO DRG rate,25865.29,100,,,case rate,100% Highmark Trad DRG rate,5420.97,100,,,case rate,100% WV Medicaid DRG rate,19787.79,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,4298.38,100,,,case rate,100% PEIA DRG rate,19235.27,100,,,case rate,100% The Health Plan DRG rate,4298.38,54416.4225,
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITHOUT CC/MCC,869,MS-DRG,,,,,Inpatient,,,,,,27182.4575,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,27182.4575,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,9884.53,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,3008.7,102,,,case rate,102% WV Medicaid DRG rate,16309.4745,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,2749.68,100,,,case rate,100% PEIA with CHIP DRG base rate,13014.86,100,,,case rate,100% Highmark ACA DRG rate,16458,100,,,case rate,100% Highmark PPO DRG rate,16458,100,,,case rate,100% Highmark Trad DRG rate,2949.7,100,,,case rate,100% WV Medicaid DRG rate,9884.53,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,2338.87,100,,,case rate,100% PEIA DRG rate,12239.34,100,,,case rate,100% The Health Plan DRG rate,2338.87,27182.4575,
SEPTICEMIA OR SEVERE SEPSIS WITH MV >96 HOURS,870,MS-DRG,,,,,Inpatient,,,,,,19074.33,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,19074.33,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,6936.12,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,29580.26,102,,,case rate,102% WV Medicaid DRG rate,11444.598,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,27033.66,100,,,case rate,100% PEIA with CHIP DRG base rate,131239.61,100,,,case rate,100% Highmark ACA DRG rate,165959.64,100,,,case rate,100% Highmark PPO DRG rate,165959.64,100,,,case rate,100% Highmark Trad DRG rate,29000.22,100,,,case rate,100% WV Medicaid DRG rate,6936.12,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,22994.79,100,,,case rate,100% PEIA DRG rate,123419.35,100,,,case rate,100% The Health Plan DRG rate,6936.12,165959.64,
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITH MCC,7,MS-DRG,,,,,Inpatient,,,,,,174854.02,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,174854.02,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,63583.28,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,54403.91,102,,,case rate,102% WV Medicaid DRG rate,104912.412,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,49720.21,100,,,case rate,100% PEIA with CHIP DRG base rate,231135.78,100,,,case rate,100% Highmark ACA DRG rate,292283.78,100,,,case rate,100% Highmark PPO DRG rate,292283.78,100,,,case rate,100% Highmark Trad DRG rate,53337.11,100,,,case rate,100% WV Medicaid DRG rate,63583.28,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,42291.95,100,,,case rate,100% PEIA DRG rate,217362.94,100,,,case rate,100% The Health Plan DRG rate,42291.95,292283.78,
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITHOUT MCC,872,MS-DRG,,,,,Inpatient,,,,,,50394.5475,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,50394.5475,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,18325.29,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,4994.59,102,,,case rate,102% WV Medicaid DRG rate,30236.7285,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,4564.6,100,,,case rate,100% PEIA with CHIP DRG base rate,19406.41,100,,,case rate,100% Highmark ACA DRG rate,24540.46,100,,,case rate,100% Highmark PPO DRG rate,24540.46,100,,,case rate,100% Highmark Trad DRG rate,4896.65,100,,,case rate,100% WV Medicaid DRG rate,18325.29,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,3882.64,100,,,case rate,100% PEIA DRG rate,18250.02,100,,,case rate,100% The Health Plan DRG rate,3882.64,50394.5475,
O.R. PROCEDURES WITH PRINCIPAL DIAGNOSIS OF MENTAL ILLNESS,876,MS-DRG,,,,,Inpatient,,,,,,26469.2175,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,26469.2175,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,9625.17,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,21228.46,102,,,case rate,102% WV Medicaid DRG rate,15881.5305,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,19400.87,100,,,case rate,100% PEIA with CHIP DRG base rate,70312.65,100,,,case rate,100% Highmark ACA DRG rate,88914.18,100,,,case rate,100% Highmark PPO DRG rate,88914.18,100,,,case rate,100% Highmark Trad DRG rate,20812.19,100,,,case rate,100% WV Medicaid DRG rate,9625.17,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,16502.36,100,,,case rate,100% PEIA DRG rate,66122.89,100,,,case rate,100% The Health Plan DRG rate,9625.17,88914.18,
ACUTE ADJUSTMENT REACTION AND PSYCHOSOCIAL DYSFUNCTION,880,MS-DRG,,,,,Inpatient,,,,,,82299.2775,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,82299.2775,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,29927.01,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,3318.88,102,,,case rate,102% WV Medicaid DRG rate,49379.5665,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,3033.16,100,,,case rate,100% PEIA with CHIP DRG base rate,17987.53,100,,,case rate,100% Highmark ACA DRG rate,22746.21,100,,,case rate,100% Highmark PPO DRG rate,22746.21,100,,,case rate,100% Highmark Trad DRG rate,3253.8,100,,,case rate,100% WV Medicaid DRG rate,29927.01,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,2580,100,,,case rate,100% PEIA DRG rate,16915.69,100,,,case rate,100% The Health Plan DRG rate,2580,82299.2775,
DEPRESSIVE NEUROSES,881,MS-DRG,,,,,Inpatient,,,,,,23333.09,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,23333.09,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,8484.76,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,2237.25,102,,,case rate,102% WV Medicaid DRG rate,13999.854,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,2044.64,100,,,case rate,100% PEIA with CHIP DRG base rate,17081.18,100,,,case rate,100% Highmark ACA DRG rate,21600.08,100,,,case rate,100% Highmark PPO DRG rate,21600.08,100,,,case rate,100% Highmark Trad DRG rate,2193.38,100,,,case rate,100% WV Medicaid DRG rate,8484.76,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,1739.17,100,,,case rate,100% PEIA DRG rate,16063.35,100,,,case rate,100% The Health Plan DRG rate,1739.17,23333.09,
NEUROSES EXCEPT DEPRESSIVE,882,MS-DRG,,,,,Inpatient,,,,,,22027.665,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,22027.665,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,8010.06,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,2550.55,102,,,case rate,102% WV Medicaid DRG rate,13216.599,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,2330.97,100,,,case rate,100% PEIA with CHIP DRG base rate,17699.23,100,,,case rate,100% Highmark ACA DRG rate,22381.64,100,,,case rate,100% Highmark PPO DRG rate,22381.64,100,,,case rate,100% Highmark Trad DRG rate,2500.54,100,,,case rate,100% WV Medicaid DRG rate,8010.06,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,1982.72,100,,,case rate,100% PEIA DRG rate,16644.57,100,,,case rate,100% The Health Plan DRG rate,1982.72,22381.64,
DISORDERS OF PERSONALITY AND IMPULSE CONTROL,883,MS-DRG,,,,,Inpatient,,,,,,22491.1225,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,22491.1225,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,8178.59,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,3215.93,102,,,case rate,102% WV Medicaid DRG rate,13494.6735,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,2939.07,100,,,case rate,100% PEIA with CHIP DRG base rate,35338.16,100,,,case rate,100% Highmark ACA DRG rate,44687.03,100,,,case rate,100% Highmark PPO DRG rate,44687.03,100,,,case rate,100% Highmark Trad DRG rate,3152.87,100,,,case rate,100% WV Medicaid DRG rate,8178.59,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,2499.97,100,,,case rate,100% PEIA DRG rate,33232.44,100,,,case rate,100% The Health Plan DRG rate,2499.97,44687.03,
ORGANIC DISTURBANCES AND INTELLECTUAL DISABILITY,884,MS-DRG,,,,,Inpatient,,,,,,41570.6225,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,41570.6225,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,15116.59,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,3028.75,102,,,case rate,102% WV Medicaid DRG rate,24942.3735,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,2768,100,,,case rate,100% PEIA with CHIP DRG base rate,33105.27,100,,,case rate,100% Highmark ACA DRG rate,41863.41,100,,,case rate,100% Highmark PPO DRG rate,41863.41,100,,,case rate,100% Highmark Trad DRG rate,2969.36,100,,,case rate,100% WV Medicaid DRG rate,15116.59,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,2354.46,100,,,case rate,100% PEIA DRG rate,31132.6,100,,,case rate,100% The Health Plan DRG rate,2354.46,41863.41,
PSYCHOSES,885,MS-DRG,,,,,Inpatient,,,,,,40424.8075,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,40424.8075,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,14699.93,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,2957.89,102,,,case rate,102% WV Medicaid DRG rate,24254.8845,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,2703.24,100,,,case rate,100% PEIA with CHIP DRG base rate,25747.08,100,,,case rate,100% Highmark ACA DRG rate,32558.58,100,,,case rate,100% Highmark PPO DRG rate,32558.58,100,,,case rate,100% Highmark Trad DRG rate,2899.89,100,,,case rate,100% WV Medicaid DRG rate,14699.93,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,2299.38,100,,,case rate,100% PEIA DRG rate,24212.87,100,,,case rate,100% The Health Plan DRG rate,2299.38,40424.8075,
BEHAVIORAL AND DEVELOPMENTAL DISORDERS,886,MS-DRG,,,,,Inpatient,,,,,,33356.895,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,33356.895,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,12129.78,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,2132.07,102,,,case rate,102% WV Medicaid DRG rate,20014.137,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,1948.52,100,,,case rate,100% PEIA with CHIP DRG base rate,31688.27,100,,,case rate,100% Highmark ACA DRG rate,40071.55,100,,,case rate,100% Highmark PPO DRG rate,40071.55,100,,,case rate,100% Highmark Trad DRG rate,2090.26,100,,,case rate,100% WV Medicaid DRG rate,12129.78,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,1657.41,100,,,case rate,100% PEIA DRG rate,29800.04,100,,,case rate,100% The Health Plan DRG rate,1657.41,40071.55,
OTHER MENTAL DISORDER DIAGNOSES,887,MS-DRG,,,,,Inpatient,,,,,,35146.4575,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,35146.4575,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,12780.53,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,8610.73,102,,,case rate,102% WV Medicaid DRG rate,21087.8745,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,7869.42,100,,,case rate,100% PEIA with CHIP DRG base rate,24412.99,100,,,case rate,100% Highmark ACA DRG rate,30871.56,100,,,case rate,100% Highmark PPO DRG rate,30871.56,100,,,case rate,100% Highmark Trad DRG rate,8441.89,100,,,case rate,100% WV Medicaid DRG rate,12780.53,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,6693.72,100,,,case rate,100% PEIA DRG rate,22958.28,100,,,case rate,100% The Health Plan DRG rate,6693.72,35146.4575,
"ALCOHOL, DRUG ABUSE OR DEPENDENCE, LEFT AMA",894,MS-DRG,,,,,Inpatient,,,,,,33382.635,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,33382.635,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,12139.14,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,2259.53,102,,,case rate,102% WV Medicaid DRG rate,20029.581,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,2065.01,100,,,case rate,100% PEIA with CHIP DRG base rate,10825.3,100,,,case rate,100% Highmark ACA DRG rate,13689.19,100,,,case rate,100% Highmark PPO DRG rate,13689.19,100,,,case rate,100% Highmark Trad DRG rate,2215.22,100,,,case rate,100% WV Medicaid DRG rate,12139.14,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,1756.49,100,,,case rate,100% PEIA DRG rate,10180.25,100,,,case rate,100% The Health Plan DRG rate,1756.49,33382.635,
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITH REHABILITATION THERAPY",895,MS-DRG,,,,,Inpatient,,,,,,14722.9225,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,14722.9225,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,5353.79,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,15318.47,102,,,case rate,102% WV Medicaid DRG rate,8833.7535,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,13999.68,100,,,case rate,100% PEIA with CHIP DRG base rate,30314.62,100,,,case rate,100% Highmark ACA DRG rate,38334.49,100,,,case rate,100% Highmark PPO DRG rate,38334.49,100,,,case rate,100% Highmark Trad DRG rate,15018.09,100,,,case rate,100% WV Medicaid DRG rate,5353.79,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,11908.11,100,,,case rate,100% PEIA DRG rate,28508.24,100,,,case rate,100% The Health Plan DRG rate,5353.79,38334.49,
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITH MCC",896,MS-DRG,,,,,Inpatient,,,,,,40133.8575,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,40133.8575,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,14594.13,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,7466.26,102,,,case rate,102% WV Medicaid DRG rate,24080.3145,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,6823.48,100,,,case rate,100% PEIA with CHIP DRG base rate,33504.74,100,,,case rate,100% Highmark ACA DRG rate,42368.57,100,,,case rate,100% Highmark PPO DRG rate,42368.57,100,,,case rate,100% Highmark Trad DRG rate,7319.85,100,,,case rate,100% WV Medicaid DRG rate,14594.13,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,5804.04,100,,,case rate,100% PEIA DRG rate,31508.27,100,,,case rate,100% The Health Plan DRG rate,5804.04,42368.57,
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITHOUT MCC",897,MS-DRG,,,,,Inpatient,,,,,,45203.7025,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,45203.7025,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,16437.71,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,2786.31,102,,,case rate,102% WV Medicaid DRG rate,27122.2215,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,2546.43,100,,,case rate,100% PEIA with CHIP DRG base rate,16122.07,100,,,case rate,100% Highmark ACA DRG rate,20387.24,100,,,case rate,100% Highmark PPO DRG rate,20387.24,100,,,case rate,100% Highmark Trad DRG rate,2731.67,100,,,case rate,100% WV Medicaid DRG rate,16437.71,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,2165.99,100,,,case rate,100% PEIA DRG rate,15161.39,100,,,case rate,100% The Health Plan DRG rate,2165.99,45203.7025,
WOUND DEBRIDEMENTS FOR INJURIES WITH MCC,901,MS-DRG,,,,,Inpatient,,,,,,21919.535,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,21919.535,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,7970.74,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,18692.61,102,,,case rate,102% WV Medicaid DRG rate,13151.721,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,17083.34,100,,,case rate,100% PEIA with CHIP DRG base rate,81548.74,100,,,case rate,100% Highmark ACA DRG rate,103122.82,100,,,case rate,100% Highmark PPO DRG rate,103122.82,100,,,case rate,100% Highmark Trad DRG rate,18326.07,100,,,case rate,100% WV Medicaid DRG rate,7970.74,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,14531.07,100,,,case rate,100% PEIA DRG rate,76689.44,100,,,case rate,100% The Health Plan DRG rate,7970.74,103122.82,
WOUND DEBRIDEMENTS FOR INJURIES WITH CC,902,MS-DRG,,,,,Inpatient,,,,,,113256.4125,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,113256.4125,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,41184.15,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,7684.64,102,,,case rate,102% WV Medicaid DRG rate,67953.8475,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,7023.06,100,,,case rate,100% PEIA with CHIP DRG base rate,35513.4,100,,,case rate,100% Highmark ACA DRG rate,44908.63,100,,,case rate,100% Highmark PPO DRG rate,44908.63,100,,,case rate,100% Highmark Trad DRG rate,7533.95,100,,,case rate,100% WV Medicaid DRG rate,41184.15,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,5973.8,100,,,case rate,100% PEIA DRG rate,33397.24,100,,,case rate,100% The Health Plan DRG rate,5973.8,113256.4125,
WOUND DEBRIDEMENTS FOR INJURIES WITHOUT CC/MCC,903,MS-DRG,,,,,Inpatient,,,,,,51028.01,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,51028.01,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,18555.64,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,5524.04,102,,,case rate,102% WV Medicaid DRG rate,30616.806,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,5048.47,100,,,case rate,100% PEIA with CHIP DRG base rate,23393.58,100,,,case rate,100% Highmark ACA DRG rate,29582.46,100,,,case rate,100% Highmark PPO DRG rate,29582.46,100,,,case rate,100% Highmark Trad DRG rate,5415.72,100,,,case rate,100% WV Medicaid DRG rate,18555.64,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,4294.22,100,,,case rate,100% PEIA DRG rate,21999.62,100,,,case rate,100% The Health Plan DRG rate,4294.22,51028.01,
SKIN GRAFTS FOR INJURIES WITH CC/MCC,904,MS-DRG,,,,,Inpatient,,,,,,31299.5925,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,31299.5925,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,11381.67,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,17059.69,102,,,case rate,102% WV Medicaid DRG rate,18779.7555,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,15591,100,,,case rate,100% PEIA with CHIP DRG base rate,61356.58,100,,,case rate,100% Highmark ACA DRG rate,77588.73,100,,,case rate,100% Highmark PPO DRG rate,77588.73,100,,,case rate,100% Highmark Trad DRG rate,16725.17,100,,,case rate,100% WV Medicaid DRG rate,11381.67,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,13261.68,100,,,case rate,100% PEIA DRG rate,57700.48,100,,,case rate,100% The Health Plan DRG rate,11381.67,77588.73,
SKIN GRAFTS FOR INJURIES WITHOUT CC/MCC,905,MS-DRG,,,,,Inpatient,,,,,,91455.3475,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,91455.3475,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,33256.49,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,10360.42,102,,,case rate,102% WV Medicaid DRG rate,54873.2085,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,9468.48,100,,,case rate,100% PEIA with CHIP DRG base rate,29841.66,100,,,case rate,100% Highmark ACA DRG rate,37736.4,100,,,case rate,100% Highmark PPO DRG rate,37736.4,100,,,case rate,100% Highmark Trad DRG rate,10157.27,100,,,case rate,100% WV Medicaid DRG rate,33256.49,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,8053.88,100,,,case rate,100% PEIA DRG rate,28063.46,100,,,case rate,100% The Health Plan DRG rate,8053.88,91455.3475,
HAND PROCEDURES FOR INJURIES,906,MS-DRG,,,,,Inpatient,,,,,,40164.74,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,40164.74,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,14605.36,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,6336.05,102,,,case rate,102% WV Medicaid DRG rate,24098.844,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,5790.57,100,,,case rate,100% PEIA with CHIP DRG base rate,35454.99,100,,,case rate,100% Highmark ACA DRG rate,44834.76,100,,,case rate,100% Highmark PPO DRG rate,44834.76,100,,,case rate,100% Highmark Trad DRG rate,6211.81,100,,,case rate,100% WV Medicaid DRG rate,14605.36,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,4925.45,100,,,case rate,100% PEIA DRG rate,33342.31,100,,,case rate,100% The Health Plan DRG rate,4925.45,44834.76,
OTHER O.R. PROCEDURES FOR INJURIES WITH MCC,907,MS-DRG,,,,,Inpatient,,,,,,46032.8,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,46032.8,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,16739.2,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,11442.5,102,,,case rate,102% WV Medicaid DRG rate,27619.68,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,10457.4,100,,,case rate,100% PEIA with CHIP DRG base rate,70086.54,100,,,case rate,100% Highmark ACA DRG rate,88628.25,100,,,case rate,100% Highmark PPO DRG rate,88628.25,100,,,case rate,100% Highmark Trad DRG rate,11218.13,100,,,case rate,100% WV Medicaid DRG rate,16739.2,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,8895.05,100,,,case rate,100% PEIA DRG rate,65910.25,100,,,case rate,100% The Health Plan DRG rate,8895.05,88628.25,
OTHER O.R. PROCEDURES FOR INJURIES WITH CC,908,MS-DRG,,,,,Inpatient,,,,,,99535.1225,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,99535.1225,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,36194.59,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,10083.22,102,,,case rate,102% WV Medicaid DRG rate,59721.0735,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,9215.14,100,,,case rate,100% PEIA with CHIP DRG base rate,37763.26,100,,,case rate,100% Highmark ACA DRG rate,47753.69,100,,,case rate,100% Highmark PPO DRG rate,47753.69,100,,,case rate,100% Highmark Trad DRG rate,9885.5,100,,,case rate,100% WV Medicaid DRG rate,36194.59,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,7838.39,100,,,case rate,100% PEIA DRG rate,35513.03,100,,,case rate,100% The Health Plan DRG rate,7838.39,99535.1225,
OTHER O.R. PROCEDURES FOR INJURIES WITHOUT CC/MCC,909,MS-DRG,,,,,Inpatient,,,,,,52951.3325,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,52951.3325,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,19255.03,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,6184.97,102,,,case rate,102% WV Medicaid DRG rate,31770.7995,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,5652.5,100,,,case rate,100% PEIA with CHIP DRG base rate,25556.76,100,,,case rate,100% Highmark ACA DRG rate,32317.92,100,,,case rate,100% Highmark PPO DRG rate,32317.92,100,,,case rate,100% Highmark Trad DRG rate,6063.69,100,,,case rate,100% WV Medicaid DRG rate,19255.03,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,4808.01,100,,,case rate,100% PEIA DRG rate,24033.89,100,,,case rate,100% The Health Plan DRG rate,4808.01,52951.3325,
TRAUMATIC INJURY WITH MCC,913,MS-DRG,,,,,Inpatient,,,,,,35138.675,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,35138.675,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,12777.7,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,10056.48,102,,,case rate,102% WV Medicaid DRG rate,21083.205,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,9190.7,100,,,case rate,100% PEIA with CHIP DRG base rate,28160.86,100,,,case rate,100% Highmark ACA DRG rate,35610.95,100,,,case rate,100% Highmark PPO DRG rate,35610.95,100,,,case rate,100% Highmark Trad DRG rate,9859.28,100,,,case rate,100% WV Medicaid DRG rate,12777.7,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,7817.6,100,,,case rate,100% PEIA DRG rate,26482.82,100,,,case rate,100% The Health Plan DRG rate,7817.6,35610.95,
TRAUMATIC INJURY WITHOUT MCC,914,MS-DRG,,,,,Inpatient,,,,,,38985.485,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,38985.485,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,14176.54,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,4687.08,102,,,case rate,102% WV Medicaid DRG rate,23391.291,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,4283.56,100,,,case rate,100% PEIA with CHIP DRG base rate,17103.79,100,,,case rate,100% Highmark ACA DRG rate,21628.68,100,,,case rate,100% Highmark PPO DRG rate,21628.68,100,,,case rate,100% Highmark Trad DRG rate,4595.17,100,,,case rate,100% WV Medicaid DRG rate,14176.54,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,3643.59,100,,,case rate,100% PEIA DRG rate,16084.62,100,,,case rate,100% The Health Plan DRG rate,3643.59,38985.485,
ALLERGIC REACTIONS WITH MCC,915,MS-DRG,,,,,Inpatient,,,,,,22892.8425,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,22892.8425,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,8324.67,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,6118.56,102,,,case rate,102% WV Medicaid DRG rate,13735.7055,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,5591.81,100,,,case rate,100% PEIA with CHIP DRG base rate,33427.48,100,,,case rate,100% Highmark ACA DRG rate,42270.87,100,,,case rate,100% Highmark PPO DRG rate,42270.87,100,,,case rate,100% Highmark Trad DRG rate,5998.58,100,,,case rate,100% WV Medicaid DRG rate,8324.67,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,4756.38,100,,,case rate,100% PEIA DRG rate,31435.62,100,,,case rate,100% The Health Plan DRG rate,4756.38,42270.87,
ALLERGIC REACTIONS WITHOUT MCC,916,MS-DRG,,,,,Inpatient,,,,,,46864.455,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,46864.455,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,17041.62,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,3483.33,102,,,case rate,102% WV Medicaid DRG rate,28118.673,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,3183.45,100,,,case rate,100% PEIA with CHIP DRG base rate,12413.77,100,,,case rate,100% Highmark ACA DRG rate,15697.89,100,,,case rate,100% Highmark PPO DRG rate,15697.89,100,,,case rate,100% Highmark Trad DRG rate,3415.03,100,,,case rate,100% WV Medicaid DRG rate,17041.62,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,2707.84,100,,,case rate,100% PEIA DRG rate,11674.06,100,,,case rate,100% The Health Plan DRG rate,2707.84,46864.455,
POISONING AND TOXIC EFFECTS OF DRUGS WITH MCC,917,MS-DRG,,,,,Inpatient,,,,,,17102.03,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,17102.03,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,6218.92,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,6763.89,102,,,case rate,102% WV Medicaid DRG rate,10261.218,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,6181.58,100,,,case rate,100% PEIA with CHIP DRG base rate,30071.54,100,,,case rate,100% Highmark ACA DRG rate,38027.11,100,,,case rate,100% Highmark PPO DRG rate,38027.11,100,,,case rate,100% Highmark Trad DRG rate,6631.26,100,,,case rate,100% WV Medicaid DRG rate,6218.92,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,5258.04,100,,,case rate,100% PEIA DRG rate,28279.65,100,,,case rate,100% The Health Plan DRG rate,5258.04,38027.11,
POISONING AND TOXIC EFFECTS OF DRUGS WITHOUT MCC,918,MS-DRG,,,,,Inpatient,,,,,,39201.745,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,39201.745,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,14255.18,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,3215.49,102,,,case rate,102% WV Medicaid DRG rate,23521.047,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,2938.66,100,,,case rate,100% PEIA with CHIP DRG base rate,16221.94,100,,,case rate,100% Highmark ACA DRG rate,20513.53,100,,,case rate,100% Highmark PPO DRG rate,20513.53,100,,,case rate,100% Highmark Trad DRG rate,3152.44,100,,,case rate,100% WV Medicaid DRG rate,14255.18,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,2499.62,100,,,case rate,100% PEIA DRG rate,15255.31,100,,,case rate,100% The Health Plan DRG rate,2499.62,39201.745,
COMPLICATIONS OF TREATMENT WITH MCC,919,MS-DRG,,,,,Inpatient,,,,,,21054.3575,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,21054.3575,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,7656.13,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,8527.39,102,,,case rate,102% WV Medicaid DRG rate,12632.6145,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,7793.26,100,,,case rate,100% PEIA with CHIP DRG base rate,34382.82,100,,,case rate,100% Highmark ACA DRG rate,43478.95,100,,,case rate,100% Highmark PPO DRG rate,43478.95,100,,,case rate,100% Highmark Trad DRG rate,8360.18,100,,,case rate,100% WV Medicaid DRG rate,7656.13,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,6628.94,100,,,case rate,100% PEIA DRG rate,32334.03,100,,,case rate,100% The Health Plan DRG rate,6628.94,43478.95,
COMPLICATIONS OF TREATMENT WITH CC,920,MS-DRG,,,,,Inpatient,,,,,,46182.125,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,46182.125,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,16793.5,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,5049.41,102,,,case rate,102% WV Medicaid DRG rate,27709.275,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,4614.7,100,,,case rate,100% PEIA with CHIP DRG base rate,19479.89,100,,,case rate,100% Highmark ACA DRG rate,24633.39,100,,,case rate,100% Highmark PPO DRG rate,24633.39,100,,,case rate,100% Highmark Trad DRG rate,4950.39,100,,,case rate,100% WV Medicaid DRG rate,16793.5,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,3925.26,100,,,case rate,100% PEIA DRG rate,18319.13,100,,,case rate,100% The Health Plan DRG rate,3925.26,46182.125,
COMPLICATIONS OF TREATMENT WITHOUT CC/MCC,921,MS-DRG,,,,,Inpatient,,,,,,26309.58,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,26309.58,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,9567.12,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,3984.26,102,,,case rate,102% WV Medicaid DRG rate,15785.748,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,3641.25,100,,,case rate,100% PEIA with CHIP DRG base rate,13148.65,100,,,case rate,100% Highmark ACA DRG rate,16627.18,100,,,case rate,100% Highmark PPO DRG rate,16627.18,100,,,case rate,100% Highmark Trad DRG rate,3906.14,100,,,case rate,100% WV Medicaid DRG rate,9567.12,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,3097.25,100,,,case rate,100% PEIA DRG rate,12365.15,100,,,case rate,100% The Health Plan DRG rate,3097.25,26309.58,
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITH MCC",922,MS-DRG,,,,,Inpatient,,,,,,18742.185,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,18742.185,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,6815.34,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,9668.75,102,,,case rate,102% WV Medicaid DRG rate,11245.311,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,8836.35,100,,,case rate,100% PEIA with CHIP DRG base rate,32879.15,100,,,case rate,100% Highmark ACA DRG rate,41577.48,100,,,case rate,100% Highmark PPO DRG rate,41577.48,100,,,case rate,100% Highmark Trad DRG rate,9479.15,100,,,case rate,100% WV Medicaid DRG rate,6815.34,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,7516.19,100,,,case rate,100% PEIA DRG rate,30919.96,100,,,case rate,100% The Health Plan DRG rate,6815.34,41577.48,
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITHOUT MCC",923,MS-DRG,,,,,Inpatient,,,,,,40059.14,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,40059.14,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,14566.96,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,3037.67,102,,,case rate,102% WV Medicaid DRG rate,24035.484,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,2776.15,100,,,case rate,100% PEIA with CHIP DRG base rate,19057.81,100,,,case rate,100% Highmark ACA DRG rate,24099.64,100,,,case rate,100% Highmark PPO DRG rate,24099.64,100,,,case rate,100% Highmark Trad DRG rate,2978.1,100,,,case rate,100% WV Medicaid DRG rate,14566.96,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,2361.39,100,,,case rate,100% PEIA DRG rate,17922.2,100,,,case rate,100% The Health Plan DRG rate,2361.39,40059.14,
EXTENSIVE BURNS OR FULL THICKNESS BURNS WITH MV >96 HOURS WITH SKIN GRAFT,927,MS-DRG,,,,,Inpatient,,,,,,24285.745,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,24285.745,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,8831.18,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,80285.13,102,,,case rate,102% WV Medicaid DRG rate,14571.447,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,73373.29,100,,,case rate,100% PEIA with CHIP DRG base rate,496676.98,100,,,case rate,100% Highmark ACA DRG rate,628075.1,100,,,case rate,100% Highmark PPO DRG rate,628075.1,100,,,case rate,100% Highmark Trad DRG rate,78710.83,100,,,case rate,100% WV Medicaid DRG rate,8831.18,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,62411.22,100,,,case rate,100% PEIA DRG rate,467081.17,100,,,case rate,100% The Health Plan DRG rate,8831.18,628075.1,
FULL THICKNESS BURN WITH SKIN GRAFT OR INHALATION INJURY WITH CC/MCC,928,MS-DRG,,,,,Inpatient,,,,,,488759.1225,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,488759.1225,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,177730.59,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,22838.65,102,,,case rate,102% WV Medicaid DRG rate,293255.4735,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,20872.44,100,,,case rate,100% PEIA with CHIP DRG base rate,130387.91,100,,,case rate,100% Highmark ACA DRG rate,164882.61,100,,,case rate,100% Highmark PPO DRG rate,164882.61,100,,,case rate,100% Highmark Trad DRG rate,22390.81,100,,,case rate,100% WV Medicaid DRG rate,177730.59,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,17754.07,100,,,case rate,100% PEIA DRG rate,122618.4,100,,,case rate,100% The Health Plan DRG rate,17754.07,488759.1225,
FULL THICKNESS BURN WITH SKIN GRAFT OR INHALATION INJURY WITHOUT CC/MCC,929,MS-DRG,,,,,Inpatient,,,,,,159415.3825,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,159415.3825,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,57969.23,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,19517.99,102,,,case rate,102% WV Medicaid DRG rate,95649.2295,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,17837.66,100,,,case rate,100% PEIA with CHIP DRG base rate,60589.67,100,,,case rate,100% Highmark ACA DRG rate,76618.93,100,,,case rate,100% Highmark PPO DRG rate,76618.93,100,,,case rate,100% Highmark Trad DRG rate,19135.26,100,,,case rate,100% WV Medicaid DRG rate,57969.23,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,15172.69,100,,,case rate,100% PEIA DRG rate,56979.27,100,,,case rate,100% The Health Plan DRG rate,15172.69,159415.3825,
EXTENSIVE BURNS OR FULL THICKNESS BURNS WITH MV >96 HOURS WITHOUT SKIN GRAFT,933,MS-DRG,,,,,Inpatient,,,,,,75669.0825,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,75669.0825,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,27516.03,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,6006.25,102,,,case rate,102% WV Medicaid DRG rate,45401.4495,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,5489.17,100,,,case rate,100% PEIA with CHIP DRG base rate,57131.98,100,,,case rate,100% Highmark ACA DRG rate,72246.5,100,,,case rate,100% Highmark PPO DRG rate,72246.5,100,,,case rate,100% Highmark Trad DRG rate,5888.48,100,,,case rate,100% WV Medicaid DRG rate,27516.03,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,4669.08,100,,,case rate,100% PEIA DRG rate,53727.62,100,,,case rate,100% The Health Plan DRG rate,4669.08,75669.0825,
FULL THICKNESS BURN WITHOUT SKIN GRAFT OR INHALATION INJURY,934,MS-DRG,,,,,Inpatient,,,,,,78094.61,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,78094.61,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,28398.04,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,12475.11,102,,,case rate,102% WV Medicaid DRG rate,46856.766,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,11401.11,100,,,case rate,100% PEIA with CHIP DRG base rate,39428.98,100,,,case rate,100% Highmark ACA DRG rate,49860.09,100,,,case rate,100% Highmark PPO DRG rate,49860.09,100,,,case rate,100% Highmark Trad DRG rate,12230.49,100,,,case rate,100% WV Medicaid DRG rate,28398.04,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,9697.77,100,,,case rate,100% PEIA DRG rate,37079.5,100,,,case rate,100% The Health Plan DRG rate,9697.77,78094.61,
NON-EXTENSIVE BURNS,935,MS-DRG,,,,,Inpatient,,,,,,48303.805,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,48303.805,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,17565.02,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,5418.87,102,,,case rate,102% WV Medicaid DRG rate,28982.283,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,4952.35,100,,,case rate,100% PEIA with CHIP DRG base rate,38460.45,100,,,case rate,100% Highmark ACA DRG rate,48635.33,100,,,case rate,100% Highmark PPO DRG rate,48635.33,100,,,case rate,100% Highmark Trad DRG rate,5312.61,100,,,case rate,100% WV Medicaid DRG rate,17565.02,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,4212.46,100,,,case rate,100% PEIA DRG rate,36168.68,100,,,case rate,100% The Health Plan DRG rate,4212.46,48635.33,
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH MCC,939,MS-DRG,,,,,Inpatient,,,,,,52117.065,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,52117.065,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,18951.66,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,20568.87,102,,,case rate,102% WV Medicaid DRG rate,31270.239,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,18798.07,100,,,case rate,100% PEIA with CHIP DRG base rate,60585.9,100,,,case rate,100% Highmark ACA DRG rate,76614.17,100,,,case rate,100% Highmark PPO DRG rate,76614.17,100,,,case rate,100% Highmark Trad DRG rate,20165.54,100,,,case rate,100% WV Medicaid DRG rate,18951.66,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,15989.61,100,,,case rate,100% PEIA DRG rate,56975.73,100,,,case rate,100% The Health Plan DRG rate,15989.61,76614.17,
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH CC,940,MS-DRG,,,,,Inpatient,,,,,,79744.995,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,79744.995,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,28998.18,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,9787.74,102,,,case rate,102% WV Medicaid DRG rate,47846.997,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,8945.1,100,,,case rate,100% PEIA with CHIP DRG base rate,40825.24,100,,,case rate,100% Highmark ACA DRG rate,51625.74,100,,,case rate,100% Highmark PPO DRG rate,51625.74,100,,,case rate,100% Highmark Trad DRG rate,9595.81,100,,,case rate,100% WV Medicaid DRG rate,28998.18,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,7608.69,100,,,case rate,100% PEIA DRG rate,38392.56,100,,,case rate,100% The Health Plan DRG rate,7608.69,79744.995,
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITHOUT CC/MCC,941,MS-DRG,,,,,Inpatient,,,,,,56731.2075,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,56731.2075,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,20629.53,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,7035.74,102,,,case rate,102% WV Medicaid DRG rate,34038.7245,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,6430.03,100,,,case rate,100% PEIA with CHIP DRG base rate,34972.61,100,,,case rate,100% Highmark ACA DRG rate,44224.77,100,,,case rate,100% Highmark PPO DRG rate,44224.77,100,,,case rate,100% Highmark Trad DRG rate,6897.78,100,,,case rate,100% WV Medicaid DRG rate,20629.53,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,5469.37,100,,,case rate,100% PEIA DRG rate,32888.67,100,,,case rate,100% The Health Plan DRG rate,5469.37,56731.2075,
REHABILITATION WITH CC/MCC,945,MS-DRG,,,,,Inpatient,,,,,,48597.3125,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,48597.3125,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,17671.75,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,,,,,other,Not Separately reimbursable,29158.3875,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,,,,,other,Not Separately reimbursable,28443.51,100,,,case rate,100% Highmark ACA DRG rate,35968.37,100,,,case rate,100% Highmark PPO DRG rate,35968.37,100,,,case rate,100% Highmark Trad DRG rate,,,,,other,Not Separately reimbursable,17671.75,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,,,,,other,Not Separately reimbursable,26748.63,100,,,case rate,100% The Health Plan DRG rate,17671.75,48597.3125,
REHABILITATION WITHOUT CC/MCC,946,MS-DRG,,,,,Inpatient,,,,,,38756.355,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,38756.355,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,14093.22,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,,,,,other,Not Separately reimbursable,23253.813,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,,,,,other,Not Separately reimbursable,19082.31,100,,,case rate,100% Highmark ACA DRG rate,24130.62,100,,,case rate,100% Highmark PPO DRG rate,24130.62,100,,,case rate,100% Highmark Trad DRG rate,,,,,other,Not Separately reimbursable,14093.22,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,,,,,other,Not Separately reimbursable,17945.24,100,,,case rate,100% The Health Plan DRG rate,14093.22,38756.355,
SIGNS AND SYMPTOMS WITH MCC,947,MS-DRG,,,,,Inpatient,,,,,,28904.975,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,28904.975,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,10510.9,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,5776.74,102,,,case rate,102% WV Medicaid DRG rate,17342.985,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,5279.41,100,,,case rate,100% PEIA with CHIP DRG base rate,23583.9,100,,,case rate,100% Highmark ACA DRG rate,29823.12,100,,,case rate,100% Highmark PPO DRG rate,29823.12,100,,,case rate,100% Highmark Trad DRG rate,5663.46,100,,,case rate,100% WV Medicaid DRG rate,10510.9,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,4490.66,100,,,case rate,100% PEIA DRG rate,22178.59,100,,,case rate,100% The Health Plan DRG rate,4490.66,29823.12,
SIGNS AND SYMPTOMS WITHOUT MCC,948,MS-DRG,,,,,Inpatient,,,,,,31299.5925,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,31299.5925,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,11381.67,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,4106.82,102,,,case rate,102% WV Medicaid DRG rate,18779.7555,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,3753.26,100,,,case rate,100% PEIA with CHIP DRG base rate,15093.24,100,,,case rate,100% Highmark ACA DRG rate,19086.23,100,,,case rate,100% Highmark PPO DRG rate,19086.23,100,,,case rate,100% Highmark Trad DRG rate,4026.29,100,,,case rate,100% WV Medicaid DRG rate,11381.67,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,3192.52,100,,,case rate,100% PEIA DRG rate,14193.87,100,,,case rate,100% The Health Plan DRG rate,3192.52,31299.5925,
AFTERCARE WITH CC/MCC,949,MS-DRG,,,,,Inpatient,,,,,,20021.87,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,20021.87,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,7280.68,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,5477.25,102,,,case rate,102% WV Medicaid DRG rate,12013.122,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,5005.7,100,,,case rate,100% PEIA with CHIP DRG base rate,19523.23,100,,,case rate,100% Highmark ACA DRG rate,24688.19,100,,,case rate,100% Highmark PPO DRG rate,24688.19,100,,,case rate,100% Highmark Trad DRG rate,5369.85,100,,,case rate,100% WV Medicaid DRG rate,7280.68,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,4257.85,100,,,case rate,100% PEIA DRG rate,18359.89,100,,,case rate,100% The Health Plan DRG rate,4257.85,24688.19,
AFTERCARE WITHOUT CC/MCC,950,MS-DRG,,,,,Inpatient,,,,,,30691.9525,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,30691.9525,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,11160.71,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,4712.04,102,,,case rate,102% WV Medicaid DRG rate,18415.1715,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,4306.37,100,,,case rate,100% PEIA with CHIP DRG base rate,11837.17,100,,,case rate,100% Highmark ACA DRG rate,14968.75,100,,,case rate,100% Highmark PPO DRG rate,14968.75,100,,,case rate,100% Highmark Trad DRG rate,4619.64,100,,,case rate,100% WV Medicaid DRG rate,11160.71,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,3662.99,100,,,case rate,100% PEIA DRG rate,11131.82,100,,,case rate,100% The Health Plan DRG rate,3662.99,30691.9525,
OTHER FACTORS INFLUENCING HEALTH STATUS,951,MS-DRG,,,,,Inpatient,,,,,,18268.3875,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,18268.3875,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,6643.05,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,1900.32,102,,,case rate,102% WV Medicaid DRG rate,10961.0325,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,1736.72,100,,,case rate,100% PEIA with CHIP DRG base rate,11117.37,100,,,case rate,100% Highmark ACA DRG rate,14058.52,100,,,case rate,100% Highmark PPO DRG rate,14058.52,100,,,case rate,100% Highmark Trad DRG rate,1863.06,100,,,case rate,100% WV Medicaid DRG rate,6643.05,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,1477.25,100,,,case rate,100% PEIA DRG rate,10454.91,100,,,case rate,100% The Health Plan DRG rate,1477.25,18268.3875,
CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA,955,MS-DRG,,,,,Inpatient,,,,,,14655.9325,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,14655.9325,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,5329.43,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,44737.84,102,,,case rate,102% WV Medicaid DRG rate,8793.5595,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,40886.3,100,,,case rate,100% PEIA with CHIP DRG base rate,114757.64,100,,,case rate,100% Highmark ACA DRG rate,145117.29,100,,,case rate,100% Highmark PPO DRG rate,145117.29,100,,,case rate,100% Highmark Trad DRG rate,43860.58,100,,,case rate,100% WV Medicaid DRG rate,5329.43,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,34777.84,100,,,case rate,100% PEIA DRG rate,107919.5,100,,,case rate,100% The Health Plan DRG rate,5329.43,145117.29,
"LIMB REATTACHMENT, HIP AND FEMUR PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA",956,MS-DRG,,,,,Inpatient,,,,,,173440.4375,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,173440.4375,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,63069.25,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,16865.38,102,,,case rate,102% WV Medicaid DRG rate,104064.2625,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,15413.42,100,,,case rate,100% PEIA with CHIP DRG base rate,73076.92,100,,,case rate,100% Highmark ACA DRG rate,92409.75,100,,,case rate,100% Highmark PPO DRG rate,92409.75,100,,,case rate,100% Highmark Trad DRG rate,16534.67,100,,,case rate,100% WV Medicaid DRG rate,63069.25,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,13110.63,100,,,case rate,100% PEIA DRG rate,68722.44,100,,,case rate,100% The Health Plan DRG rate,13110.63,173440.4375,
OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA WITH MCC,957,MS-DRG,,,,,Inpatient,,,,,,97951.6175,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,97951.6175,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,35618.77,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,29779.47,102,,,case rate,102% WV Medicaid DRG rate,58770.9705,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,27215.72,100,,,case rate,100% PEIA with CHIP DRG base rate,136282,100,,,case rate,100% Highmark ACA DRG rate,172336.01,100,,,case rate,100% Highmark PPO DRG rate,172336.01,100,,,case rate,100% Highmark Trad DRG rate,29195.53,100,,,case rate,100% WV Medicaid DRG rate,35618.77,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,23149.66,100,,,case rate,100% PEIA DRG rate,128161.27,100,,,case rate,100% The Health Plan DRG rate,23149.66,172336.01,
OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA WITH CC,958,MS-DRG,,,,,Inpatient,,,,,,190807.705,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,190807.705,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,69384.62,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,18083.38,102,,,case rate,102% WV Medicaid DRG rate,114484.623,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,16526.56,100,,,case rate,100% PEIA with CHIP DRG base rate,76216.17,100,,,case rate,100% Highmark ACA DRG rate,96379.49,100,,,case rate,100% Highmark PPO DRG rate,96379.49,100,,,case rate,100% Highmark Trad DRG rate,17728.79,100,,,case rate,100% WV Medicaid DRG rate,69384.62,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,14057.47,100,,,case rate,100% PEIA DRG rate,71674.62,100,,,case rate,100% The Health Plan DRG rate,14057.47,190807.705,
OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA WITHOUT CC/MCC,959,MS-DRG,,,,,Inpatient,,,,,,107383.21,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,107383.21,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,39048.44,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,17060.13,102,,,case rate,102% WV Medicaid DRG rate,64429.926,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,15591.41,100,,,case rate,100% PEIA with CHIP DRG base rate,47718.01,100,,,case rate,100% Highmark ACA DRG rate,60342.03,100,,,case rate,100% Highmark PPO DRG rate,60342.03,100,,,case rate,100% Highmark Trad DRG rate,16725.6,100,,,case rate,100% WV Medicaid DRG rate,39048.44,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,13262.03,100,,,case rate,100% PEIA DRG rate,44874.61,100,,,case rate,100% The Health Plan DRG rate,13262.03,107383.21,
OTHER MULTIPLE SIGNIFICANT TRAUMA WITH MCC,963,MS-DRG,,,,,Inpatient,,,,,,66139.645,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,66139.645,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,24050.78,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,16261.5,102,,,case rate,102% WV Medicaid DRG rate,39683.787,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,14861.53,100,,,case rate,100% PEIA with CHIP DRG base rate,51522.41,100,,,case rate,100% Highmark ACA DRG rate,65152.9,100,,,case rate,100% Highmark PPO DRG rate,65152.9,100,,,case rate,100% Highmark Trad DRG rate,15942.63,100,,,case rate,100% WV Medicaid DRG rate,24050.78,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,12641.19,100,,,case rate,100% PEIA DRG rate,48452.32,100,,,case rate,100% The Health Plan DRG rate,12641.19,66139.645,
OTHER MULTIPLE SIGNIFICANT TRAUMA WITH CC,964,MS-DRG,,,,,Inpatient,,,,,,71405.1525,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,71405.1525,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,25965.51,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,7519.29,102,,,case rate,102% WV Medicaid DRG rate,42843.0915,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,6871.95,100,,,case rate,100% PEIA with CHIP DRG base rate,28283.34,100,,,case rate,100% Highmark ACA DRG rate,35765.83,100,,,case rate,100% Highmark PPO DRG rate,35765.83,100,,,case rate,100% Highmark Trad DRG rate,7371.85,100,,,case rate,100% WV Medicaid DRG rate,25965.51,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,5845.27,100,,,case rate,100% PEIA DRG rate,26598.01,100,,,case rate,100% The Health Plan DRG rate,5845.27,71405.1525,
OTHER MULTIPLE SIGNIFICANT TRAUMA WITHOUT CC/MCC,965,MS-DRG,,,,,Inpatient,,,,,,37708.4125,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,37708.4125,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,13712.15,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,4603.74,102,,,case rate,102% WV Medicaid DRG rate,22625.0475,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,4207.4,100,,,case rate,100% PEIA with CHIP DRG base rate,18012.02,100,,,case rate,100% Highmark ACA DRG rate,22777.19,100,,,case rate,100% Highmark PPO DRG rate,22777.19,100,,,case rate,100% Highmark Trad DRG rate,4513.47,100,,,case rate,100% WV Medicaid DRG rate,13712.15,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,3578.81,100,,,case rate,100% PEIA DRG rate,16938.73,100,,,case rate,100% The Health Plan DRG rate,3578.81,37708.4125,
HIV WITH EXTENSIVE O.R. PROCEDURES WITH MCC,969,MS-DRG,,,,,Inpatient,,,,,,23428.3775,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,23428.3775,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,8519.41,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,48136.05,102,,,case rate,102% WV Medicaid DRG rate,14057.0265,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,43991.96,100,,,case rate,100% PEIA with CHIP DRG base rate,129500.4,100,,,case rate,100% Highmark ACA DRG rate,163760.31,100,,,case rate,100% Highmark PPO DRG rate,163760.31,100,,,case rate,100% Highmark Trad DRG rate,47192.16,100,,,case rate,100% WV Medicaid DRG rate,8519.41,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,37419.5,100,,,case rate,100% PEIA DRG rate,121783.78,100,,,case rate,100% The Health Plan DRG rate,8519.41,163760.31,
HIV WITH EXTENSIVE O.R. PROCEDURES WITHOUT MCC,970,MS-DRG,,,,,Inpatient,,,,,,186613.3225,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,186613.3225,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,67859.39,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,20511.82,102,,,case rate,102% WV Medicaid DRG rate,111967.9935,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,18745.94,100,,,case rate,100% PEIA with CHIP DRG base rate,45306.11,100,,,case rate,100% Highmark ACA DRG rate,57292.04,100,,,case rate,100% Highmark PPO DRG rate,57292.04,100,,,case rate,100% Highmark Trad DRG rate,20109.61,100,,,case rate,100% WV Medicaid DRG rate,67859.39,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,15945.27,100,,,case rate,100% PEIA DRG rate,42606.42,100,,,case rate,100% The Health Plan DRG rate,15945.27,186613.3225,
HIV WITH MAJOR RELATED CONDITION WITH MCC,974,MS-DRG,,,,,Inpatient,,,,,,79521.035,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,79521.035,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,28916.74,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,10990.59,102,,,case rate,102% WV Medicaid DRG rate,47712.621,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,10044.4,100,,,case rate,100% PEIA with CHIP DRG base rate,54955.61,100,,,case rate,100% Highmark ACA DRG rate,69494.36,100,,,case rate,100% Highmark PPO DRG rate,69494.36,100,,,case rate,100% Highmark Trad DRG rate,10775.08,100,,,case rate,100% WV Medicaid DRG rate,28916.74,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,8543.75,100,,,case rate,100% PEIA DRG rate,51680.93,100,,,case rate,100% The Health Plan DRG rate,8543.75,79521.035,
HIV WITH MAJOR RELATED CONDITION WITH CC,975,MS-DRG,,,,,Inpatient,,,,,,73974.8075,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,73974.8075,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,26899.93,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,6757.2,102,,,case rate,102% WV Medicaid DRG rate,44384.8845,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,6175.47,100,,,case rate,100% PEIA with CHIP DRG base rate,25688.66,100,,,case rate,100% Highmark ACA DRG rate,32484.71,100,,,case rate,100% Highmark PPO DRG rate,32484.71,100,,,case rate,100% Highmark Trad DRG rate,6624.7,100,,,case rate,100% WV Medicaid DRG rate,26899.93,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,5252.84,100,,,case rate,100% PEIA DRG rate,24157.94,100,,,case rate,100% The Health Plan DRG rate,5252.84,73974.8075,
HIV WITH MAJOR RELATED CONDITION WITHOUT CC/MCC,976,MS-DRG,,,,,Inpatient,,,,,,35421.925,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,35421.925,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,12880.7,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,6128.37,102,,,case rate,102% WV Medicaid DRG rate,21253.155,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,5600.77,100,,,case rate,100% PEIA with CHIP DRG base rate,15927.99,100,,,case rate,100% Highmark ACA DRG rate,20141.81,100,,,case rate,100% Highmark PPO DRG rate,20141.81,100,,,case rate,100% Highmark Trad DRG rate,6008.2,100,,,case rate,100% WV Medicaid DRG rate,12880.7,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,4764.01,100,,,case rate,100% PEIA DRG rate,14978.88,100,,,case rate,100% The Health Plan DRG rate,4764.01,35421.925,
HIV WITH OR WITHOUT OTHER RELATED CONDITION,977,MS-DRG,,,,,Inpatient,,,,,,23760.495,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,23760.495,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,8640.18,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,8634.35,102,,,case rate,102% WV Medicaid DRG rate,14256.297,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,7891.01,100,,,case rate,100% PEIA with CHIP DRG base rate,26683.57,100,,,case rate,100% Highmark ACA DRG rate,33742.83,100,,,case rate,100% Highmark PPO DRG rate,33742.83,100,,,case rate,100% Highmark Trad DRG rate,8465.04,100,,,case rate,100% WV Medicaid DRG rate,8640.18,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,6712.08,100,,,case rate,100% PEIA DRG rate,25093.56,100,,,case rate,100% The Health Plan DRG rate,6712.08,33742.83,
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,981,MS-DRG,,,,,Inpatient,,,,,,33470.195,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,33470.195,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,12170.98,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,23267.38,102,,,case rate,102% WV Medicaid DRG rate,20082.117,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,21264.27,100,,,case rate,100% PEIA with CHIP DRG base rate,89323.36,100,,,case rate,100% Highmark ACA DRG rate,112954.25,100,,,case rate,100% Highmark PPO DRG rate,112954.25,100,,,case rate,100% Highmark Trad DRG rate,22811.14,100,,,case rate,100% WV Medicaid DRG rate,12170.98,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,18087.36,100,,,case rate,100% PEIA DRG rate,84000.79,100,,,case rate,100% The Health Plan DRG rate,12170.98,112954.25,
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,982,MS-DRG,,,,,Inpatient,,,,,,117937.4625,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,117937.4625,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,42886.35,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,10716.06,102,,,case rate,102% WV Medicaid DRG rate,70762.4775,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,9793.5,100,,,case rate,100% PEIA with CHIP DRG base rate,46843.7,100,,,case rate,100% Highmark ACA DRG rate,59236.41,100,,,case rate,100% Highmark PPO DRG rate,59236.41,100,,,case rate,100% Highmark Trad DRG rate,10505.93,100,,,case rate,100% WV Medicaid DRG rate,42886.35,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,8330.34,100,,,case rate,100% PEIA DRG rate,44052.39,100,,,case rate,100% The Health Plan DRG rate,8330.34,117937.4625,
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITHOUT CC/MCC,983,MS-DRG,,,,,Inpatient,,,,,,64581.7975,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,64581.7975,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,23484.29,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,7687.31,102,,,case rate,102% WV Medicaid DRG rate,38749.0785,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,7025.5,100,,,case rate,100% PEIA with CHIP DRG base rate,30812.07,100,,,case rate,100% Highmark ACA DRG rate,38963.55,100,,,case rate,100% Highmark PPO DRG rate,38963.55,100,,,case rate,100% Highmark Trad DRG rate,7536.57,100,,,case rate,100% WV Medicaid DRG rate,23484.29,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,5975.88,100,,,case rate,100% PEIA DRG rate,28976.05,100,,,case rate,100% The Health Plan DRG rate,5975.88,64581.7975,
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,987,MS-DRG,,,,,Inpatient,,,,,,43004.775,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,43004.775,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,15638.1,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,14904.89,102,,,case rate,102% WV Medicaid DRG rate,25802.865,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,13621.71,100,,,case rate,100% PEIA with CHIP DRG base rate,63627.16,100,,,case rate,100% Highmark ACA DRG rate,80460.01,100,,,case rate,100% Highmark PPO DRG rate,80460.01,100,,,case rate,100% Highmark Trad DRG rate,14612.62,100,,,case rate,100% WV Medicaid DRG rate,15638.1,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,11586.61,100,,,case rate,100% PEIA DRG rate,59835.77,100,,,case rate,100% The Health Plan DRG rate,11586.61,80460.01,
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,988,MS-DRG,,,,,Inpatient,,,,,,85443.1325,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,85443.1325,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,31070.23,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,9008.27,102,,,case rate,102% WV Medicaid DRG rate,51265.8795,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,8232.73,100,,,case rate,100% PEIA with CHIP DRG base rate,31976.57,100,,,case rate,100% Highmark ACA DRG rate,40436.12,100,,,case rate,100% Highmark PPO DRG rate,40436.12,100,,,case rate,100% Highmark Trad DRG rate,8831.63,100,,,case rate,100% WV Medicaid DRG rate,31070.23,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,7002.75,100,,,case rate,100% PEIA DRG rate,30071.16,100,,,case rate,100% The Health Plan DRG rate,7002.75,85443.1325,
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITHOUT CC/MCC,989,MS-DRG,,,,,Inpatient,,,,,,43679.405,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,43679.405,275,MS-DRG,,case rate,275% CMS Medicare MS-DRG,15883.42,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,5460.31,102,,,case rate,102% WV Medicaid DRG rate,26207.643,165,MS-DRG,,case rate,165% CMS Medicare MS-DRG,4990.23,100,,,case rate,100% PEIA with CHIP DRG base rate,20356.09,100,,,case rate,100% Highmark ACA DRG rate,25741.39,100,,,case rate,100% Highmark PPO DRG rate,25741.39,100,,,case rate,100% Highmark Trad DRG rate,5353.24,100,,,case rate,100% WV Medicaid DRG rate,15883.42,100,MS-DRG,,case rate,100% CMS Medicare MS-DRG,4244.68,100,,,case rate,100% PEIA DRG rate,19143.12,100,,,case rate,100% The Health Plan DRG rate,4244.68,43679.405,